Selected Articles on Global Health and Anesthesia

When searching for these articles, use you can get the citations most quickly by just entering the PMID (Pubmed’s unique identifier) as the search term in Pubmed, Ovid Citation, or any database using Medline search.

Clinical topics: Airway

Clinical topics: Burns

Clinical topics: Pain & Sedation

Collaboration and Communication

Disaster relief / Disaster tourism


Drug distribution and shortages

Education projects / Distance learning [see also: Training programs and University partnerships]

Equipment and Technology

Global burden of surgical disease [see also: Lancet Commission; Trauma; Maternal health; Pediatric surgery]

Hospital and clinical facilities [see also Lancet Commission; Global burden of surgical disease]

Legal considerations

Maternal health / maternal mortality [see also: Lancet Commission]

Pediatric Critical Care/ Neonatal Resuscitation

Pediatric Surgery

Resident and student electives abroad [see also Education projects / Distance learning]

Short-term medical missions – Ethical considerations

Short-term missions – Impact and long-term outcomes

Standards of care/QA [see also: Lancet Commission]

Trauma and Non-communicable Diseases

Training programs / University partnerships [See also: Resident/ student electives; and Education projects/distance learning]

Volunteer Preparation, Guidelines and Personal safety

Workforce – Brain Drain [see also: Lancet Commission]

Workforce – Physician and non-physician providers [see also: Lancet Commission]

Lancet Commission 2015

Clinical topics: Airway


Firth PG, Solomon JB, Roberts LL, Gleeson TD. Airway management of tetanus after the Haitian earthquake ‑ new insights into old observations. Anes Analg 2011; 113(3): 545‑547.

Fidkowski CW, Zheng H, Firth PG. Anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12, 979 cases. Anesth Analg 2010; 111(4): 1016‑1025. PMID: 20802055

Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 4 years. The reviewed articles total 12,979 pediatric bronchoscopies. Most aspirated foreign bodies are organic materials (81%, confidence interval [CI] = 77%‑86%), nuts and seeds being the most common. The majority of foreign bodies (88%, CI = 85%‑91%) lodge in the bronchial tree, with the remainder catching in the larynx or trachea. The incidence of right‑sided foreign bodies (52%, CI = 48%‑55%) is higher than that of left‑sided foreign bodies (33%, CI = 30%‑37%). A small number of objects fragment and lodge in different parts of the airways. Only 11% (CI = 8%‑16%) of the foreign bodies were radio‑opaque on radiograph, with chest radiographs being normal in 17% of children (CI = 13%‑22%).

Although rigid bronchoscopy is the traditional diagnostic “gold standard,” the use of computerized tomography, virtual bronchoscopy, and flexible bronchoscopy is increasing. Reported mortality during bronchoscopy is 0.42%. Although asphyxia at presentation or initial emergency bronchoscopy causes some deaths, hypoxic cardiac arrest during retrieval of the object, bronchial rupture, and unspecified intraoperative complications in previously stable patients constitute the majority of in‑hospital fatalities. Major complications include severe laryngeal edema or bronchospasm requiring tracheotomy or reintubation, pneumothorax, pneumomediastinum, cardiac arrest, tracheal or bronchial laceration, and hypoxic brain damage (0.96%). Aspiration of gastric contents is not reported.

Preoperative assessment should determine where the aspirated foreign body has lodged, what was aspirated, and when the aspiration occurred (“what, where, when”). The choices of inhaled or IV induction, spontaneous or controlled ventilation, and inhaled or IV maintenance may be individualized to the circumstances.

Although several anesthetic techniques are effective for managing children with foreign body aspiration, there is no consensus from the literature as to which technique is optimal. An induction that maintains spontaneous ventilation is commonly practiced to minimize the risk of converting a partial proximal obstruction to a complete obstruction. Controlled ventilation combined with IV drugs and paralysis allows for suitable rigid bronchoscopy conditions and a consistent level of anesthesia. Close communication between the anesthesiologist, bronchoscopist, and assistants is essential.

∧Back to top

Clinical topics: Burns


Forjuoh SN. Burns in low- and middle-income countries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns. 2006 Aug;32(5): 529-37. Jun 14. PMID: 16777340


Burn prevention requires adequate knowledge of the epidemiological characteristics and associated risk factors. While much has been accomplished in the areas of primary and secondary prevention of fires and burns in many developed or high-income countries (HICs), such as the United States, due to sustained research on the descriptive epidemiology and risk factors, the same cannot be said of developing or low- and middle-income countries (LMICs). To move from data to action and assist preventive efforts in LMICs, a review of the available literature was conducted to assess the current status of burn preventive efforts. A MEDLINE search (1974-2003) was conducted on empirical studies published in English on the descriptive epidemiology, risk factors, treatment, and prevention of burns in LMICs. Review of the 117 identified studies revealed basically the same descriptive epidemiological characteristics but slightly different risk factors of burns including the presence of pre-existing impairments in children, lapses in child supervision, storage of flammable substances in the home, low maternal education, and overcrowding as well as several treatment modalities and preventive efforts including immediate application of cool water to a burned area. Continuous evaluation of promising interventions and those with unknown efficacy that have been attempted in LMICs, along with testing interventions that have proven effective in HICs in these LIMC settings, is needed to spearhead the move from data to action in preventing burns in LMICs.



Albertyn R, Bickler SW, Rode H. Paediatric burn injuries in Sub Saharan Africa – an overview. Burns. 2006 Aug;32(5): 605-12. PMID: 16713683


Paediatric burn injuries in Sub Saharan Africa are common and often lead to devastating consequences. Unfortunately relevant and accurate data regarding these injuries is sketchy and incomplete. This paper reviews the available information on the epidemiology of paediatric burns in Africa, associated health problems and contributing environmental factors responsible for these burns. The current status of burn care, the lack of infrastructure, and traditional methods of treatment, further contribute to the unsatisfactory status of overall burn management, prevention, and rehabilitation of burn survivors. A strategy for improving burn care in Africa has been formulated. The management of childhood burns will only be successful if educational, social, fiscal and infrastructure standards are improved. Traditional beliefs and methods cannot be discarded as they play an important role in the management of these children. It is furthermore essential that local and central government organisations support these initiatives. Clearly, the children of Africa deserve better burn care.

∧Back to top

Clinical topics: Pain and Sedation


Jackson T, Thomas S, Stabile V, Han X, Shotwell M, McQueen K.  Prevalence of chronic pain in low-income and middle-income countries: a systematic review and meta-analysis. Lancet. 2015 Apr 27;385 Suppl 2: S10.


BACKGROUND: The global burden of chronic pain and disability could be related to unmet surgical needs. This systematic review and meta-analysis aims to characterise existing data regarding the prevalence and associations of chronic pain in low-income and middle-income countries; this is essential to allow better assessment of its relationship to pre-operative and post-operative pain as emergency and essential surgical services are expanded.

METHODS: According to PRISMA guidelines, we searched PubMed, PsycInfo, and Cochrane registries for articles published before Dec 31, 2013, using the search terms “pain AND (chronic OR persistent) AND (low income countries OR middle income countries OR LMIC OR Africa OR Asia OR Central America OR South America) AND (incidence OR prevalence).” We excluded paediatric populations (aged younger than 18 years) and those with acute pain or pain associated with known trauma, surgery, infection, or medical disorders.

FINDINGS: We identified 122 publications in 28 low-income and middle-income countries for systematic review; 79 surveys from general adult populations, elderly general populations, or workers. The prevalence of any type of chronic pain was 33% (95% CI 26-40) in the general adult population, 56% (36-75) in the general elderly population, and 35% (4-88) in workers; lower back pain was 18% (14-24), 31% (22-41), and 44% (33-55), respectively; headache 39% (27-53), 49% (37-60), and 52% (16-86), respectively; chronic daily headache 5% (3-7), not available, and 12% (8-19), respectively; musculoskeletal pain 26% (19-33), 39% (23-57), and 86% (56-93), respectively; joint pain 14% (11-18), 42% (26-60), and not available, respectively; and widespread pain 14% (9-22), 22% (9-46), and not available, respectively. Due to limited data, meta-analysis could only be done in single populations for some conditions. For general adult populations, chronic migraine was 10% (5-20); chronic tension-type headache was 4% (2-9); chronic pelvic pain or prostatitis was 11% (8-17); and fibromyalgia was 4% (3-7). In elderly general populations, prevalence of temporomandibular disorder was 7% (1-31) and abdominal pain was 6% (1-28). Heterogeneity in prevalence was largely secondary to variable definitions of pain chronicity. Associations were not readily amenable to meta-analysis; yet of the 122 publications, pain was described in association with disability in 50, female sex in 40, older age in 34, depression in 36, anxiety in 19, and multiple somatic complaints in 13.

INTERPRETATION: The prevalence of pain in low-income and middle-income countries is consistent with Global Burden of Disease data, with higher rates in the elderly general population and workers than in the general adult population. 28% of the global burden of disease that could be averted by surgery and safe anaesthesia might also be related to the chronic pain burden. Trauma, cancer, birth complications, congenital defects, and other surgical diseases potentially lead to chronic pain if not treated or if treated inadequately. This meta-analysis shows the range of chronic pain in low-income and middle-income countries, but has fallen short of revealing clear causes for the pain. The demonstration of the prevalence of chronic pain is essential as the era of global surgery begins, to allow benchmarking of this prevalence in the future as emergency and essential surgery services are expanded in low-income and middle-income countries.



Mahmoud MA, Mason KP. A forecast of relevant pediatric sedation trends. Curr Opin Anesthesiol 2016, 29 (suppl 1): S56–S67


Over the past decade, the field of pediatric sedation has benefited from contributions which include the introduction and update of policies, procedures, and guidelines regarding training, physiologic monitoring and delivery, the approval of new sedatives, the multispecialty collaborations intended to advance the field and the development of sedatives, and delivery systems. This review will explore new drug innovations as well as evolved formulations of already approved agents, unique sedative delivery systems, the clinical application of pharmacogenetics and will conclude with a reflection on the current and future trends and focus of pediatric sedation research.

∧Back to top

Collaboration and Communication


Ginwalla R, Rickard J. Surgical Missions – The View From the Other Side. JAMA Surg. 2015;150(4)289-91

Key Points            

Missions must be incorporated into long term planning of LMIC infrastructure and phase out with time or become part of health system. There are few data on efficacy and cost effectiveness. Clefts are usually good for missions, but some a multidisciplinary team will often be needed to rehab patients and require long term partnership with locals. Complex procedures have higher M&M than in HICs. The educational role must be clear and coincide with site curriculum. Agenda should be determined by local training program. Missions should be locally driven and coordinated at MOH or hospital level. All of this would allow redistribution of local skills towards education and training, creating contextually sustainable local health care workforce. There are no short term missions regulations currently. Registry should be created for MOH and locals to request or advertise for missions. Local surgeons should play pivotal roles in determining when and where trips happen.

 Fisher QA, Fisher G. The case for collaboration among humanitarian surgical programs in low resource countries. Anesth Analg. 2014 Feb;118(2): 448-53. PMID: 24445642


With burgeoning activity in global health programs that provide training, medical-surgical services and infrastructure support, participants become increasingly aware of the need for effective partnerships with like-minded and complementary organizations. Effective partnerships are critical in addressing the challenges of fractionation and duplication of efforts, development of meaningful conversations among agencies, and objective evaluation of value and outcome. Alliances are effective when the network of partners is chosen based on their unique contributions and capabilities, and members operate in a coordinated manner, amplifying one another’s capacities. A wide range of appropriate collaborative efforts are feasible for governmental agencies, nongovernmental organizations, academic institutions, and in-country hosts engaged in humanitarian surgical or educational assistance. Donors play an essential role in fostering communication and cooperation among agencies. Transparency, ethical standards, quality review, and valid outcome measurement are universal components of effective humanitarian work.


Maiers C, Reynolds M, Haselkorn M. Challenges to Effective Information and Communication Systems in Humanitarian Relief Organizations. 2005 IEEE; 82-91

Butler MW. Fragmented international volunteerism: need for a global pediatric surgery network. J Pediatr Surg. 2010 Feb;45(2): 303-9. PMID: 20152341


INTRODUCTION: Pediatric general surgeons volunteering internationally often work independently, some without prior assessment of the needs of those they wish to assist. Consequently, care may be inefficient, duplicated, or misdirected. A study was performed to assess whether a network for pediatric surgery volunteer work exists.

METHODS: A search of the Internet was performed to determine whether a pediatric surgery network exists. Worldwide pediatric surgery societies were identified and grouped by country according to income. Web sites for medical volunteer organizations were examined for links to a network of pediatric surgery volunteer work.

RESULTS: A search of the Internet revealed no pediatric surgery volunteer network. Ninety-seven pediatric surgery societies were identified. Fifty-one of the organizations were identified as residing in low- and middle-income countries. Searching 50 Web sites for these societies revealed no existing pediatric surgery network. Of 45 Web sites for volunteer medical work, 1 surgery networking Web site was identified. Only 4 pediatric general surgery international volunteer opportunities were cited on that Web site.

CONCLUSIONS: This study demonstrated that no pediatric surgery volunteer network exists. By identifying pediatric surgery organizations in low- and middle-income countries, it is speculated that one might link the surgeons in these regions with those wishing to volunteer their services.

