by Tiffany Chien

Graphic design by Stefanie Jinyin Wang

When thinking about international public health, there is often emphasis on vaccinations, nutrition, and maternal and child health while overlooking surgery. Tragically, nearly five billion people worldwide lack access to safe, affordable, and timely surgical care, a substantial increase from earlier estimates of two billion.^1,2 This discrepancy arises from differing definitions of surgical access: the previous estimate is based on the total distribution of operating theatres, while The Lancet Commission on Global Surgery advocates for a more inclusive approach including high-quality, timely, and financially supported surgical and anesthesia care for all.¹ 

Despite progress in global health, mortality and morbidity rates in Low- and Middle-Income Countries (LMICs) continue to rise due to limited resources in surgical care. In many African nations, one person dies of surgically-treatable disease every two seconds.³ The challenges to surgical access are multifactorial, with structural, cultural, and financial barriers being the primary hurdles patients face.⁴ Structural barriers include lack of trained personnel and equipment, with ~67% of households citing these as primary obstacles.⁴ Cultural barriers mainly involve distrust in medical systems and poor treatment quality. Financial obstacles include treatment costs, lack of savings, and travel expenses.⁴ For instance, in regions like sub-Saharan Africa and Southeast Asia, travel costs prevent many patients from receiving cleft lip and palate surgeries.⁵

LMICS often lack adequate services such as essential equipment, infrastructure, and specialized expertise. Even with available resources, a shortage of trained personnel hinders appropriate and timely diagnoses. To further complicate things, those that receive referrals still struggle with access to motorized transport, with many patients travelling more than 10 km to reach emergency care.⁶ Furthermore, many congenital conditions like cleft lip, palate, and craniosynostosis—a birth defect involving the premature fusion of the skull—require timely surgical intervention. Cleft lip and palate surgeries are typically performed on children from 3 months to 1.5 years of age to optimize feeding and speech development. Meanwhile, craniosynostosis repairs are best done before 4 months after birth to improve surgical outcomes and prevent pressure-related long-term neuropsychological impairments.^5-8 Unfortunately, in LMICs, the average age for a child’s first cleft surgery is 3.24 years, and those in economically disadvantaged areas tend to receive craniosynostosis consultation later, leading to delays in surgical intervention and poorer developmental outcomes.^7.8

Financial catastrophe occurs when health expenditures exceed 10% of total household spending or surpass more than 40% of non-food spending, heavily impacting already vulnerable populations.⁹ Astonishingly, 33 million individuals globally experience financial catastrophe from surgery costs alone, while 48 million struggle with additional nonmedical costs, including transportation, lodging, food, and informal payments.⁹ While financial hardship is a concern for all income levels, LMICs are at particularly high risk due to the disproportionate inflation of surgical costs relative to household income. Patients in these areas are forced to make the trade-off between receiving treatment at the hospital, or, alternatively, facing impoverishment. Moreover, out-of-pocket payments remain the primary means of financing healthcare in many LMICs, and while health insurance programs have been introduced to reduce this burden, coverage remains limited and inconsistent.^9,10 As such, access to surgical care remains severely restricted, leaving many unable to afford appropriate, and oftentimes, life-saving procedures.

What is being done to change the surgical landscape in LMICs in particular?

Non-governmental organizations (NGOs) play a vital role in addressing these gaps, providing over 50% of surgical services in some LMICs.¹¹ Mercy Ships, for example, works in partnership with host LMIC nations to deliver free surgeries and offer training on hospital ships in sub-Saharan Africa.¹¹ Many of the common types of surgeries performed are life-changing, including cleft lip and palate surgeries, tumour removals from the head and neck, surgery after burns, and correction of neglected limb deformities.¹¹ Nevertheless, ship-based care is temporary, with limited long-term healthcare development, continuity of expertise, and sustainable post-operative support. Additionally, travel time and non-medical costs remain obstacles for patients in rural areas. One way of addressing these challenges is shifting to a decentralized patient recruitment strategy which targets rural populations with limited surgical access. For instance, a study in Madagascar found that decentralized recruitment reached poorer patients in remote areas who faced financial and logistical difficulties, ensuring care reaches the most underserved populations.¹¹

Global surgery is a vital component of a strong global health system and should be given higher priority for attention and resources. To do so, we need to actively address barriers and provide comprehensive systemic and patient-centred solutions. In addition to offering free services, developing country-specific selection strategies, such as actively seeking patients in rural areas, are integral for ensuring surgical care is accessible and available. Additionally, local communities, NGOs, and leaders should collaborate to identify those most in need, using routinely collected patient demographic information and economic status to assess progress in improving surgical care access.¹¹ Hopefully, a better understanding of surgical need through research, policy, and advocacy will train the current generation of surgeons to adopt a more holistic, patient-focused approach, paving the way for more inclusive and sustainable surgical care worldwide.

