Conditions that are treated primarily or frequently by surgery constitute a significant portion of the global burden of disease. In 2011, injuries killed nearly 5 million people; 270,000 women died from complications of pregnancy (WHO 2014). Many of these injury- and obstetric-related deaths, as well as deaths from other causes such as abdominal emergencies and congenital anomalies, could be prevented by improved access to surgical care.
Despite this substantial burden, surgical services are not being delivered to many of those who need them most. An estimated 2 billion people lack access to even the most basic surgical care (Funk and others 2010). This need has not been widely acknowledged, and priorities for investing in health systems’ surgical capacities have only recently been investigated. Indeed, until the 1990s, health policy in resource-constrained settings focused sharply on infectious diseases and undernutrition, especially in children. Surgical capacity was developing in urban areas but was often viewed as a secondary priority that principally served those who were better off.
In the 1990s, a number of studies began to question the perception that surgery was costly and low in effectiveness. Economic evaluations of cataract surgery found the procedure to be cost-effective, even under resource-constrained circumstances; Javitt pioneered cost-effectiveness analysis (CEA) for surgery, including his chapter on cataract in Disease Control Priorities, first edition (DCP1) in 1993 (Javitt 1993). In 2003, McCord and Chowdhury enriched the approach to economic evaluation in surgery in a paper looking at the overall cost-effectiveness of a surgical platform in Bangladesh (McCord and Chowdhury 2003). By design, DCP2, published in 2006, placed much more emphasis on surgery than had previous health policy documents. DCP2 included a dedicated chapter on surgery that amplified the approach of McCord and Chowdhury and provided an initial estimate of the amount of disease burden that could be addressed by surgical intervention in LMICs (Debas and others 2006). DCP3 places still greater emphasis on surgery by dedicating this entire volume (out of a total of nine volumes) to the topic. There is also a growing academic literature on surgery’s importance in health system development; for example, Paul Farmer and Jim Kim’s paper observes that “surgery may be thought of as the neglected stepchild of global public health” (Farmer and Kim 2008, 533). The WHO is paying increasing attention to surgical care through such vehicles as its Global Initiative for Emergency and Essential Surgical Care. Finally, the creation of The Lancet Commission on Global Surgery, now well into its work, points to a major change in the perceived importance of surgery.
The chapter seeks to do the following:
Better define the health burden of conditions requiring surgery
Identify those surgical procedures that are the most cost-effective and cost-beneficial
Describe the health care policies and platforms that can universally deliver these procedures at high quality. In particular, Essential Surgery seeks to define and study a package of essential surgical procedures that would lead to significant improvements in health if they were universally delivered. This chapter and the volume focus on the situation of low-income countries (LICs) and lower-middle-income countries.
Box 1.1 describes the history, objectives, and contents of DCP3 (Jamison 2015).
© 2015 International Bank for Reconstruction and Development / The World Bank.