∧Back to top

Disaster Relief / Disaster Tourism


Eyal N, Firth P, and MGH Disaster Relief Ethics Group. Repeat triage in disaster relief: questions from Haiti. PLoS Curr. 2012 October 22; 4: e4fbbdec6279ec. PMID: 23145352; PMCID: PMC3492089

During a mass casualty disaster, the acute imbalance between need for treatment and capacity to supply care poses difficult rationing problems. It is common to assume that such disasters call for Autilitarian@ procedures that deliberately prioritize saving the most lives over other considerations. A group of medical responders to the 2010 Haitian earthquake faced particular challenges in determining how to allocate limited treatment, time and other resources between existing patients and potential patients not yet under care. We identified that rationing dilemmas points occurred at three points: when care had to be limited, when care had to be completed prematurely, and when care had to be withdrawn. “Repeat triage” refers to rationing challenges occurring at all these points, where the allocation of care is between existing and potential patients. By contrast, “initial triage” designates the allocation of access to treatment among new arrivals, all of whom are potential patients. Repeat and initial triage differ significantly. Several considerations make repeat triage special by supporting limited priority to existing patients, in transgression of pure “utilitarian” procedures: (1) Pragmatically, often it is more efficient to complete treatment on existing patients, for whom prognosis can be established with greater certainty and without added time, than to attempt to save new patients; (2) A fiduciary trust relationship has been formed between care‑giver and existing patients, which may make the moral obligation towards them somewhat stronger than the one to potential patients; (3) Existing patients will have often arrived earlier, so when needs are equal, the “first come, first served” principle prioritizes them for care; (4) Withdrawal of care during repeat triage may constitute active rather than passive harm, and more often a serious transgression of patient autonomy; (5) Health providers should normally not be asked to behave in ways that profoundly violate their personal and professional integrity, and abandoning existing patients may do so. For these reasons, responders can permissibly give a degree of priority to existing patients over newcomers in disaster.


Kumar A. Haiti Disaster TourismCA Medical Shame [letter] Prehospital and Disaster Medicine 2010;25(6)

Defining disaster tourism is a difficult task, especially for the medical responders who come to treat patients in such disastrous conditions. Judging the responses of a few persons on their own set of standards and criticizing their efforts in an emergency situation in which there are no unified mechanisms of responses raises some pertinent questions.



van Hoving DJ, Smith WP, Kramer EB, de Vries S, Docrat F, Wallis LA. Haiti: The South African perspective. S Afr Med J. 2010 Jul 26;100(8): 513-5. PMID: 20822619


BACKGROUND AND PROBLEM STATEMENT: The South African response to the Haitian earthquake consisted of two independent non-government organisations (NGOs) working separately with minimal contact. Both teams experienced problems during the deployment, mainly owing to not following the International Search and Rescue Advisory Group (INSARAG) guidelines.

CRITICAL AREAS IDENTIFIED: To improve future South African disaster responses, three functional deployment categories were identified: urban search and rescue, triage and initial stabilisation, and definitive care. To best achieve this, four critical components need to be taken into account: rapid deployment, intelligence from the site, government facilitation, and working under the auspices of recognised organisations such as the United Nations and the World Health Organization.

CONCLUSION: The proposed way forward for South African medical teams responding to disasters is to be unified under a leading academic body, to have an up-to-date volunteer database, and for volunteers to be current with the international search and rescue course currently being developed by the Medical Working Group of INSARAG. An additional consideration is that South African rescue and relief personnel have a primary responsibility to the citizens of South Africa, then the Southern African Development Community region, then the rest of the African continent and finally further afield. The commitment of government, private and military health services as well as NGOs is paramount for a unified response.



Van Hoving DJ, Wallis LA, Docrat F, De Vries S. Haiti disaster tourism–a medical shame. Prehosp Disaster Med. 2010 May-Jun;25(3): 201-2. PMID: 20586008


The devastating Haiti earthquake rightly resulted in an outpouring of international aid. Relief teams can be of tremendous value during disasters due to natural hazards. Although nobly motivated to help, all emergency interventions have unintended consequences. In the immediate aftermath of the earthquake, many selfless individuals committed to help, but was this really all in the name of reaching out a helping hand This case report illustrates that medical disaster tourism is alive and well.

∧Back to top



Howie SR, Hill SE, Peel D, Sanneh M, Njie M, Hill PC, Mulholland K, Adegbola RA. Beyond good intentions: lessons on equipment donation from an African hospital. Bull World Health Organ. 2008 Jan;86(1): 52-6. PMID: 18235890


OBJECTIVE: In 2000, a referral hospital in the Gambia accepted a donation of oxygen concentrators to help maintain oxygen supplies. The concentrators broke down and were put into storage. A case study was done to find the reasons for the problem and to draw lessons to help improve both oxygen supplies and the success of future equipment donations.

METHODS: A technical assessment of the concentrators was carried out by a biomedical engineer with relevant expertise. Semi-structured interviews were undertaken with key informants, and content analysis and inductive approaches were applied to construct the history of the episode and the reasons for the failure.

FINDINGS: Interviews confirmed the importance of technical problems with the equipment. They also revealed that the donation process was flawed, and that the hospital did not have the expertise to assess or maintain the equipment. Technical assessment showed that all units had the wrong voltage and frequency, leading to overheating and breakdown. Subsequently a hospital donations committee was established to oversee the donations process. On-site biomedical engineering expertise was arranged with a nongovernmental organization (NGO) partner.

CONCLUSION: Appropriate donations of medical equipment, including oxygen concentrators, can be of benefit to hospitals in resource-poor settings, but recipients and donors need to actively manage donations to ensure that the donations are beneficial. Success requires planning, technical expertise and local participation. Partners with relevant skills and resources may also be needed. In 2002, WHO produced guidelines for medical equipment donations, which address problems that might be encountered. These guidelines should be publicized and used.

∧Back to top

Drug distribution and shortages


Mackey TK, Liang BA, York P, Kubic T. Counterfeit drug penetration into global legitimate medicine supply chains: a global assessment. Am J Trop Med Hyg. 2015 Jun;92(6 Suppl): 59-67. PMID: 25897059


Counterfeit medicines are a global public health risk. We assess counterfeit reports involving the legitimate supply chain using 2009-2011 data from the Pharmaceutical Security Institute Counterfeit Incident System (PSI CIS) database that uses both open and nonpublic data sources. Of the 1,510 identified CIS reports involving counterfeits, 27.6% reported China as the source country of the incident/detection. Further, 51.3% were reported as counterfeit but the specific counterfeit subcategory was not known or verifiable. The most prevalent therapeutic category was anti-infectives (21.1%) with most reports originating from health-related government agencies. Geographically, Asian and Latin American regions and, economically, middle-income markets were most represented. A total of 127 (64.8%) of a total of 196 countries had no legitimate supply chain CIS counterfeit reports. Improvements in surveillance, including detection of security breaches, data collection, analysis, and dissemination are urgently needed to address public health needs to combat the global counterfeit medicines trade.

∧Back to top

Education Projects / Distance Learning

[see also: Training programs and University partnerships]


Livingston P, Evans F, Nsereko E, Nyirigira G, Ruhato P, Sargeant J, Chipp M, Enright A. Safer obstetric anesthesia through education and mentorship: a model for knowledge translation in Rwanda. Can J Anaesth.;61(11): 1028-39. PMID: 25145938.


High rates of maternal mortality remain a widespread problem in the developing world. Skilled anesthesia providers are required for the safe conduct of Cesarean delivery and resuscitation during obstetrical crises. Few anesthesia providers in low-resource settings have access to continuing education. In Rwanda, anesthesia technicians with only three years of post-secondary training must manage complex maternal emergencies in geographically isolated areas. The purpose of this special article is to describe implementation of the SAFE (Safer Anesthesia From Education) Obstetric Anesthesia course in Rwanda, a three-day refresher course designed to improve obstetrical anesthesia knowledge and skills for practitioners in low-resource areas. In addition, we describe how the course facilitated the knowledge-to-action (KTA) cycle whereby a series of steps are followed to promote the uptake of new knowledge into clinical practice. The KTA cycle requires locally relevant teaching interventions and continuation of knowledge post intervention. In Rwanda, this meant carefully considering educational needs, revising curricula to suit the local context, employing active experiential learning during the SAFE Obstetric Anesthesia course, encouraging supportive relationships with peers and mentors, and using participant action plans for change, post-course logbooks, and follow-up interviews with participants six months after the course. During those interviews, participants reported improvements in clinical practice and greater confidence in coordinating team activities. Anesthesia safety remains challenged by resource limitations and resistance to change by health care providers who did not attend the course. Future teaching interventions will address the need for team training.



Oyston JP. We should do more to train anesthesia technicians in Africa. Can J Anaesth. 2015 Apr;62(4): 435-6. [Comment on Livingston P, Safer obstetric anesthesia through education and mentorship: a model for knowledge translation in Rwanda] PMID: 25467753.


Kiwanuka JK, Ttendo SS, Eromo E, Joseph SE, Duan ME, Haastrup AA, Baker K, Firth PG. Synchronous distance anesthesia education by Internet videoconference between Uganda and the United States. J Clin Anesth. 2015 Sep;27(6): 499‑503. PMID: 26001319


OBJECTIVE: We evaluated the effectiveness of anesthesia education delivered via Internet videoconferencing between the Massachusetts General Hospital, Boston, MA, and Mbarara Regional Referral Hospital, Uganda.

METHODS: This is a prospective educational study. The setting is the education in 2 hospitals in Uganda and the United States. The subjects are anesthesia residents. The interventions are anesthesia education lectures delivered in person and via Internet videoconferencing. Measurements were the average pre‑lecture and post‑lecture scores of the local, remote, and combined audiences were compared.

RESULTS: Post‑lecture test scores improved over pre‑lecture scores: local audience, 59% ” 22% to 81% ” 16%, P = .0002, g = 1.144; remote audience, 51% ” 19% to 81% ” 8%, P < .0001, g = 2.058; and combined scores, 56% ” 14% to 82% ” 8%, P < .0001, g = 2.069).

CONCLUSIONS: Transfer of anesthetic knowledge occurs via small group lectures delivered both in person and remotely via synchronous Internet videoconferencing. This technique may be useful to expand educational capacity and international cooperation between academic institutions, a particular priority in the growing field of global health.



Dubowitz G, Evans FM. Developing a curriculum for anaesthesia training in low- and middle- income countries. Best Pract Res Clin Anaesthesiol 2012; 26: 17-21. PMID: 22559953

∧Back to top

Equipment and technology


Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry AF, Enright AC, Wilson IH, Dziekan G, Gawande AA. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet. 2010 Sep 25;376(9746): 1055-61. PMID: 20598365


BACKGROUND: Surgery is an essential part of health care, but resources to ensure the availability of surgical services are often inadequate. We estimated the global distribution of operating theatres and quantified the availability of pulse oximetry, which is an essential monitoring device during surgery and a potential measure of operating theatre resources.

METHODS: We calculated ratios of the number of operating theatres to hospital beds in seven geographical regions worldwide on the basis of profiles from 769 hospitals in 92 countries that participated in WHO’s safe surgery saves lives initiative. We used hospital bed figures from 190 WHO member states to estimate the number of operating theatres per 100,000 people in 21 subregions throughout the world. To estimate availability of pulse oximetry, we sent surveys to anaesthesia providers in 72 countries selected to ensure a geographically and demographically diverse sample. A predictive regression model was used to estimate the pulse oximetry need for countries that did not provide data.

FINDINGS: The estimated number of operating theatres ranged from 1×0 (95% CI 0×9-1×2) per 100,000 people in west sub-Saharan Africa to 25×1 (20×9-30×1) per 100,000 in eastern Europe. High-income subregions all averaged more than 14 per 100,000 people, whereas all low-income subregions, representing 2×2 billion people, had fewer than two theatres per 100,000. Pulse oximetry data from 54 countries suggested that around 77,700 (63,195-95,533) theatres worldwide (19×2% [15×2-23×9]) were not equipped with pulse oximeters.

INTERPRETATION: Improvements in public-health strategies and monitoring are needed to reduce disparities for more than 2 billion people without adequate access to surgical care.



Malkin R, Keane A. Evidence-based approach to the maintenance of laboratory and medical equipment in resource-poor settings. Med Biol Eng Comput. 2010 Jul;48(7): 721-6. PMID: 20490939


Much of the laboratory and medical equipment in resource-poor settings is out-of-service. The most commonly cited reasons are (1) a lack of spare parts and (2) a lack of highly trained technicians. However, there is little data to support these hypotheses, or to generate evidence-based solutions to the problem. We studied 2,849 equipment-repair requests (of which 2,529 were out-of-service medical equipment) from 60 resource-poor hospitals located in 11 nations in Africa, Europe, Asia, and Central America. Each piece of equipment was analyzed by an engineer or an engineering student and a repair was attempted using only locally available materials. If the piece was placed back into service, we assumed that the engineer’s problem analysis was correct. A total of 1,821 pieces of medical equipment were placed back into service, or 72%, without requiring the use of imported spare parts. Of those pieces repaired, 1,704 were sufficiently documented to determine what knowledge was required to place the equipment back into service. We found that six domains of knowledge were required to accomplish 99% of the repairs: electrical (18%), mechanical (18%), power supply (14%), plumbing (19%), motors (5%), and installation or user training (25%). A further analysis of the domains shows that 66% of the out-of-service equipment was placed back into service using only 107 skills covering basic knowledge in each domain; far less knowledge than that required of a biomedical engineer or biomedical engineering technician. We conclude that a great majority of laboratory and medical equipment can be put back into service without importing spare parts and using only basic knowledge. Capacity building in resource-poor settings should first focus on a limited set of knowledge; a body of knowledge that we call the biomedical technician’s assistant (BTA). This data set suggests that a supported BTA could place 66% of the out-of-service laboratory and medical equipment in their hospital back into service.



Bogod DG. One day for Africa: anaesthesia in Uganda and beyond [commentary on Hodges 2007]. Anaesthesia. 2007 Jan;62(1): 1-3. PMID: 17156219


Voigt HF, Krishnan SM. Editorial comment on Malkin and Keane (2010). Med Biol Eng Comput. 2010 Jul;48(7): 719-20. PMID: 20505998


Malkin and Keane (Med Biol Eng Comput, 2010) take an innovative approach to determine if unused, broken medical and laboratory equipment could be repaired by volunteers with limited resources. Their positive results led them to suggest that resource-poor countries might benefit from an on-the-job educational program for local high school graduates. The program would train biomedical technician assistants (BTAs) who would repair medical devices and instrumentation and return them to service. This is a program worth pursuing in resource-poor countries.