Acknowledgements: 

To learn more about reconstructive surgery and access to surgery in a global context, we invite you to listen to the upcoming episode of Raw Talk Podcast on Reconstructive Surgery. Also, check out some interesting resources the team has compiled in the episode’s show notes on the Raw Talk Podcast website. We would like to acknowledge the efforts and ideas of the rest of the episode team: Avni and Bellinda were Show Hosts on the episode. Anisa and Selina were our Content Creator and Promo respectively; Raina was our Audio Engineer; and Noor was our Executive Producer.

References

1. Meara JG, Leather AJM, Hagander L, et al. The Lancet Commission on Global Surgery Global surgery 2030: Evidence and solutions for achieving health, welfare and economic development. Lancet Commissions. 2015;386(9993):569-624.
2. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6): 316-23. doi:10.1016/S2214-109X(15)70115-4.
3. 2024: Mercy Ships doubles down efforts to bring surgical care and training to sub-Saharan Africa as studies pinpoint critical gaps in surgical, obstetric, and anesthetic care – Mercy Ships Africa [Internet]. Mercy Ships. [cited 2025 Feb 28]. Available from: https://mercyships.africa/2024-mercy-ships-doubles-down-efforts-to-bring-surgical-care-and-training-to-sub-saharan-africa-as-studies-pinpoint-critical-gaps-in-surgical-obstetric-and-anesthetic-care/

4. Yao CA, Swanson J, Chanson D, Taro TB, Gura B, Figueiredo JC, et al. Barriers to Reconstructive Surgery in low- and middle-Income Countries: A Cross-Sectional Study of 453 Cleft Lip and Cleft Palate Patients in Vietnam. Plast Reconstr Surg. 2016; 138(5):887e-95e. doi:10.1097/PRS.0000000000002656.
5. O’Brien PF, Teti SA, Dewar C, et al. Optimal timing of endoscopic sagittal suturectomy. J Neurosurg Pediatr. Published online February 21, 2025. doi:10.3171/2024.11.PEDS24272
6. Porto Junior S, Meira DA, da Cunha BLB, et al. Endoscopic surgery for craniosynostosis: A systematic review and single-arm meta analysis. Clin Neurol Neurosurg. 2024;242:108296. doi:10.1016/j.clineuro.2024.108296
7. Jolibois MI, Roohani I, Moshal T, et al. Sociodemographic Factors Associated with Delayed Presentation in Craniosynostosis Surgery at a Tertiary Children’s Hospital. Plast Reconstr Surg. 2024;12(8):1-8. doi:10.1097/GOX.0000000000006035.
8. Grimes CE, Bowman KG, Dodgion CM, et al. Systematic Review of Barriers to Surgical Care in Low-Income and Middle-Income Countries. World J Surg. 2011;35:941-50. doi:10.1007/s00268-011-1010-1.
9. Shrime MG, Dare AJ, Alkire BC, et al. Catastrophic expenditure to pay for surgery worldwide: a modelling study. Lancet Glob Health. 2015; 3 Suppl 2(0 2):S38–S44. doi:10.1016/S2214-109X(15)70085-9.
10. Hooley B, Afriyie DO, Fink G, et al. Health insurance coverage in low-income and middle-income countries: progress made to date and related changes in private and public health expenditure. BMJ Glob Health. 2022; 7(5): e008722. doi:10.1136/bmjgh-2022-008722. 
11. White MC, Hamer M, Biddell J, et al. Facilitating access to surgical care through a decentralised case-finding strategy: experience in Madagascar. BMJ global health. 2017;2(3):1-6. doi:10.1136/bmjgh-2017-000427.