New global surgical and anaesthesia indicators in the World Development Indicators dataset

Raykar NP, et al. BMJ Glob Health 2017;2:e000265. doi:10.1136/bmjgh-2016-000265 Although 5 billion people lack access to surgery and anaesthesia care, little systems-level data exist to address this health inequity and social injustice. Data drive quality improvement processes in business and health systems in high-resource settings, but clinicians and policymakers in low-resource environments have been metaphorically—and often literally—operating in the dark. The challenges to obtaining accurate health systems data involve nearly all clinical delivery platforms in global health and have been well documented and are also relevant to surgery and anaesthesia. They include insufficient national-level investment in analytics, insufficient donor investment in data collection, little analysis of global health funding streams, limited tools and resources for data collection at the local level, and limited accessibility of collected data to those best positioned to implement data-driven solutions. Such gaps undermine advocacy, as the problems remain invisible and thus fail to inspire political will. In January 2014, at the inception of a global surgical movement designed to realign stakeholders into a structured approach to surgical systems strengthening, Dr Jim Kim, President of the World Bank Group, challenged The Lancet Commission on Global Surgery (LCoGS) to develop consensus-based indicators and timebound targets to track progress. Sixteen months later, in April 2015, after thorough consultation with clinicians, researchers, hospital administrators and policymakers, the Commission recommended six core indicators to assess surgical and anaesthesia systems strength. When these indicators (summarised in table 1) are considered together, they serve as basic proxies of surgical health system functioning. The LCoGS indicators assess multiple aspects of surgical and anaesthesia care delivery within a country. Where are the facilities capable of providing surgical care and how close are they to the populations that need them? How many surgical and anaesthesia providers are present? What quantity of surgical care is provided to a population? What is the quality of the care at its most basic level; namely, how many people die following surgical care? What is the affordability of surgical care? The latter was included because medical expense itself is a major source of impoverishment worldwide. In formulating these six questions and arriving at specific indicators, decisions had to be made on what measurable aspects of a health system could serve as suitable proxies. In-hospital perioperative mortality eliminates the need for expensive or unavailable outpatient follow-up, could serve as a proxy for safety and provide a benchmark for improvement. Hospitals capable of providing the ‘Bellwether Procedures’, defined as a laparotomy, caesarean delivery and treatment of an open fracture, were used as a proven proxy for hospitals capable of providing a variety of surgical and anaesthesia capacities. Finally, the affordability of surgical care was interrogated by calculating the likelihood of it generating impoverishing or catastrophic expense based on local surgical procedure charges and World Bank datasets on population income. By June 2015, a group of international academic institutions had partnered with the World Bank and the WHO’s Global Initiative for Emergency and Essential Surgical Care to collect national-level data on these indicators from around the world. The authors of this editorial were either (1) core members of the LCoGS with a particular role in drafting the indicators (NPR, SB, JD, SLMG, LH, AJML, KAM, JGM) and/or (2) involved in conceiving or directing this global indicator data collection effort (NPR, JSNK, SB, WJ, SM, ES, TW, MGS, New global surgical and anaesthesia indicators in the World Development Indicators dataset