∧Back to top

Global burden of surgical disease / Essential surgical services

[see also: Lancet Commission; Trauma; Maternal health; Pediatric surgery]


Wall AE. Benchmarks for international surgery. Arch Surg. 2012 Sep;147(9): 796-7. PMID: 22987163


Botman M, Meester RJ, Voorhoeve R, et al. The Amsterdam declaration on essential surgical care. World J Surg, 39 (2015), pp. 1335‑1340 [http: //‑015‑3057‑x/fulltext.html]

Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA, Wilson IH. Anaesthesia services in developing countries: defining the problems. Anaesthesia. 2007 Jan;62(1): 4-11. PMID: 17156220


We describe the use of a questionnaire to define the difficulties in providing anaesthesia in Uganda. The results show that 23% of anaesthetists have the facilities to deliver safe anaesthesia to an adult, 13% to deliver safe anaesthesia to a child and 6% to deliver safe anaesthesia for a Caesarean section. The questionnaire identified shortages of personnel, drugs, equipment and training that have not been quantified or accurately described before. The method used provides an easy and effective way to gain essential data for any country or national anaesthesia society wishing to investigate anaesthesia services in its hospitals. Solutions require improvements in local management, finance and logistics, and action to ensure that the importance of anaesthesia within acute sector healthcare is fully recognised. Major investment in terms of personnel and equipment is required to modernise and improve the safety of anaesthesia for patients in Uganda.



Hodges S. Anaesthesia and global health initiatives for children in a low-resource environment. Curr Opin Anesthesiol 2016, 29: 367–371. PMID: 26905873

Summary: As the United Nations moves from Millennium Development Goals to Sustainable Development Goals, we find ourselves with the opportunity to influence the priority of global health initiatives. Previously, the global health community has failed to recognise the importance of access to safe, affordable surgery and developing the necessary specialities that support it as most of the funding focus had been on primary healthcare and infectious diseases.

Recent findings: Now the WHO is publishing guidelines to safe surgery and the Lancet Commission on Global Surgery has been launched. However, this is only the start; anaesthesia remains a forgotten speciality within the world of public and global health and there are still challenges in escalating surgery in low and middle-income countries to an acceptable level that is affordable and timely.

Conclusion: Although there is increased world interest in safe surgery and anaesthesia this has not yet been translated into a mandate that will compel countries to invest in improving levels of infrastructure, accessibility, manpower, and safety. A general anaesthetic remains a dangerous event in a child’s life in resource limited countries.



Ozgediz D, Kijjambu S, Galukande M, Dubowitz G, Mabweijano J, Mijumbi C, et al. Africa’s neglected surgical workforce crisis. Lancet. 2008 Feb 23;371(9613): 627-8. PMID: 18295007

Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008 Jul 12;372(9633): 139-44. PMID: 18582931


BACKGROUND: Little is known about the amount and availability of surgical care globally. We estimated the number of major operations undertaken worldwide, described their distribution, and assessed the importance of surgical care in global public-health policy.

METHODS: We gathered demographic, health, and economic data for 192 member states of WHO. Data for the rate of surgery were sought from several sources including governmental agencies, statistical and epidemiological organisations, published studies, and individuals involved in surgical policy initiatives. We also obtained per-head total expenditure on health from analyses done in 2004. Major surgery was defined as any intervention occurring in a hospital operating theatre involving the incision, excision, manipulation, or suturing of tissue, usually requiring regional or general anaesthesia or sedation. We created a model to estimate rates of major surgery for countries for which such data were unavailable, then used demographic information to calculate the total worldwide volume of surgery.

FINDINGS: We obtained surgical data for 56 (29%) of 192 WHO member states. We estimated that 234.2 (95% CI 187.2-281.2) million major surgical procedures are undertaken every year worldwide. Countries spending US$100 or less per head on health care have an estimated mean rate of major surgery of 295 (SE 53) procedures per 100 000 population per year, whereas those spending more than $1000 have a mean rate of 11 110 (SE 1300; p<0.0001). Middle-expenditure ($401-1000) and high-expenditure (>$1000) countries, accounting for 30.2% of the world’s population, provided 73.6% (172.3 million) of operations worldwide in 2004, whereas poor-expenditure (</=$100) countries account for 34.8% of the global population yet undertook only 3.5% (8.1 million) of all surgical procedures in 2004.

INTERPRETATION: Worldwide volume of surgery is large. In view of the high death and complication rates of major surgical procedures, surgical safety should now be a substantial global public-health concern. The disproportionate scarcity of surgical access in low-income settings suggests a large unaddressed disease burden worldwide. Public-health efforts and surveillance in surgery should be established.



Velji A, Bryant JH. Global health: evolving meanings. Infect Dis Clin North Am. 2011 Jun;25(2): 299-309. PMID: 21628046


Approaches to health, health care, and the terminology to describe global health have evolved over the past 70 years since the introduction of the Constitution of the World Health Organization and definition of health in broader terms. The early focus on individual care gradually shifted to community, population, and global approaches, with associated changes in the site of medical care, the personnel who provide it, and the education and training of those personnel. Concomitantly, goals changed from purely curative care to disease prevention and health promotion. Health was better understood to exist within the larger political, social, cultural, and ethical settings.



McIntyre T, Zenilman ME. Globalization of surgery: let’s get serious [comment on Chu et al.]. Arch Surg. 2010 Aug;145(8): 715-6. PMID: 20713920

McQueen KA. Anesthesia and the global burden of surgical disease. Int Anesthesiol Clin. 2010 Spring;48(2): 91-107. PMID: 20386230

Doull L, Campbell F. Human resources for health in fragile states. Lancet. 2008 Feb 23;371(9613): 626-7. PMID: 18295006

Cherian MN, Merry AF, Wilson IH. The World Health Organization and anaesthesia. Anaesthesia. 2007 Dec;62 Suppl 1: 65-6. PMID: 17937717


The World Health Organization has been involved in a wide range of global healthcare initiatives for many years. Recently an initiative ‘Safe Surgery Saves Lives’ has been launched to improve the safety of surgery throughout the world. Safe anaesthesia is a key component to achieving this aim.



Mock CN, Donkor P, Gawande A, Jamison DT, Kruk ME, Debas HT; DCP3 Essential Surgery Author Group. Essential surgery: key messages from Disease Control Priorities, 3rd edition. Lancet. 2015 May 30;385(9983): 2209-19. PMID: 25662414


The World Bank will publish the nine volumes of Disease Control Priorities, 3rd edition, in 2015-16. Volume 1–Essential Surgery–identifies 44 surgical procedures as essential on the basis that they address substantial needs, are cost effective, and are feasible to implement. This report summarises and critically assesses the volume’s five key findings. First, provision of essential surgical procedures would avert about 1×5 million deaths a year, or 6-7% of all avertable deaths in low-income and middle-income countries. Second, essential surgical procedures rank among the most cost effective of all health interventions. The surgical platform of the first-level hospital delivers 28 of the 44 essential procedures, making investment in this platform also highly cost effective. Third, measures to expand access to surgery, such as task sharing, have been shown to be safe and effective while countries make long-term investments in building surgical and anaesthesia workforces. Because emergency procedures constitute 23 of the 28 procedures provided at first-level hospitals, expansion of access requires that such facilities be widely geographically diffused. Fourth, substantial disparities remain in the safety of surgical care, driven by high perioperative mortality rates including anaesthesia-related deaths in low-income and middle-income countries. Feasible measures, such as WHO’s Surgical Safety Checklist, have led to improvements in safety and quality. Fifth, the large burden of surgical disorders, cost-effectiveness of essential surgery, and strong public demand for surgical services suggest that universal coverage of essential surgery should be financed early on the path to universal health coverage. We point to estimates that full coverage of the component of universal coverage of essential surgery applicable to first-level hospitals would require just over US$3 billion annually of additional spending and yield a benefit-cost ratio of more than 10: 1. It would efficiently and equitably provide health benefits, financial protection, and contributions to stronger health systems.



Cherian MN, Noel L, Buyanjargal Y, Salik G. Essential emergency surgical, procedures in resource-limited facilities: a WHO workshop in Mongolia. World Hosp Health Serv. 2004;40(4): 24-9. PMID: 15751550


A WHO ‘Training of Trainers’ workshop on essential emergency surgical procedures was organised in collaboration with the Ministry of Health, Mongolia. The participants included doctors and nurses from the six selected aimags (provinces). Facilitators of the workshop included experts from the Faculty of Health Science University, Mongolian Surgeon’s Association and Mongolian Association of Anaesthesiologists association with the Swiss Surgical Team of the International College of Surgeons, Surgical Department of Nurse’s College, Trauma Orthopaedic Clinical Hospital, the Department of Quality Assurance of the Directorate of Medical Services, Ministry of Health. Facilitators from the Hospital University of Geneva, Geneva Foundation of Medical Education and Research (RHR) and Evidence and Information for Policy in Geneva, Switzerland participated via video link. The workshop included lectures, discussions, role playing and ‘hands on’ basic skills training. Videoconference and e-learning sessions using the WHO e-learning tools were conducted at the Global Development Learning Centre. The topics covered during this training workshop included team responsibility and organisation in a health care facility; patient safety; disaster planning; appropriate use of oxygen; management of bleeding, burns and trauma; basic anaesthetic and resuscitation techniques; prevention of HIV transmission; sterilisation of equipment; waste disposal; hygiene; record keeping, monitoring and evaluation of quality of care and checklists prior to surgery to assure that the correct patient gets the correct surgery on the correct side at the correct time. Recommendations were made by the participants on the next steps after this training.

∧Back to top

Hospital and clinical facilities

[see also Lancet Commission; Global burden of surgical disease]


Lyon CB, Merchant AI, Schwalbach T, Pinto EF, Jeque EC, McQueen KA. Anesthetic Care in Mozambique. Anesth Analg. 2016;122: 1634-9PMID: 26983052


BACKGROUND: The World Bank and Lancet Commission in 2015 have prioritized surgery in Low-Income Countries (LIC) and Lower-Middle Income Countries (LMICs). This is consistent with the shift in the global burden of disease from communicable to noncommunicable diseases over the past 20 years. Essential surgery must be performed safely, with adequate anesthesia monitoring and intervention. Unfortunately, a huge barrier to providing safe surgery includes the paucity of an anesthesia workforce. In this study, we qualitatively evaluated the anesthesia capacity of Mozambique, a LIC in Africa with limited access to anesthesia and safe surgical care. Country-based solutions are suggested that can expand to other LIC and LMICs.

METHODS: A comprehensive review of the Mozambique anesthesia system was conducted through interviews with personnel in the Ministry of Health (MOH), a school of medicine, a public central referral hospital, a general first referral hospital, a private care hospital, and leaders in the physician anesthesia community. Personnel databases were acquired from the MOH and Maputo Central Hospital.

RESULTS: Quantitative results reveal minimal anesthesia capacity (290 anesthesia providers for a population of >25 million or 0.01: 10,000). The majority of physician anesthesiologists practice in urban settings, and many work in the private sector. There is minimal capacity for growth given only 1 Mozambique anesthesia residency with inadequate resources. The most commonly perceived barriers to safe anesthesia in this critical shortage are lack of teachers, lack of medical student interest in and exposure to anesthesia, need for more schools, low allocation to anesthesia from the list of available specialist prospects by MOH, and low public payments to anesthesiologists. Qualitative results show assets of a good health system design, a supportive environment for learning in the residency, improvement in anesthetic care in past decades, and a desire for more educational opportunities and teachers.

CONCLUSIONS: Mozambique has a strong health system design but few resources for surgery and safe anesthesia. At present, similar to other LICs, human resources, access to essential medicines, and safety monitoring limit safe anesthesia in Mozambique


Firth P, Ttendo S. Intensive care in low income settings: A critical need. N Eng J Med. 2012; 267 (21): 1974‑1976. PMID: 23171093


Mbararra hospital, a major regional tertiary hospital in Uganda, has an ICU. Lack of access to early treatment means that many Ugandan patients present in critical condition, with late stages of disease. Many of these diseases are acute, isolated problems that are possible to cure. The leading causes of premature death in low‑income countries include obstetrical complications, traffic accidents, pneumonia, and malaria. In Mbarara, by contrast to resource-rich countries, the ICU functions largely as the site of basic rescue interventions for young patients who are acutely ill with curable diseases. The need for managing late presentations and critical illness is a sentinel for broader issues in the health system. Besides improved facilities, system improvements in education, access, physician emigration, are among the issues needing to be addressed.

∧Back to top

Legal considerations

[no entries]

∧Back to top

Maternal health / Maternal mortality

[see also Lancet Commission]


Tomta K, Maman FO, Agbétra N, Baeta S, Ahouangbévi S, Chobli M. Maternal deaths and anesthetics in the Lomé (Togo) University Hospital. Sante. 2003 Apr-Jun;13(2): 77-80. PMID: 14530117


AIM: To assess the results of anesthesia practices in a department particularly inadequately staffed with physicians specializing in anesthesiology.

SETTING AND METHODS: This six-month prospective study (from January through June 2002) took place in the anesthesiology/intensive care unit of the obstetrics and gynecology department of Lomé University Hospital Center. A case report file was completed for each patient, and all anesthetics administered in the obstetrical department (labor and delivery room) were recorded and considered. We examined the perinatal deaths among women who underwent surgery.

