title: Projections to achieve minimum surgical rate threshold: an observational study.
abstract: BACKGROUND
  Recent work has indicated an increase in surgical services, especially in resource poor settings. However, the rate of growth is poorly understood and likely insufficient to meet public health needs. We previously identified a range of 4344 to 5028 operations per 100 000 population annually to be related to desirable health outcomes. From this and other evidence, the Lancet Commission on Global Surgery recommends a minimum rate of 5000 operations per 100 000 population. We evaluate rates of growth in surgery and estimate the time it will take to reach this minimum surgical rate threshold.
  
  
  METHODS
  We aggregated 2004 and 2012 country-level surgical rate estimates into the 21 Global Burden of Disease (GBD) regions. We calculated mean rates of surgery proportional to population size and estimate rate of growth between these years. We then extrapolated the time it will take to reach a surgical rate of 5000 operations per 100 000 population based on linear rates of change.
  
  
  RESULTS
  All but two regions (central Europe and southern Latin America) experienced growth in their surgical rates during the past 8 years; the fastest growth occurred in regions with the lowest surgical rates. 14 regions representing 79% of the world's population (5·5 billion people) did not meet the recommended surgical rate threshold in 2012. If surgical capacity grows at current rates, seven regions (central sub-Saharan Africa, east Asia, eastern sub-Saharan Africa, north Africa and middle east, south Asia, southeast Asia, and western sub-Saharan Africa) will not meet the recommended surgical rate threshold by 2035; Eastern Sub-Saharan Africa will not reach this level until 2124.
  
  
  CONCLUSIONS
  The rates of growth in surgical service delivery are exceedingly variable, but the largest growth rates were noted in the poorest regions. Although this study does not address the quality of care, and rates of surgery are unlikely to change linearly, this exercise is useful to project how many years it could take regions to reach specific surgical rates. At current rates of growth, 4·9 billion people (70% of the world's population) will still be living in countries below the minimum recommended rate of surgery in 2035. A strategy for strengthening surgical capacity is essential if these targets are to be met as part of integrated health system development.
  
  
  BACKGROUND
  None.
authors: Stanford University School of Medicine, Stanford, CA, USA. Electronic address: pturibe@stanford.edu.
authors: Tarsicio
authors: T
authors: Uribe-Leitz
authors: Stanford University School of Medicine, Stanford, CA, USA.
authors: Micaela M
authors: MM
authors: Esquivel
authors: Massachusetts General Hospital, Department of Surgery, Boston, MA, USA.
authors: George
authors: G
authors: Molina
authors: Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA.
authors: Stuart R
authors: SR
authors: Lipsitz
authors: Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
authors: Stéphane
authors: S
authors: Verguet
authors: Center for Surgery and Public Health, at Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Department of Surgery, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA.
authors: John
authors: J
authors: Rose
authors: Department of Surgery, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA.
authors: Stephen W
authors: SW
authors: Bickler
authors: Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA.
authors: Atul A
authors: AA
authors: Gawande
authors: Massachusetts General Hospital, Department of Surgery, Boston, MA, USA.
authors: Alex B
authors: AB
authors: Haynes
authors: Stanford University School of Medicine, Stanford, CA, USA.
authors: Thomas G
authors: TG
authors: Weiser