Global Surgery System Strengthening: It Is All About the Right Metrics

TLDR

Progress toward universal safe, affordable surgery hinges on consensus about which metrics to use, and the Lancet Commission identified six key indicators covering access, timeliness, safety, and affordability. This article examines the definition, validity, feasibility, and relevance of each metric and discusses their progress toward inclusion in WHO and World Bank core indicator lists and their application in national surgical plans for low‑ and middle‑income countries. The authors identify stakeholder‑specific messages tailored to patients, practitioners, providers, communities, politicians, policymakers, and payers to promote metric adoption. Their experience implementing the metrics in the Pacific and sub‑Saharan Africa demonstrates progress toward WHO and World Bank inclusion and informs national surgical plans to scale up safe, affordable, timely care.

Abstract

Progress in achieving "universal access to safe, affordable surgery, and anesthesia care when needed" is dependent on consensus not only about the key messages but also on what metrics should be used to set goals and measure progress. The Lancet Commission on Global Surgery not only achieved consensus on key messages but also recommended 6 key metrics to inform national surgical plans and monitor scale-up toward 2030. These metrics measure access to surgery, as well as its timeliness, safety, and affordability: (1) Two-hour access to the 3 Bellwether procedures (cesarean delivery, emergency laparotomy, and management of an open fracture); (2) Surgeon, Anesthetist, and Obstetrician workforce >20/100,000; (3) Surgical volume of 5000 procedures/100,000; (4) Reporting of perioperative mortality rate; and (5 and 6) Risk rates of catastrophic expenditure and impoverishment when requiring surgery. This article discusses the definition, validity, feasibility, relevance, and progress with each of these metrics. The authors share their experience of introducing the metrics in the Pacific and sub-Saharan Africa. We identify appropriate messages for each potential stakeholder-the patients, practitioners, providers (health services and hospitals), public (community), politicians, policymakers, and payers. We discuss progress toward the metrics being included in core indicator lists by the World Health Organization and the World Bank and how they have been, or may be, used to inform National Surgical Plans in low- and middle-income countries to scale-up the delivery of safe, affordable, and timely surgical and anesthesia care to all who need it.