RESULTS: Anesthetics were administered to 318 women during cesarean delivery (306) and uterine scar repair (12). Nearly all patients (98%) were classified in categories 1 or 2 of the ASA physical status classification system (healthy or mild systemic disease). General anesthesia was induced in 95.9% of the women and spinal bloc used for 4.1%. Thiopental was used most often, and certain drugs, including succinylcholine and ephedrine, were not available as needed. Intraoperative monitoring was essentially nonexistent. Emergency situations accounted for 89.6% of these surgical procedures. Of the 16 cases requiring transfusions, an inadequate supply of blood products or the patient’s inability to obtain blood was reported in 14 of the cases. Twelve deaths occurred, for a mortality rate among surgical patients of 3.8%. The principal causes of death were respiratory complications of anesthesia and of pregnancy-related toxemia and the unavailability of hypertonic solutions and blood products.

CONCLUSION: The results of this survey show that anesthetics play a role in maternal mortality in Togo. Good practice guidelines adapted to this setting must therefore be developed.



Mavalankar D, Singh A, Bhat R, Desai A, Patel SR. Indian public-private partnership for skilled birth-attendance. Lancet. 2008 Feb 23;371(9613): 631-2. PMID: 18295010

Tumwebaze J. Lamula’s story. Anaesthesia. 2007 Dec;62 Suppl 1: 4. PMID: 17937705

Starrs AM. Delivering for women. Lancet. 2007 Oct 13;370(9595): 1285-7. PMID: 17933629

Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014 Sep 13;384(9947): 980-1004. PMID: 24797575


BACKGROUND: The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 live births) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.

METHODS: We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.

FINDINGS: 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0×3% (-1×1 to 0×6) from 1990 to 2003, and -2×7% (-3×9 to -1×5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0×4% (0×2-0×6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956×8 (685×1-1262×8) in South Sudan to 2×4 (1×6-3×6) in Iceland.

INTERPRETATION: Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.

FUNDING: Bill & Melinda Gates Foundation.



Hill K, Thomas K, AbouZahr C, Walker N, Say L, Inoue M, Suzuki E; Maternal Mortality Working Group. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet. 2007 Oct 13;370(9595): 1311-9. PMID: 17933645


BACKGROUND: Maternal mortality, as a largely avoidable cause of death, is an important focus of international development efforts, and a target for Millennium Development Goal (MDG) 5. However, data weaknesses have made monitoring progress problematic. In 2006, a new maternal mortality working group was established to develop improved estimation methods and make new estimates of maternal mortality for 2005, and to analyse trends in maternal mortality since 1990.

METHODS: We developed and used a range of methods, depending on the type of data available, to produce comparable country, regional, and global estimates of maternal mortality ratios for 2005 and to assess trends between 1990 and 2005.

FINDINGS: We estimate that there were 535,900 maternal deaths in 2005, corresponding to a maternal mortality ratio of 402 (uncertainty bounds 216-654) deaths per 100,000 live births. Most maternal deaths in 2005 were concentrated in sub-Saharan Africa (270,500, 50%) and Asia (240,600, 45%). For all countries with data, there was a decrease of 2.5% per year in the maternal mortality ratio between 1990 and 2005 (p<0.0001); however, there was no evidence of a significant reduction in maternal mortality ratios in sub-Saharan Africa in the same period.

INTERPRETATION: Although some regions have shown some progress since 1990 in reducing maternal deaths, maternal mortality ratios in sub-Saharan Africa have remained very high, with little evidence of improvement in the past 15 years. To achieve MDG5 targets by 2015 will require sustained and urgent emphasis on improved pregnancy and delivery care throughout the developing world.

 ∧Back to top 

Pediatric critical care / Neonatal resuscitation


Little G, Niermeyer S, Singhal N, Lawn J, Keenan W. Neonatal resuscitation: a global challenge. Pediatrics. 2010 Nov;126(5): e1259-60. PMID: 2097478

Embu HY, Yiltok SJ, Isamade ES, Nuhu SI, Oyeniran OO, Uba FA. Paediatric admissions and outcome in a general intensive care unit [in Jos, Nigeria]. Afr J Paediatr Surg. 2011 Jan-Apr;8(1): 57-61. PMID: 21478588


BACKGROUND: It is believed that intensive care greatly improves the prognosis for critically ill children and that critically ill children admitted to a dedicated Paediatric Intensive Care Unit (PICU) do better than those admitted to a general intensive care unit (ICU).

METHODS: A retrospective study of all paediatric (< 16 years) admissions to our general ICU from January 1994 to December 2007.

RESULTS: Out of a total of 1364 admissions, 302 (22.1%) were in the paediatric age group. Their age ranged from a few hours old to 15 years with a mean of 4.9 ” 2.5 years. The male: female ratio was 1.5: 1. Postoperative admissions made up 51.7% of the admissions while trauma and burn made up 31.6% of admissions. Medical cases on the other hand constituted 11.6% of admissions. Of the 302 children admitted to the ICU, 193 were transferred from the ICU to other wards or in some cases other hospitals while 109 patients died giving a mortality rate of 36.1%. Mortality was significantly high in post-surgical paediatric patients and in patients with burn and tetanus. The length of stay (LOS) in the ICU ranged from less than one day to 56 days with a mean of 5.5 days.

CONCLUSION: We found an increasing rate of paediatric admissions to our general ICU over the years. We also found a high mortality rate among paediatric patients admitted to our ICU. The poor outcome in paediatric patients managed in our ICU appears to be a reflection of the inadequacy of facilities. Better equipping our ICUs and improved man-power development would improve the outcome for our critically ill children. Hospitals in our region should also begin to look into the feasibility of establishing PICUs in order to further improve the standard of critical care for our children.

  ∧Back to top

Pediatric surgery


Sekabira J. Paediatric surgery in Uganda. J Pediatr Surg. 2015 Feb;50(2): 236-9. PMID: 25638609


The Hugh Greenwood Lecture acknowledges the extremely generous support from Mr Greenwood that has enabled the BAPS to establish funds to advance paediatric surgical training in developing countries. In this Inaugural Lecture, Dr. Sekabira, the first Hugh Greenwood Fellow, describes the influence that this has had on his career and reviews the state of paediatric surgery in Uganda.

 ∧Back to top 

Resident and student electives abroad

[see also Education projects / distance learning]


Khan OA, Guerrant R, Sanders J, Carpenter C, Spottswood M, Jones DS, O’Callahan C, et al. Global health education in U.S. medical schools. BMC Med Educ. 2013 Jan 18;13: 3. PMID: 23331630


Interest in global health (GH) among medical students worldwide is measurably increasing. There is a concomitant emphasis on emphasizing globally-relevant health professions education. Through a structured literature review, expert consensus recommendations, and contact with relevant professional organizations, we review the existing state of GH education in US medical schools for which data were available. Several recommendations from professional societies have been developed, along with a renewed emphasis on competencies in global health. The implementation of these recommendations was not observed as being uniform across medical schools, with variation noted in the presence of global health curricula. Recommendations for including GH in medical education are suggested, as well as ways to formalize GH curricula, while providing flexibility for innovation and adaptation.



Bryant JH, Velji A. Global health and the role of universities in the twenty-first century. Infect Dis Clin North Am. 2011 Jun;25(2): 311-21. PMID: 21628047


A vast gap exists between knowledge, generation of knowledge, and the application of knowledge to the needs and benefit of the global population. In middle-income and lower-income countries, universities are becoming more engaged with the communities in which they are located to try to solve the difficult problems of poverty and poor health. Global collaborations and reform of medical education in the twenty-first century will help move universities out of cloistered academic settings and into the community to bring the changes needed to equitably meet the health needs of all.



Suchdev PS, Shah A, Derby KS, Hall L, Schubert C, Pak-Gorstein S, et al. Acad Pediatr. A proposed model curriculum in global child health for pediatric residents. 2012 May-Jun;12(3): 229-37. PMID: 22484282


OBJECTIVE: In response to the increasing engagement in global health (GH) among pediatric residents and faculty, academic GH training opportunities are growing rapidly in scale and number. However, consensus to guide residency programs regarding best practice guidelines or model curricula has not been established. We aimed to highlight critical components of well-established GH tracks and develop a model curriculum in GH for pediatric residency programs.

METHODS: We identified 43 existing formal GH curricula offered by U.S. pediatric residency programs in April 2011 and selected 8 programs with GH tracks on the basis of our inclusion criteria. A working group composed of the directors of these GH tracks, medical educators, and trainees and faculty with GH experience collaborated to develop a consensus model curriculum, which included GH core topics, learning modalities, and approaches to evaluation within the framework of the competencies for residency education outlined by the Accreditation Council for Graduate Medical Education.

RESULTS: Common curricular components among the identified GH tracks included didactics in various topics of global child health, domestic and international field experiences, completion of a scholarly project, and mentorship. The proposed model curriculum identifies strengths of established pediatric GH tracks and uses competency-based learning objectives.

CONCLUSIONS: This proposed pediatric GH curriculum based on lessons learned by directors of established GH residency tracks will support residency programs in creating and sustaining successful programs in GH education. The curriculum can be adapted to fit the needs of various programs, depending on their resources and focus areas. Evaluation outcomes need to be standardized so that the impact of this curriculum can be effectively measured.



Jayaraman SP, Ayzengart AL, Goetz LH, Ozgediz D, Farmer DL. Global health in general surgery residency: a national survey. J Am Coll Surg. 2009 Mar;208(3): 426-33. PMID: 19318005


BACKGROUND: Interest in global health during postgraduate training is increasing across disciplines. There are limited data from surgery residency programs on their attitudes and scope of activities in this area. This study aims to understand how global health education fits into postgraduate surgical training in the US.

STUDY DESIGN: In 2007 to 2008, we conducted a nationwide survey of program directors at all 253 US general surgery residencies using a Web-based questionnaire modified from a previously published survey. The goals of global health activities, type of activity (ie, clinical versus research), and challenges to establishing these programs were analyzed.

RESULTS: Seventy-three programs responded to the survey (29%). Of the respondents, 23 (33%) offered educational activities in global health and 86% (n = 18) of these offered clinical rotations abroad. The primary goals of these activities were to prepare residents for a career in global health and to improve resident recruitment. The greatest barriers to establishing these activities were time constraints for faculty and residents, lack of approval from the Accreditation Council for Graduate Medical Education and Residency Review Committee, and funding concerns. Lack of interest at the institution level was listed by only 5% of program directors. Of the 47 programs not offering such activities, 57% (n = 27) were interested in establishing them.

CONCLUSIONS: Few general surgery residency programs currently offer clinical or other educational opportunities in global health. Most residencies that responded to our survey are interested in such activities but face many barriers, including time constraints, Residency Review Committee restrictions, and funding.



Evans F, Mallepally R, Dubowitz G, Vasilopoulos, T, McClain C, Enneking K. Influencing Anesthesia Residency Selection: Impact of Global Health Opportunities. Can J Anaesth.


PURPOSE: There is growing evidence to suggest that the current generation of medical students and young physicians is interested in global health. However, there are few data on the interest in global health by students pursuing a career in anesthesiology. The objective of this survey was to evaluate the importance of global health opportunities in regard to applicants’ choice of anesthesiology residency programs.

METHODS: Anesthesiology residency program directors in the United States were invited to distribute an online survey to recently matched residents. To reduce study bias, the survey included a wide selection of reasons for program choices in addition to global health. Participants were asked to rate independently, on a scale of 1 to 10 (1 = least important, 10 = most important), the importance that each factor had on their selection of an anesthesiology residency program.

RESULTS: Of the 117 U.S. anesthesiology programs contacted, 87 (74%) distributed the survey. Completed surveys were obtained from 582 of 1,092 (53%) polled participants. All factors assessed were rated between 5 and 9 and the global health median [interquartile range] rating was 6 [3-7]. Nearly half of the survey respondents were interested in incorporating global health into future careers. More than three-quarters reported being interested in participating in, or reading about, global health activities during their residency. Responders with previous global health experience, or who were interested in an “in-country” experience, were more likely to choose programs that had global health opportunities available during residency.

CONCLUSIONS: Anesthesia residency program applicants are interested in global health. Having a global health opportunity was an important reason for choosing a residency program, comparable to some more traditional factors. Regardless of previous global health experience, the majority of future anesthesia residents are either planning or considering participation in global health activities during or after training.



Dumbarton, TC, Bould, MD. Thinking globally, training locally [Editorial]. Can J Anaesth. 2016; PMID 270302

∧Back to top

Short-term missions – Ethical considerations


DeCamp M. Ethical review of global short-term medical volunteerism. HEC Forum. 2011 Jun;23(2): 91-103. PMID: 21604023


Global short-term medical volunteerism is growing, and properly conducted, is a tool in the fight for greater global health equity. It is intrinsically “ethical” (i.e., it involves ethics at every step) and depends upon ethical conduct for its success. At present, ethical guidelines remain in their infancy, which presents a unique opportunity. This paper presents a set of basic ethical principles, building on prior work in this area and previously developed guidelines for international clinical research. The content of these principles, and the benchmarks used to evaluate them, remain intentionally vague and can only be filled by collaboration with those on-the-ground in local communities where this work occurs. Ethical review must additionally take into consideration the different obligations arising from the type of institution, type of intervention, and type of relationship involved. This paper argues that frequent and formalized ethical review, conducted from the beginning with the local community (where this community helps define the terms of debate), remains the most important ethical safeguard for this work.



Philpott J. Training for a global state of mind. Virtual Mentor. 2010 Mar 1;12(3): 231-6. PMID: 2314087


At a meeting with a group of postgraduate medical trainees at the University of Toronto, I asked them to brainstorm a list of reasons why students or universities want to be involved in global health education (see table 1). Then we tried to assign them to one of three categories:

1.  Motivations I’d rather suppress

2. Motivations I can tolerate

3. Motivations to which I aspire

I suspect that it is the absence of a global state of mind that has driven an uprising of sorts on the part of medical trainees demanding global health curricula…Young students have recognized the limitations of a biomedical framework that focuses primarily on the health needs of the world’s wealthiest citizens. They also appreciate the collaborative, reciprocal learning that occurs when they interact with patients and colleagues from other cultures and locations…the goal is not to teach or study global health as a distinct subject or skill-set. But every topic of medicine needs to be reconsidered from a global perspective.



