Global access to surgical care: a modelling study.
BACKGROUND
More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commission's vision.


METHODS
We modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability. We built a chance tree for each country to model the probability of surgical access with respect to each dimension, and from this we constructed a statistical model to estimate the proportion of the population in each country that does not have access to surgical services. We accounted for uncertainty with one-way sensitivity analyses, multiple imputation for missing data, and probabilistic sensitivity analysis.


RESULTS
At least 4·8 billion people (95% posterior credible interval 4·6-5·0 [67%, 64-70]) of the world's population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western sub-Saharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access.


CONCLUSIONS
Most of the world's population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all.


BACKGROUND
None.
Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA; Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, USA.
Blake C
BC
Alkire
Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, USA. Electronic address: nraykar@bidmc.harvard.edu.
Nakul P
NP
Raykar
Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA; Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, USA.
Mark G
MG
Shrime
Department of Surgery, Stanford University, Palo Alto, USA.
Thomas G
TG
Weiser
Rudy Children's Hospital, University of California, San Diego, CA, USA.
Stephen W
SW
Bickler
Department of Surgery, University of California, San Diego, CA, USA.
John A
JA
Rose
Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.
Cameron T
CT
Nutt
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA; Department of Surgery, Medical College of Wisconsin, Wauwatosa, USA.
Sarah L M
SL
Greenberg
Department of Surgery, University of Washington, Seattle, USA.
Meera
M
Kotagal
Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA; Department of Surgery, Massachusetts General Hospital, Boston, USA.
Johanna N
JN
Riesel
Department of Surgery, Stanford University, Palo Alto, USA.
Micaela
M
Esquivel
Department of Surgery, Stanford University, Palo Alto, USA.
Tarsicio
T
Uribe-Leitz
Ariadne Labs, Boston, USA; Department of Surgery, Massachusetts General Hospital, Boston, USA.
George
G
Molina
Department of Surgery, BARC Hospital, Mumbai, India; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
Nobhojit
N
Roy
Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, USA.
John G
JG
Meara
Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA; Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA; Partners-In-Health, Boston, USA.
Paul E
PE
Farmer
D017954:Africa South of the Sahara; D001208:Asia; D003906:Developing Countries; D014943:Global Health; D006296:Health Services; D006297:Health Services Accessibility; D006801:Humans; D007182:Income