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  • It s springtime for surgery declared Meena Cherian


    “It\'s springtime for surgery!” declared Meena Cherian at the launch of the at the end of April. It certainly seems so. In a few days\' time, WHO Member State representatives will gather at the 68th World Health Assembly to discuss, among other things, the adoption a on surgical care and anaesthesia as a component of universal health coverage. An explicit surgical outcome was also included in WHO\'s recent . And the of the World Bank\'s Disease Control Priorities, third edition, is devoted to essential surgery. But back to the Commission. A massive under­taking involving thousands of stakeholders across 111 countries and six continents, the Commission went from inception to realisation in a little over 2 years. The process generated a bewildering volume of original research (some of the key papers of which are published in a ), a comprehensive outline of the present landscape, and an ambitious roadmap for the future of surgery and anaesthesia as part of the post-2015 agenda. The Sustainable Development Goals are a “fairytale” without inclusion of scaled-up surgical services, declared Gavin Yamey at the Commission\'s launch. Maternal and neonatal mortality targets, injury targets, cancer targets, poverty targets—none of these are remotely achievable without improved access to caesarean sections, fracture management, and tumour resection, and without bold new strategies for improving the affordability of procedures that save lives but condemn recipients to poverty. Access, safety, and affordability are the key tenets of the Commission\'s work. In both reviewing previous efforts and embarking on , the authors reveal the shocking inequity in access to surgical services worldwide. A paper published in this issue of shows that, if access is measured according to whether a person can reach a facility in a timely manner, whether adequate surgical capacity is available there, whether the facility can perform procedures safely, and whether the surgery can be obtained without catastrophic expenditure, an estimated 5 billion people globally are without access. This figure as a proportion of the GDC-0994 as a whole ranges from 15% in high-income countries to 98% in low-income countries. also showed that almost 4 billion people today would incur catastrophic expenditure if they were to undergo necessary surgery. Contrary to popular belief, however, provision of adequate surgical services does not have to be impover­ishing for governments. A showed that scaling up provision to 5000 major operations per 100 000 population per year between 2012 and 2030 would cost low-income and middle-income countries US$300–420 billion. It sounds a lot, but with lack of access to surgical services costing an estimated $12 trillion (or 2% of GDP) in lost productivity in these countries over the years 2015–30, the economic case for scaling up becomes clear.
    Global surgical care is gaining ground on the public health platform. Throughout 2015–16, the World Bank is publishing the long-anticipated third edition of its (DCP3). First published in 1993, these reports aim to systematically identify effective interventions to address the disease burden in low-income and middle-income countries. For the first time since its inception, the DCP now includes a distinct volume on the value of surgical care. Volume 1——focuses on the benefits of surgical care, including its potential to substantially decrease mortality while being exceptionally cost-effective; the issues of access to life-saving surgery, perioperative safety, and the inclusion of surgery in universal health coverage are also specifically addressed. The recognition of surgery as an essential component of global public health stems from a growing body of academic literature detailing the disparities in access to surgical care. Population-based surveys have been instrumental in quantifying the unmet need for surgical care, and hospital-based studies have shed light on deficiencies in human and material resources required for basic surgical care. Global estimates of surgical care and need, arising from complex statistical models, have also been essential in quantifying the problem and have been especially effective in gaining the attention of stakeholders and decision-makers from outside the surgical sphere. In 2008, Weiser and colleagues estimated that, of the 234 million surgical procedures done annually worldwide, only 3·5% occurred in countries with health expenditures of US$100 or less per capita. Funk and colleagues estimated that more than 2 billion people worldwide lack access to adequate surgical care.