Crump JA, Sugarman J; Working Group on Ethics Guidelines for Global Health Training (WEIGHT). Ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg. 2010 Dec;83(6): 1178-82. PMID: 21118918


Academic global health programs are growing rapidly in scale and number. Students of many disciplines increasingly desire global health content in their curricula. Global health curricula often include field experiences that involve crossing international and socio-cultural borders. Although global health training experiences offer potential benefits to trainees and to sending institutions, these experiences are sometimes problematic and raise ethical challenges. The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) developed a set of guidelines for institutions, trainees, and sponsors of field-based global health training on ethics and best practices in this setting. Because only limited data have been collected within the context of existing global health training, the guidelines were informed by the published literature and the experience of WEIGHT members. The Working Group on Ethics Guidelines for Global Health Training encourages efforts to develop and implement a means of assessing the potential benefits and harms of global health training programs.



Asgary R, Junck E. New trends of short-term humanitarian medical volunteerism: professional and ethical considerations. J Med Ethics. 2013 Oct;39(10): 625-31. PMID: 23236086


Short-term humanitarian medical volunteerism has grown significantly among both clinicians and trainees over the past several years. Increasingly, both volunteers and their respective institutions have faced important challenges in regard to medical ethics and professional codes that should not be overlooked. We explore these potential concerns and their risk factors in three categories: ethical responsibilities in patient care, professional responsibility to communities and populations, and institutional responsibilities towards trainees. We discuss factors increasing the risk of harm to patients and communities, including inadequate preparation, the use of advanced technology and the translation of Western medicine, issues with clinical epidemiology and test utility, difficulties with the principles of justice and clinical justice, the lack of population-based medicine, sociopolitical effects of foreign aid, volunteer stress management, and need for sufficient trainee supervision. We review existing resources and offer suggestions for future skill-based training, organisational responsibilities, and ethical preparation.



DeCamp M. Scrutinizing global short-term medical outreach. Hastings Cent Rep. 2007 Nov-Dec;37(6): 21-3. PMID: 18179101


Well-designed research asks questions that are appropriate, answerable, and affordable; well-designed outreach should do the same. The benefits…must be balanced against potential harm resulting from the trip. Harms, of course, figure prominently in discussions of research ethics. Unfortunately, just as little guidance exists on how to consider the benefits of an outreach trip, precious little exists on what harms might occur as a result of the outreach or on how to deal with them.

Ethical issues in medical outreach are often left to individuals’ professional guidelines. We reject this approach for clinical trials in developing countries; we should also reject it for outreach.



Schein M. Seven sins of humanitarian medicine. World J Surg. 2010 Mar;34(3): 471-2. PMID: 2017530

Stone GS, Olson KR. The Ethics of Medical Volunteerism. Med Clin North Am. 2016 Mar;100(2): 237-46.

PMID: 26900110


Responding to disparities in health, thousands of health care providers volunteer annually for short-term medical service trips (MSTs) to serve communities in need as a result of environmental, geographic, historical, or sociopolitical factors. Although well intentioned, short-term MSTs have the potential to benefit and harm those involved, including participants and communities being served. The contexts, resource and time limitations, and language and cultural barriers present ethical challenges. There have been increasing requests for standardized global guidelines, transparency, and open review of MSTs and their outcomes. Principles of mission, partnership, preparation, reflection, support, sustainability, and evaluation inform and equip those engaging in medical volunteerism.



O’Neil E Jr. The “Ethical Imperative” of global health service. Virtual Mentor. 2006 Dec 1;8(12): 846-50. PMID: 23241546

Prah Ruger J. Good medical ethics, justice and provincial globalism. J Med Ethics. 2015 Jan;41(1): 103-6. PMID: 25516948


The summer 2014 Ebola virus outbreak in Western Africa illustrates global health’s striking inequalities. Globalisation has also increased pandemics, and disparate health system conditions mean that where one falls ill or is injured in the world can mean the difference between quality care, substandard care or no care at all, between full recovery, permanent ill effects and death. Yet attention to the normative underpinnings of global health justice and distribution remains, despite some important exceptions, inadequate in medical ethics, bioethics and political philosophy. We need a theoretical foundation on which to build a more just world. Provincial globalism (PG), grounded in capability theory, offers a foundation; it provides the components of a global health justice framework that can guide implementation. Under PG, all persons possess certain health entitlements. Global health justice requires progressively securing this health capabilities threshold for every person.



Ott BB, Olson RM. Ethical issues of medical missions: the clinicians’ view. HEC Forum. 2011 Jun;23(2): 105-13. PMID: 21598049


Surgery is an important part of health care worldwide. Without access to surgical treatments, morbidity and mortality increase. Access to surgical treatment is a significant problem in global public health because surgical services are not equally distributed in the world. There is a disproportionate scarcity of surgical access in low-income countries. There are many charitable organizations around the world that sponsor surgical missions to underserved nations. One such organization is Operation Smile International, a group with which both authors have volunteered. This paper will describe the purpose and processes involved in Operation Smile and identify some of the key ethical issues that arise in short term medical volunteer work highlighting the importance of sustainability.



Holt GR. Ethical conduct of humanitarian medical missions: I. Informed Consent. Arch Facial Plast Surg. 2012 May-Jun;14(3): 215-7. PMID: 22596265


Altruistic and socially conscious physicians are dedicating a portion of their professional lives to humanitarian relief of disadvantaged populations in increasing numbers. These efforts are primarily carried out through short-term medical missions(STMMs) throughout the international community.(1) There is a great deal of professional and personal reward to physicians who participate in medical missions, and their experiences as related to colleagues may serve to encourage others to participate as well. Indeed, there is an increasing interest in, and enthusiasm for, medical students to participate in international volunteer electives during medical school, particularly in developing countries. Their positive experiences often shape their future commitment to volunteerism as a physician.



Wall A. The Context of Ethical Problems in Medical Volunteer Work. Hec Forum 2011;23(2): 79-90. PMID 21604022


Ethical problems are common in clinical medicine, so medical volunteers who practice clinical medicine in developing countries should expect to encounter them just as they would in their practice in the developed world. However, as this article argues, medical volunteers in developing countries should not expect to encounter the same ethical problems as those that dominate Western biomedicine or to address ethical problems in the same way as they do in their practice in developed countries. For example, poor health and advanced disease increase the risks and decrease the potential benefits of some interventions. Consequently, when medical volunteers intervene too readily, without considering the nutritional and general health status of patients, the results can be devastating. Medical volunteers cannot assume that the outcomes of interventions in developing countries will be comparable to the outcomes of the same interventions in developed countries. Rather, they must realistically consider the complex medical conditions of patients when determining whether or not to intervene. Similarly, medical volunteers may face the question of whether to provide a pharmaceutical or perform an intervention that is below the acceptable standard of care versus the alternative of doing nothing. This article critically explores the contextual features of medical volunteer work in developing countries that differentiate it from medical practice in developed countries, arguing that this context contributes to the creation of unique ethical problems and affects the way in which these problems should be analyzed and resolved.



Wall A. Ethics in Global Surgery. World Journal of Surgery 2014;38(7): 1574‑1580. PMID: 24789014


Global surgery, while historically a small niche, is becoming a larger part of the global health enterprise. This article discusses the burden of global surgery, emphasizing the importance of addressing surgical needs in low‑ and middle‑income countries. It describes the barriers to surgical care in the developing world, the ethical challenges that these barriers create, and strategies to overcome these barriers. It emphasizes the crucial role of preparation for global surgical interventions as a way to maximize benefits as well as minimize harms and ethical challenges. It ends with the cautionary statement that preparation does not eliminate ethical problems, so surgical volunteers must be prepared not only for the technical challenges of global surgery but also for the ethical challenges.



Langowski MK, Iltis AS. Global health needs and the short-term medical volunteer: ethical considerations. HEC Forum. 2011 Jun;23(2): 71-8. PMID: 21761217

Wall LL. Ethical concerns regarding operations by volunteer surgeons on vulnerable patient groups: the case of women with obstetric fistulas. HEC Forum. 2011 Jun;23(2): 115-27. PMID: 21598050


By their very nature, overseas medical missions (and even domestic medical charities such as “free clinics”) are designed to serve “vulnerable populations.” If these groups were capable of protecting their own interests, they would not need the help of medical volunteers: their medical needs would be met through existing government health programs or by utilizing their own resources. Medical volunteerism thus seems like an unfettered good: a charitable activity provided by well-meaning doctors and nurses who want to give of their time, skills, and resources to help those who would not otherwise be able to take care of their medical needs. In this article, I argue that if medical volunteerism is to be “good,” however, it must always meet certain basic ethical requirements. These requirements may be (and perhaps often are) overlooked in the rush to organize and carry out short-term medical missions. I illustrate my point with special reference to short-term medical missions designed to provide surgical repair of obstetric vesico-vaginal fistula, a condition in which the tissues that normally separate the bladder from the vagina are destroyed by obstetric trauma, leading to continuous and unremitting incontinence in the affected woman.


Dunn M. A global affair. J Med Ethics. 2013 Oct;39(10): 601-2. PMID: 24051413

∧Back to top

Short-term missions – Impact and long-term outcomes


Froese A. Anesthesia and the role of short-term service delivery in developing countries. Can J Anaesth. 2007 Nov;54(11): 940-6. PMID: 17975241


PURPOSE: To clarify the ongoing need for involvement of anesthesiologists in short-term surgical projects in developing countries, and provide information to guide the selection of, application for, and preparation for these rewarding experiences.

OBSERVATIONS: The lack of safe anesthesia services severely limits the performance of needed surgical procedures in developing countries around the world. Even in countries where well-trained anesthesiologists are available in major urban centres, resources are often absent or limited for large numbers of people in rural or remote areas. Anesthesiologists are highly sought members of surgical teams. Internet sites provide extensive project information. Projects occur in Central and South America, Africa, Asia and Eastern Europe. Projects can bring specialized surgical expertise to an otherwise well-serviced urban area, or work in remote areas that have surgical services only when a team comes. Available equipment, drugs, housing, food and transportation vary markedly with project site. Flexibility, adaptability and problem-solving skills are essential. Translators provide language assistance. Anesthesiologists who have experience providing anesthetics in settings with less technological support can assist other anesthesiologists in adapting to less sophisticated settings.

CONCLUSIONS: Severe shortages of trained health professionals plague developing countries, reflecting complex economic and political problems that will require decades for resolution. Until such time as surgical services are widely available and affordable in remote as well as urban areas of developing countries, anesthesiologists will continue to provide a valuable and personally rewarding contribution through short-term assistance.



Horlbeck D, Boston M, Balough B, Sierra B, Saenz G, Heinichen J, et al. Humanitarian otologic missions: long-term surgical results. Otolaryngol Head Neck Surg. 2009 Apr;140(4): 559-65. PMID: 19328347


OBJECTIVE: The purpose of this study was to determine the efficacy of treating chronic ear disease by performing a single surgical intervention in the austere environment of a developing nation.

SUBJECTS AND METHODS: Data were collected from retrospective chart reviews on 121 patients who underwent surgical treatment of chronic ear disease during humanitarian surgical missions in South and Central America. Surgical outcomes and clinical course were assessed at 10 to 12 months after the initial surgery.

RESULTS: A total of 117 patients were included in the study. Follow-up records were available for 75 patients (64%). A total of 20 surgeries were performed for dry perforations (group 1), 30 for chronically draining ears (group 2), and 25 for cholesteatomas (group 3). Surgical success was determined as 60 percent, 74 percent, and 92 percent for groups 1, 2, and 3, respectively.

CONCLUSIONS: Surgical results during international otologic outreach missions to developing nations fall within the results expected in developed nations.



Martiniuk AL, Manouchehrian M, Negin JA, Zwi AB. Brain Gains: a literature review of medical missions to low and middle-income countries. BMC Health Serv Res. 2012 May 29;12: 134. PMID: 22643123


BACKGROUND: Healthcare professionals’ participation in short-term medical missions to low and middle income countries (LMIC) to provide healthcare has become common over the past 50 years yet little is known about the quantity and quality of these missions. The aim of this study was to review medical mission publications over 25 years to better understand missions and their potential impact on health systems in LMICs.

METHODS: A literature review was conducted by searching Medline for articles published from 1985-2009 about medical missions to LMICs, revealing 2512 publications. Exclusion criteria such as receiving country and mission length were applied, leaving 230 relevant articles. A data extraction sheet was used to collect information, including sending/receiving countries and funding source.

RESULTS: The majority of articles were descriptive and lacked contextual or theoretical analysis. Most missions were short-term (1 day – 1 month). The most common sending countries were the U.S. and Canada. The top destination country was Honduras, while regionally Africa received the highest number of missions. Health care professionals typically responded to presenting health needs, ranging from primary care to surgical relief. Cleft lip/palate surgeries were the next most common type of care provided.

CONCLUSIONS: Based on the articles reviewed, there is significant scope for improvement in mission planning, monitoring and evaluation as well as global and/or national policies regarding foreign medical missions. To promote optimum performance by mission staff, training in such areas as cross-cultural communication and contextual realities of mission sites should be provided. With the large number of missions conducted worldwide, efforts to ensure efficacy, harmonisation with existing government programming and transparency are needed.



Farmer D. The Need for Sustainability in Contemporary Global Health Efforts. Arch Surg. 2010;145(8): 752‑753

∧Back to top

Standards of care / QA

[see also: Lancet Commission]


Adhikari NK. Patient safety without borders: measuring the global burden of adverse events. BMJ Qual Saf. 2013 Oct;22(10): 798-801. PMID: 23996095

Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth. 2010 Nov;57(11): 1027-34. PMID: 20857254

Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. An iterative process of global quality improvement: the International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth. 2010 Nov;57(11): 1021-6. PMID: 20857255


PURPOSE: To enhance patient safety through contemporaneous and comprehensive standards for a safe practice of anesthesia that augment, enhance, and support similar standards already published by various countries and that provide a resource for countries that have yet to formulate such standards.

STANDARDS DEVELOPMENT: The Safe Anesthesia Working Group of the World Health Organization’s “Safe Surgery Saves Lives” global initiative updated the 1992 International Standards for the Safe Practice of Anaesthesia (Standards) through an iterative process of literature review, consultation, debate, drafting, and refinement. These Standards address, in detail, the organization, support, practices, and infrastructure for anesthesia care. The Standards are grounded in the fundamental principle of safety in anesthesia, i.e., the continuous presence of an appropriately trained, vigilant anesthesia professional. In effect, the use of pulse oximetry during anesthesia is now considered mandatory, with acknowledgement that compromise may be unavoidable in emergencies. At the World Congress of Anaesthesiologists in 2008, drafts were presented for comment, further refinements were made, and the Revised Standards were adopted by the World Federation of Societies of Anaesthesiologists (WFSA). These Revised Standards were posted on the WFSA website for further feedback, and minor revisions followed. The International Standards for a Safe Practice of Anesthesia 2010 were endorsed by the Executive Committee of the WFSA in March 2010. Ongoing periodic revision is planned.

CONCLUSION: While they are universally applicable, the 2010 Standards primarily target lesser-resourced areas. They are designed particularly for regions that have yet to formulate or adopt their own standards so as to promote optimum patient outcomes in every anesthetizing location in the world.



Ouro-Bang’na Maman AF, Tomta K, Ahouangbévi S, Chobli M. Deaths associated with anaesthesia in Togo, West Africa. Trop Doct. 2005 Oct;35(4): 220-2. PMID: 16354475


This study attempts to determine the anaesthetic death rate, the causes of deaths and the avoidable mortality rate (AMR) in consecutive cases. The number of anaesthetics given was 1464: 30 cases died within 24 h. The incidence of 24-h perioperative deaths per 100 anaesthetics was 2.57. In all, 50% of deaths were observed in obstetric surgery; 47% of deaths were associated with cardiovascular management, 30% with respiratory management; 93% of deaths were identified as avoidable. The AMR was 1.5% (anaesthetic AMR: 0.75%, administrative AMR: 0.68%, surgical AMR: 0.07%). Insufficient or no blood available is the only factor for administrative AMR.



Enohumah KO, Imarengiaye CO. Factors associated with anaesthesia-related maternal mortality in a tertiary hospital in Nigeria. Acta Anaesthesiol Scand. 2006 Feb;50(2): 206-10. PMID: 16430543


BACKGROUND: Maternal mortality related to anaesthesia is low compared with that resulting from obstetric factors in developed countries. The role of anaesthesia in maternal mortality in developing countries is obscure. The purposes of this study were to determine the incidence of maternal mortality related to anaesthesia, to analyse the causes and to suggest measures to improve anaesthetic safety for parturients.

METHODS: The hospital surgical registry was reviewed from 1 January 1991 to 31 December 2000 to identify patients who had undergone surgical procedures in pregnancy or puerperium. Data were obtained from the surgical registry in the Labour and Delivery Suite, Intensive Care Unit records and maternal mortality database to determine the demographic characteristics and anaesthetic technique. Maternal mortality after surgical procedures was further scrutinized to evaluate the anaesthetic care and the contribution of anaesthesia to mortality.

RESULTS: A total of 12,394 deliveries occurred in the hospital during the period under review. Caesarean section accounted for 2323 deliveries (18.7%). Eighty-four maternal mortalities were recorded, with a maternal mortality rate of 678 per 100,000 deliveries. Infection, haemorrhage, pre-eclampsia/eclampsia and anaesthesia were the leading causes of maternal mortality. Anaesthesia was the sole cause of six maternal deaths. The patients received general anaesthesia for the surgical procedure.

CONCLUSION: Difficult airway management during general anaesthesia, inadequate supervision of trainee anaesthetists and a lack of appropriate monitors were the major anaesthetic reasons for maternal mortality. Recommendations have been made to ensure that parturients and the unborn child receive the best anaesthetic care attainable in the hospital.

∧Back to top

Trauma and Non-communicable Diseases


Dagal A, Greer SE, McCunn M. International disparities in trauma care. Curr Opin Anesthesiol 2014, 27: 233–239

Purpose of review: Trauma care has been a low priority topic in the global health agenda until recently, despite its socialand economic impact. Although prevention is the key, provision and quality of trauma care has been the weakest link in the survival chain. We aim to summarize the differences in global trauma care to propose solutions in this article.

Recent findings: Patients with life-threatening injuries are six times more likely to die following a trauma in a low-income country than in a high-income country. Unintentional injuries currently rank fourth in the global causes of death, resulting in 5.8 million premature deaths and millions more with disability. The WHO member countries started the first global Decade of Action for Road Safety 2011–2020 initiative in May 2011. Governments across the world agreed to take steps to improve the safety of roads and vehicles, enhance the behavior of all road users and strengthen post-trauma care.

Summary: Several core strategies have been identified: human resource planning; physical resources (equipment and supplies); and administration (quality improvement and data collection) need to be developed for effective and adaptable prehospital care, patient transfer, in-hospital care and rehabilitation systems for injured persons worldwide. Clear definition of the problem to propose solutions is critical.

∧Back to top

Training programs / University partnerships

[See also Resident/ student electives; and Education projects/distance learning]


Bould MD, Clarkin CL, Boet S, Pigford AA, Ismailova F, Measures E, McCarthy AE, Kinnear JA. Faculty experiences regarding a global partnership for anesthesia postgraduate training: a qualitative study. Can J Anaesth. 2015 Jan;62(1): 11-21. PMID: 25361621


PURPOSE: Partnerships for postgraduate medical education between institutions in high-income countries and low- and middle-income countries are increasingly common models that can create capacity in human resources for health. Nevertheless, data are currently limited to guide the development of this kind of educational program.

METHODS: We conducted semi-structured interviews with visiting and local faculty members in the externally supported University of Zambia Master of Medicine Anesthesia Program. Interviews were thematically analyzed with qualitative methodology.

RESULTS: Respondents spoke of differences in clinical practice, including resource limitations, organizational issues, presentation and comorbidities of patients, surgical techniques, and cultural issues relating to communication and teamwork. A key theme was communication amongst distributed visiting faculty. Infrequent face-to-face meetings jeopardized programmatic learning and the consistency of teaching and assessment. Co-learning was considered central to the development of a new program, as visiting faculty had to adapt to local challenges while establishing themselves as visiting experts. An ongoing challenge for faculty was determining when to adapt to the local context to facilitate patient care and when to insist on familiar standards of practice in order to advocate for patient safety.

CONCLUSIONS: As a new and evolving program, the findings from this study highlight challenges and opportunities for faculty as part of a partnership for postgraduate medical education. Since maintaining an effective faculty is essential to ensure the sustainability of any teaching program, this work may help other similar programs to anticipate and overcome potential challenges.



Enright A. Anesthesia training in Rwanda. Can J Anaesth. 2007 Nov;54(11): 935-9. PMID: 17975240


BACKGROUND: In 2006 a program leading to a Master’s degree in Anesthesia (MMed) was established in Rwanda as a joint venture between the National University of Rwanda (NUR), the Canadian Anesthesiologists’ Society International Education Fund (CASIEF) and the American Society of Anesthesiologists Overseas Teaching Programme (ASAOTP). A MMed in Anesthesia is similar to a Fellowship in Canada and is common in many African countries. Most training programs are of three years duration. Rwanda has decided on a four-year program.

PRINCIPAL FINDINGS: The background, organization and problems of the program are described. Challenges exist in recruiting residents and in developing an academic culture and evaluation system. Inadequate equipment and drug shortages limit the types of anesthesia provided. There is need for improvement in biomedical support. Volunteer Canadian and American anesthesiologists visit Rwanda to teach for a minimum period of one month. They instruct in the operating room and also in the classroom. While the focus of the program is on residents in anesthesia, the volunteers also teach the nurse anesthetists. The program has been in existence for only one year but progress has been made. The CASIEF will devote special attention to improving the management of pain.

CONCLUSIONS: In time, it is hoped that Rwanda will become self-sufficient in training its own anesthesiologists and in retaining them to provide anesthesia services throughout the country. As anesthesia and surgery evolve, there will be a need for subspecialty training in anesthesia. It is hoped that, with continued assistance from the CASIEF and ASAOTP, the goal of the NUR will be achieved.



Newton M, Bird P. Impact of parallel anesthesia and surgical provider training in sub-Saharan Africa: a model for a resource-poor setting. World J Surg. 2010 Mar;34(3): 445-52. PMID: 19727934


BACKGROUND: The lack of appropriate numbers of anesthesia and surgical care providers in many resource-poor countries around the world, especially in rural populations, prevents adequate care of the large numbers of patients who require surgery in these settings.

METHODS: This article provides a 10-year review of a rural hospital located in East Africa which developed a training program based on parallel training of anesthesia and surgical care providers. We report the process of building the foundational aspects of a customized medical education program that addresses specific concerns related to the work in a rural African context, which may be very different from medical care provided in the urban settings of low income countries (LIC). We analyzed how the parallel training can provide the clinical tools needed to have a practical impact on the surgical burden in rural Africa.

RESULTS: The parallel training program combining training of nurse-anesthetists with the training of multiple levels of surgical care providers, from interns to fellows, led to a fourfold increase in the number of surgical cases. Surgical subspecialty training and the development of an anesthesia care team with anesthesia consultant(s) oversight can serve to maintain a high level of complex and expanding surgical case volume in a rural African hospital setting.

CONCLUSIONS: This model can be applied to other similar situations in LIC, where the anesthesia and surgical care can be coupled and then customized for the unique clinical rural setting.



Garfunkel LC, Howard CR. Expand education in global health: it is time. Acad Pediatr. 2011 Jul-Aug;11(4): 260-2. PMID: 21764014

∧Back to top

Volunteer Preparation, Guidelines and Personal safety


Freedman DO, Chen LH, Kozarsky PE. Medical Considerations before International Travel. N Engl J Med. 2016 Jul 21;375(3):247-60. PMID: 27468061

Reviews prevention of a variety of travel-related illnesses, vaccines available, and chemoprophylaxis. The on-line supplementary materials provide interactive maps for 12 different infectious diseases, geographically-specific recommendations, and a list of useful URL references for further information. Article is free online at



Panosian C. Courting danger while doing good–protecting global health workers from harm. N Engl J Med. 2010 Dec 23;363(26): 2484-5. PMID: 21175310

Fisher QA, Politis GD, Tobias JD, Proctor LT, Samandari-Stevenson R, Roth A, et al. Pediatric anesthesia for voluntary services abroad. Anesth Analg. 2002 Aug;95(2): 336-50. PMID: 12145049

Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002 Apr 4;346(14): 1067-73. PMID: 1193247

Merchant R, Chartrand D, Dain S, Dobson G, Kurrek MM, Lagacé A, Stacey S, Thiessen B; Canadian Anesthesiologists’ Society. Guidelines to the Practice of Anesthesia–Revised Edition 2014. Can J Anaesth. 2014 Jan;61(1): 46-59. PMID: 24385228


OVERVIEW: The Guidelines to the Practice of Anesthesia Revised Edition 2014 (the guidelines) were prepared by the Canadian Anesthesiologists’ Society (CAS), which reserves the right to determine their publication and distribution. Because the guidelines are subject to revision, updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2014 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the society cannot guarantee any specific patient outcome. Each anesthesiologist should exercise his or her own professional judgment in determining the proper course of action for any patient’s circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.



Politis GD, Schneider WJ, Van Beek AL, Gosain A, Migliori MR, Gregory GA, et al. Guidelines for pediatric perioperative care during short-term plastic reconstructive surgical projects in less developed nations. Anesth Analg. 2011 Jan;112(1): 183-90. PMID: 21173208

Schneider WJ, Migliori MR, Gosain AK, Gregory G, Flick R; Volunteers in Plastic Surgery Committee of the American Society of Plastic Surgeons; Plastic Surgery Foundation. Volunteers in plastic surgery guidelines for providing surgical care for children in the less developed world: part II. Ethical considerations. Plast Reconstr Surg. 2011 Sep;128(3): 216e-222e. PMID: 21865995


BACKGROUND: Many international volunteer groups provide free reconstructive plastic surgery for the poor and underserved in developing countries. An essential issue in providing this care is that it meets consistent guidelines for both quality and safety-a topic that has been addressed previously. An equally important consideration is how to provide that care in an ethical manner. No literature presently addresses the various issues involved in making those decisions.

METHODS: With these ethical considerations in mind, the Volunteers in Plastic Surgery Committee of the American Society of Plastic Surgeons/Plastic Surgery Foundation undertook a project to create a comprehensive set of guidelines for volunteer groups planning to provide this type of reconstructive plastic surgery in developing countries. The committee worked in conjunction with the Society for Pediatric Anesthesia on this project.

RESULTS: The Board of the American Society of Plastic Surgeons/Plastic Surgery Foundation has approved the ethical guidelines created for the delivery of care in developing countries. The guidelines address the variety of ethical decisions that may be faced by a team working in an underdeveloped country. These guidelines make it possible for a humanitarian effort to anticipate the types of ethical decisions that are often encountered and be prepared to deal with them appropriately.

CONCLUSIONS: Any group seeking to undertake an international mission trip in plastic surgery should be able to go to one source to find a detailed discussion of the perceived needs in providing ethical humanitarian care. This document was created to satisfy that need and is a companion to our original guidelines addressing safety and quality.



Rutala WA, Weber DJ. Disinfection and sterilization in health care facilities: what clinicians need to know. Clin Infect Dis. 2004 Sep 1;39(5): 702-9. PMID: 15356786


All invasive procedures involve contact between a medical device or surgical instrument and a patient’s sterile tissue or mucous membranes. A major risk of all such procedures is the introduction of pathogenic microbes that could lead to infection. Failure to properly disinfect or sterilize reusable medical equipment carries a risk associated with breach of the host barriers. The level of disinfection or sterilization is dependent on the intended use of the object: critical items (such as surgical instruments, which contact sterile tissue), semicritical items (such as endoscopes, which contact mucous membranes), and noncritical items (such as stethoscopes, which contact only intact skin) require sterilization, high-level disinfection, and low-level disinfection, respectively. Cleaning must always precede high-level disinfection and sterilization. Users must consider the advantages and disadvantages of specific methods when choosing a disinfection or sterilization process. Adherence to these recommendations should improve disinfection and sterilization practices in health care facilities, thereby reducing infections associated with contaminated patient-care items.

∧Back to top

Workforce – “Brain drain”

[see also Lancet Commission]


Dovlo D. The Brain Drain in Africa: An Emerging Challenge to Health Professionals’ Education. JHEA/RESA 2004; 2(3): 1-18


A health crisis is facing sub-Saharan Africa. The population has increased markedly. In recent decades, communicable diseases and ‘new’ noncommunicable disease epidemics have intensified. HIV/AIDS is perhaps the biggest health challenge. However, the supply of health workers remains low and has been worsened by their migration to developed countries. This paper reviews health professionals’ ‘brain drain’ using data from Ghana and other African countries, with proxy data supplying some information on which direct data do not exist. Not only is retention of health professionals a serious challenge, but training output has also remained limited. There are few studies of how stakeholders, including institutions of tertiary education, can moderate the effects of brain drain. Sub-Saharan Africa cannot compete economically with industrialised countries in the same health labour market. This paper discusses ways in which educational systems and the health sector can collaborate to mitigate the effects of health professionals’ migration and to sustain health services including (a) new modes of selecting candidates for the professions, (b) establishing new and relevant curricula, (c) profiling new cadres that are better retained, and (d) co-ordinating with the health sector on bonding and community service schemes to facilitate retention.



Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17): 1810-8. PMID: 16251537


BACKGROUND: There has been substantial immigration of physicians to developed countries, much of it coming from lower-income countries. Although the recipient nations and the immigrating physicians benefit from this migration, less developed countries lose important health capabilities as a result of the loss of physicians.

METHODS: Data on the countries of origin, based on countries of medical education, of international medical graduates practicing in the United States, the United Kingdom, Canada, and Australia were obtained from sources in the respective countries and analyzed separately and in aggregate. With the use of World Health Organization data, I computed an emigration factor for the countries of origin of the immigrant physicians to provide a relative measure of the number of physicians lost by emigration.

RESULTS: International medical graduates constitute between 23 and 28 percent of physicians in the United States, the United Kingdom, Canada, and Australia, and lower-income countries supply between 40 and 75 percent of these international medical graduates. India, the Philippines, and Pakistan are the leading sources of international medical graduates. The United Kingdom, Canada, and Australia draw a substantial number of physicians from South Africa, and the United States draws very heavily from the Philippines. Nine of the 20 countries with the highest emigration factors are in sub-Saharan Africa or the Caribbean.

CONCLUSIONS: Reliance on international medical graduates in the United States, the United Kingdom, Canada, and Australia is reducing the supply of physicians in many lower-income countries.



Coombes R. Developed world is robbing African countries of health staff. BMJ. 2005 Apr 23;330(7497): 923. PMID: 15845968

Cometto G, Tulenko K, Muula AS, Krech R. Health workforce brain drain: from denouncing the challenge to solving the problem. PLoS Med. 2013;10(9): e1001514. PMID: 24068895

Chen LC, Boufford JI. Fatal flows–doctors on the move. N Engl J Med. 2005 Oct 27;353(17): 1850-2. PMID: 16251543

Feeley F. Fight AIDS as well as the brain drain. Lancet. 2006 Aug 5;368(9534): 435-6. PMID: 16890815

Robinson M, Clark P. Forging solutions to health worker migration. Lancet. 2008 Feb 23;371(9613): 691-3. PMID: 18295029

Eliason S, Tuoyire DA, Awusi-Nti D, Bockarie AS. Migration Intentions of Ghanaian Medical Students: The Influence of Existing Funding Mechanisms of Medical Education (“The Fee Factor”).Ghana Med J. 2014 Jun; 48(2): 78–84. PMID: 25667554 (Free PMC Article)


BACKGROUND: To explore the effects of fee paying status on migration intentions of Ghanaian medical students.

DESIGN: Cross sectional questionnaire based survey. All established Ghanaian medical schools with students in their clinical years.

PARTICIPANTS: Fee-paying and non-fee-paying Ghanaian medical students in their clinical years

RESULTS: Approximately half (49%) of the medical students surveyed had intentions of migrating after school. Over 48% of those with migration intentions plan on doing so immediately after completing their house job, while 44% plan to migrate at least one year after their house job. The most popular destination chosen by the potential migrant doctors was North America (38%). Fee-paying students were significantly more likely (OR=2.11, CI=1.32, 3.38) than non-fee-paying students to have intentions of migrating after their training. Secondly, fee-paying students were more likely (OR=9.66, CI=4.42, 21.12) than non-fee paying students to feel they owe no allegiance to the Government of Ghana because of their fee-paying status.

CONCLUSIONS: Medical Students’ fee-paying status affects their intentions to migrate and their allegiance to the country after completion of their training.


Hagopian A, Ofosu A, Fatusi A, Biritwum R, Essel A, Gary Hart L, Watts C. The flight of physicians from West Africa: views of African physicians and implications for policy. Soc Sci Med. 2005 Oct;61(8):1750-60. PMID: 15927335

Summary: West African-trained physicians have been migrating from the sub-continent to rich countries, primarily the US and the UK, since medical education began in Nigeria and Ghana in the 1960s. In 2003, we visited six medical schools in West Africa to investigate the magnitude, causes and consequences of the migration. We conducted interviews and focus groups with faculty, administrators (deans and provosts), students and post-graduate residents in six medical schools in Ghana and Nigeria. In addition to the migration push and pull factors documented in previous literature, we learned that there is now a well-developed culture of medical migration. This culture is firmly rooted, and does not simply fail to discourage medical migration but actually encourages it. Medical school faculty are role models for the benefits of migration (and subsequent return), and they are proud of their students who successfully emigrate.



Deressa W, Azazh A. Attitudes of undergraduate medical students of Addis Ababa University towards medical practice and migration, Ethiopia. BMC Med Educ. 2012 Aug 6;12:68. PMID: 22867022 (Free PMC article)


BACKGROUND: The health care system of Ethiopia is facing a serious shortage of health workforce. While a number of strategies have been developed to improve the training and retention of medical doctors in the country, understanding the perceptions and attitudes of medical students towards their training, future practice and intent to migrate can contribute in addressing the problem. This study was carried out to assess the attitudes of Ethiopian medical students towards their training and future practice of medicine, and to identify factors associated with the intent to practice in rural or urban settings, or to migrate abroad.

METHODS: A cross-sectional study was conducted in June 2009 among 600 medical students (Year I to Internship program) of the Faculty of Medicine at Addis Ababa University in Ethiopia. A pre-tested self-administered structured questionnaire was used for data collection. Descriptive statistics were used for data summarization and presentation. Degree of association was measured by Chi Square test, with significance level set at p < 0.05. Bivariate and multivariate logistic regression analyses were used to assess associations.

RESULTS: Only 20% of the students felt ‘excellent’ about studying medicine; followed by ‘very good’ (19%), ‘good’ (30%), ‘fair’ (21%) and ‘bad’ (11%). About 35% of respondents responded they felt the standard of medical education was below their expectation. Only 30% of the students said they would like to initially practice medicine in rural settings in Ethiopia. However, students with rural backgrounds were more likely than those with urban backgrounds to say they intended to practice medicine in rural areas (adjusted OR = 2.50, 95% CI = 1.18-5.26). Similarly, students in clinical training program preferred to practice medicine in rural areas compared to pre-clinical students (adjusted OR = 1.83, 95% CI = 1.12-2.99). About 53% of the students (57% males vs. 46% females, p = 0.017) indicated aspiration to emigrate following graduation, particularly to the United States of America (42%) or European countries (15%). The attitude towards emigration was higher among Year IV (63%) and Internship (71%) students compared to Year I to Year III students (45-54%). Male students were more likely to say they would emigrate than females (adjusted OR = 1.57, 95% CI = 1.10-2.29). Likewise, students with clinical training were more likely to want to emigrate than pre-clinical students, although the difference was marginally significant (adjusted OR = 1.58, 95% CI = 1.00-2.49).

CONCLUSIONS: The attitudes of the majority of Ethiopian medical students in the capital city towards practicing medicine in rural areas were found to be poor, and the intent to migrate after completing medical training was found to be very high among the study participants, creating a huge potential for brain drain. This necessitates the importance of improving the quality of education and career choice satisfaction, creating conducive training and working conditions including retention efforts for medical graduates to serve their nation. It follows that recruiting altruistic and rural background students into medical schools is likely to produce graduates who are more likely to practice medicine in rural settings.



VSO International. Brain Gain: Making Health Worker Migration Work for Rich and Poor Countries. 2010. https: //


This paper is the outcome of a series of in‑depth interviews and group discussions with over 100 African health workers and others at the grassroots to understand their experiences of migration and their ideas for solutions to it.


VSO’s research has found that the perception of “oneway only” migration flows from poor to rich countries has little resonance with the real aspirations and plans of many migrant African health workers. The majority of those we interviewed expressed a genuine desire to return to their country of origin and to use their skills to make a difference by working in the health service or sharing the skills they had aquired with others.

There are many aspects of the UK’s immigration policy that may not be easily reconciled with the UK’s international development goals. However, we believe that increasing the coordination of immigration and development policies to facilitate circular migration for skilled health workers and overcome the barriers for those wanting to return offers a potential “triple win” scenario.

For the UK, facilitating circular migration offers the ability to continue to meet labour shortages by attracting skilled professionals to work in the health sector for defined periods of time.

For developing countries, it offers the temporary or permanent return of professionals who have acquired new skills and knowledge in the UK. These returning migrants can be deployed to help address staff shortages and improve the quality of Africa’s healthcare, including through the training of other health workers. For aspiring migrant health workers, it provides an opportunity to increase their professional skills and financial resources through legal migration in the knowledge that they will be able to find a job that uses those skills effectively on return. For migrant health workers already in the UK, diaspora volunteering and flexibility in the citizenship pathway presents a chance to make a difference back home on a temporary basis, while also “testing the water” for a potential permanent return without risking their right to stay in the UK.



Stilwell B, Diallo K, Zurn P, Vujicic M, Adams O, Dal Poz M. Migration of health-care workers from developing countries: strategic approaches to its management. Bull World Health Organ. 2004 Aug;82(8): 595-600. PMID: 15375449


Of the 175 million people (2.9% of the world’s population) living outside their country of birth in 2000, 65 million were economically active. The rise in the number of people migrating is significant for many developing countries because they are losing their better-educated nationals to richer countries. Medical practitioners and nurses represent a small proportion of the highly skilled workers who migrate, but the loss for developing countries of human resources in the health sector may mean that the capacity of the health system to deliver health care equitably is significantly compromised. It is unlikely that migration will stop given the advances in global communications and the development of global labour markets in some fields, which now include nursing. The aim of this paper is to examine some key issues related to the international migration of health workers and to discuss strategic approaches to managing migration.



Hidalgo JS. The active recruitment of health workers: a defence. J Med Ethics. 2013 Oct;39(10): 603-9. PMID: 23112042


Many organisations in rich countries actively recruit health workers from poor countries. Critics object to this recruitment on the grounds that it has harmful consequences and that it encourages health workers to violate obligations to their compatriots. Against these critics, I argue that the active recruitment of health workers from low-income countries is morally permissible. The available evidence suggests that the emigration of health workers does not in general have harmful effects on health outcomes. In addition, health workers can immigrate to rich countries and also satisfy their obligations to their compatriots. It is consequently unjustified to blame or sanction organisations that actively recruit health workers.


Sterckx S. The active recruitment of health workers: a commentary. J Med Ethics. 2013 Oct;39(10): 614-6; discussion 618-20. PMID: 23349507

Mills EJ, Schabas WA, Volmink J, Walker R, Ford N, Katabira E, et al. Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime? Lancet. 2008 Feb 23;371(9613): 685-8. PMID: 18295027

McCoy D, Bennett S, Witter S, Pond B, Baker B, Gow J, et al. Salaries and incomes of health workers in sub-Saharan Africa. Lancet. 2008 Feb 23;371(9613): 675-81. PMID: 18295025


Public-sector health workers are vital to the functioning of health systems. We aimed to investigate pay structures for health workers in the public sector in sub-Saharan Africa; the adequacy of incomes for health workers; the management of public-sector pay; and the fiscal and macroeconomic factors that impinge on pay policy for the public sector. Because salary differentials affect staff migration and retention, we also discuss pay in the private sector. We surveyed historical trends in the pay of civil servants in Africa over the past 40 years. We used some empirical data, but found that accurate and complete data were scarce. The available data suggested that pay structures vary across countries, and are often structured in complex ways. Health workers also commonly use other sources of income to supplement their formal pay. The pay and income of health workers varies widely, whether between countries, by comparison with cost of living, or between the public and private sectors. To optimise the distribution and mix of health workers, policy interventions to address their pay and incomes are needed. Fiscal constraints to increased salaries might need to be overcome in many countries, and non-financial incentives improved.



Wasswa H. Rich states “snatch” trained doctors from countries. BMJ. 2008 Mar 15;336(7644): 579. PMID: 18340061

Tulenko, K. Countries Without Doctors? How Obamacare could spark the brain drain of physicians from the developing world. Foreign Policy June 10,2010

With the passage of the Affordable Care Act (“Obamacare”), the increased number of insured Americans will expand the demand for physicians, raising the possibility of addition immigration form less well-supplied countries. Thus, while the United States is recruits thousands of doctors each year, it is simultaneously spending billions trying to build health systems in precisely the countries whose physicians it is recruiting.


Mullan F. Doctors and soccer players–African professionals on the move. N Engl J Med. 2007 Feb 1;356(5): 440-3. PMID: 17267902

Hidalgo JS. Defending the active recruitment of health workers: a response to commentators. J Med Ethics. 2013; 39(10): 618-620

Martineau T, Decker K, Bundred P. “Brain drain” of health professionals: from rhetoric to responsible action. Health Policy. 2004 Oct;70(1): 1-10. PMID: 15312705


The question of the “brain drain” of health professionals has re-emerged since last exposed in 1970s. This paper is based on exploratory studies in Ghana, South Africa and the UK, a literature review and subsequent tracking of contemporary events. It reviews what is currently known about professional migration in the health sector and its impact on health services in poorer countries. The relevant responsibilities at the global level and source and recipient country levels are then reviewed. It is concluded that that the situation is more complex than portrayed by some of the rhetoric and that meaningful dialogue and consideration of responsibilities is needed. In addition, better information is needed to monitor migration flows; source countries need to improve staff attraction and retention strategies; and recipient countries need to ensure that they do not become a permanent drain on health professionals from the developing countries



Brock G. Is active recruitment of health workers really not guilty of enabling harm or facilitating wrongdoing? J Med Ethics. 2013 Oct;39(10): 612-4; discussion 618-20. PMID: 23179463

Bhargava A. Physician emigration, population health and public policies. J Med Ethics. 2013 Oct;39(10): 616-8; discussion 618-20. PMID: 23355228

Brassington I. Recruiting medics from the poorest nations? It could be worse…. J Med Ethics. 2013 Oct;39(10): 610-1; discussion 618-20. PMID: 23161614

Hooper CR. Reply to Hidalgo’s ‘The active recruitment of health workers: a defence’ article. J Med Ethics. 2013 Oct;39(10): 611-2; discussion 618-20. PMID: 23288266

∧Back to top

Workforce – Physician and non-physician providers

[see also Lancet Commission]


Soyannwo OA, Elegbe EO. Anaesthetic manpower development in West Africa. Afr J Med Med Sci. 1999 Sep-Dec;28(3-4): 163-5. PMID: 11205823


Advances in surgery have been possible worldwide largely due to specialized manpower, innovations in modern anaesthetic techniques and drugs. Shortage of specialist manpower in anaesthesia has continued in West Africa despite various available local postgraduate training programmes. This paper examines the impact of the West African Postgraduate Medical College (WAPMC) training programme on anaesthetic manpower development in the West Africa subregion. Data collected from the records of the WAPMC revealed that from April 1992 to October 1996 a total number of 2,963 candidates attempted the primary examination of the various surgical faculties compared to 93 candidates for anaesthesia–a ratio of 32 prospective surgeons to one anaesthetist. The end point of the training produced 292 Fellows in the five-year period with only six in anaesthesia, i.e., 1 anaesthetist to 49 surgeons. Although the diploma programme of the same College produced 56 graduates in the study period, 53.6% of them were pursuing the Fellowship programme in tertiary institutions. Suggestions are proposed to redress the ever-widening gap between the number of specialist surgeons and anaesthetists in the West Africa subregion.



Yudkin JS, Owens G, Martineau F, Rowson M, Finer S. Global health-worker crisis: the UK could learn from Cuba. Lancet. 2008 Apr 26;371(9622): 1397-9. PMID: 18440415

Wilson IH. Con: anesthesia for children in the developing world should be delivered by medical anesthetists. Paediatr Anaesth. 2009 Jan;19(1): 39-41. PMID: 19076502


Surgical care for pediatric patients in poor countries is severely limited by the availability of surgeons, healthcare resources and investment in anesthesia services. Where a surgical service exists, a shortage of trained medical anesthetists limits the care that can be delivered. Where no doctors are available to administer anesthesia, some countries have utilized nonmedical anesthesia providers to provide a service. These providers should be integrated with, and supported by, their medical colleagues to ensure safe practice. Action at governmental level is required to resolve the difficult issues described in this paper.



Jacob R. Pro: anesthesia for children in the developing world should be delivered by medical anesthetists. Paediatr Anaesth. 2009 Jan;19(1): 35-8. PMID: 19076501


Outcomes from pediatric surgery when carried out by trained pediatric anesthetists are excellent. This is not the case when the anesthesia provider is poorly trained. The presence of pediatric anesthetists is not only the norm but considered mandatory for children below the age of 2-3 years in developed countries. There are many reasons why trained anesthetists are not readily available in developing countries – migration to greener pastures, inadequate training facilities, poor remuneration and support services being some of them. These problems should be addressed but safety of the children should not be compromised. One should not condone poor standards to deprive children of safe anesthesia and the caregiver of much needed self-respect.



Crisp N. Global health capacity and workforce development: turning the world upside down. Infect Dis Clin North Am. 2011 Jun;25(2): 359-67. PMID: 21628051


This article explores global health and the way in which the whole world is increasingly interdependent in terms of health. High-income countries need to help redress the balance of power and resources around the world, for self interest and self preservation if for no other reason. These countries have a particular responsibility to help support the training of more health workers and to strengthen health systems in low-income and middle-income countries. In this interdependent world, high-income countries can learn a great deal from poorer ones as well as vice versa, and concepts of mutuality and codevelopment will become increasingly important.



Phadke MA, Kshirsagar NA, Dalvi SD. Non-physician clinicians in India. Lancet. 2008 Feb 23;371(9613): 648-9. PMID: 18295019

∧Back to top


Note: most of these articles are available free at http: //


Meara JG, Leather A, Hagander L, Alkire BC, Alonso N, Ameh EA, et al [and other members of the Lancet Commission]. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015 Aug 8;386(9993): 569‑624.

Excerpt from the Executive summary (an excellent and eminently readable 56 page document analyzing and summarizing the Lancet Commission’s work and recommendations).

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life‑saving surgical and anaesthesia care in low‑income and middle‑income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case‑fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer.


To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multidisciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents


  • 5 billion people do not have access to safe, affordable surgical and anaesthesia care when needed. Access is worst in low‑income and lower‑middle‑income countries, where nine of ten people cannot access basic surgical care.
  • 143 million additional surgical procedures are needed in LMICs each year to save lives and prevent disability. Of the 313 million procedures undertaken worldwide each year, only 6% occur in the poorest countries, where over a third of the world’s population lives. Low operative volumes are associated with high case‑fatality rates from common, treatable surgical conditions. Unmet need is greatest in eastern, western, and central sub‑Saharan Africa, and south Asia.
  • 33 million individuals face catastrophic health expenditure due to payment for surgery and anaesthesia care each year. An additional 48 million cases of catastrophic expenditure are attributable to the non‑medical costs of accessing surgical care. A quarter of people who have a surgical procedure will incur financial catastrophe as a result of seeking care.
  • Investing in surgical services in LMICs is affordable, saves lives, and promotes economic growth. If LMICs were to scale‑up surgical services at rates achieved by the present best‑performing LMICs, two‑thirds of countries would be able to reach a minimum operative volume of 5000 surgical procedures per 100,000 population by 2030. Without urgent and accelerated investment in surgical scale‑up, LMICs will continue to have losses in economic productivity, estimated cumulatively at US?$12×3 trillion (2010 US$, purchasing power parity) between 2015 and 2030.
  • Surgery is an Aindivisible, indispensable part of health care.@



Alkire BC, Shrime MG, Dare AJ, Vincent JR, Meara JG. Global economic consequences of selected surgical diseases: a modelling study. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S21‑7. PMID: 25926317


BACKGROUND: The surgical burden of disease is substantial, but little is known about the associated economic consequences. We estimate the global macroeconomic impact of the surgical burden of disease due to injury, neoplasm, digestive diseases, and maternal and neonatal disorders from two distinct economic perspectives.

METHODS: We obtained mortality rate estimates for each disease for the years 2000 and 2010 from the Institute of Health Metrics and Evaluation Global Burden of Disease 2010 study, and estimates of the proportion of the burden of the selected diseases that is surgical from a paper by Shrime and colleagues. We first used the value of lost output (VLO) approach, based on the WHO’s Projecting the Economic Cost of Ill‑Health (EPIC) model, to project annual market economy losses due to these surgical diseases during 2015‑30. EPIC attempts to model how disease affects a country’s projected labour force and capital stock, which in turn are related to losses in economic output, or gross domestic product (GDP). We then used the value of lost welfare (VLW) approach, which is conceptually based on the value of a statistical life and is inclusive of non‑market losses, to estimate the present value of long‑run welfare losses resulting from mortality and short‑run welfare losses resulting from morbidity incurred during 2010. Sensitivity analyses were performed for both approaches.

FINDINGS:  During 2015‑30, the VLO approach projected that surgical conditions would result in losses of 1×25% of potential GDP, or $20×7 trillion (2010 US$, purchasing power parity) in the 128 countries with data available. When expressed as a proportion of potential GDP, annual GDP losses were greatest in low‑income and middle‑income countries, with up to a 2×5% loss in output by 2030. When total welfare losses are assessed (VLW), the present value of economic losses is estimated to be equivalent to 17% of 2010 GDP, or $14×5 trillion in the 175 countries assessed with this approach. Neoplasm and injury account for greater than 95% of total economic losses with each approach, but maternal, digestive, and neonatal disorders, which represent only 4% of losses in high‑income countries with the VLW approach, contribute to 26% of losses in low‑income countries.

INTERPRETATION: The macroeconomic impact of surgical disease is substantial and inequitably distributed. When paired with the growing number of favourable cost‑effectiveness analyses of surgical interventions in low‑income and middle‑income countries, our results suggest that building surgical capacity should be a global health priority.



Gawande A. Global surgery [commentary] Lancet. 2015 Aug 8;386(9993): 523‑5.

PMID: 26293430

Marks IH, Patel SB, Holmer H, Billingsley ML, Philipo GS. Letter from the future surgeons of 2030 [commentary on Meara et al.]. Lancet. 2015 Nov 14;386(10007): 1942.


…The challenge [of surgical inequality] remains; surgery is both a local and global health issue and must be addressed on both levels….Mobility of students and trainees is fundamental, and denying some doctors the opportunity to learn from colleagues in richer countriesCwhen the reverse is encouragedCis unjust. Technology is [also] a potential bridge between countries.



Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015 Jun;3(6): e316‑23. PMID: 25926087


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 afford ability. 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.

FINDINGS: At least 4×8 billion people (95% posterior credible interval 4×6B5×0 [67%, 64B70]) 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.

INTERPRETATION: 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.



Meara JG, Greenberg SL. Global surgery as an equal partner in health: no longer the neglected stepchild [editorial]. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S1‑2.PMID: 25926313

Shrime MG, Dare AJ, Alkire BC, O’Neill K, Meara JG. Catastrophic expenditure to pay for surgery worldwide: a modelling study. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S38‑44.


BACKGROUND: Approximately 150 million individuals worldwide face catastrophic expenditure each year from medical costs alone, and the non‑medical costs of accessing care increase that number. The proportion of this expenditure related to surgery is unknown. Because the World Bank has proposed elimination of medical impoverishment by 2030, the effect of surgical conditions on financial catastrophe should be quantified so that any financial risk   protection mechanisms can appropriately incorporate surgery.

METHODS: To estimate the global incidence of catastrophic expenditure due to surgery, we built a stochastic model. The income distribution of each country, the probability of requiring surgery, and the medical and non‑medical costs faced for surgery were incorporated. Sensitivity analyses were run to test the robustness of the model.

FINDINGS: 3×7 billion people (posterior credible interval 3×2B4×2 billion) risk catastrophic expenditure if they need surgery. Each year, 81×3 million people (80×8B81×7 million) worldwide are driven to financial catastropheC32×8 million (32×4B33×1 million) from the costs of surgery alone and 48×5 million (47×7B49×3) from associated non‑medical costs. The burden of catastrophic expenditure is highest in countries of low and middle income; within any country, it falls on the poor. Estimates were sensitive to the definition of catastrophic expenditure and the costs of care. The inequitable burden distribution was robust to model assumptions. Interpretation Half the global population is at risk of financial catastrophe from surgery. Each year, surgical conditions cause 81 million individuals to face catastrophic expenditure, of which less than half is attributable to medical costs. These findings highlight the need for financial risk protection for surgery in health‑system design.


Otremba M, Berland G, Amon JJ. Hospitals as debtor prisons. Lancet Glob Health. 2015 May;3(5): e253‑4. PMID: 25889465

Holmer H, Lantz A, Kunjumen T, Finlayson S, Hoyler M, Siyam A, Montenegro H, Kelley ET, Campbell J, Cherian MN, Hagander L. Global distribution of surgeons, anaesthesiologists, and obstetricians [corres]. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S9‑11. PMID: 25926323

Excerpt [free article]

Data on the number of licensed, qualified physician surgeons, anaesthesiologists, and obstetricians were retrieved from Ministries of Health, WHO country offices, professional societies, members of the WHO Global Initiative for Emergency & Essential Surgical Care, and from publicly available sources….Worldwide, there are an estimated 1,112,727 specialist surgeons, 550,134 anaesthesiologists and 483,357 obstetricians. Low‑income and lower‑middle income countries, representing 48% of the global population, have 20% of this workforce, or 19% of all surgeons, 15% of anaesthesiologists, and 29% of obstetricians…The results of this study represent the first truly global compilation of national surgical specialist workforce data and constitute a first step towards routinely collecting surgical workforce data through the WHO Global Surgical Workforce Database.[a global map is included in the article].



Lantz A, Holmer H, Finlayson S, Ricketts TC, Watters D, Gruen R, Hagander L. International migration of surgeons, anaesthesiologists, and obstetricians. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S11‑2. PMID: 25926314


We contacted 75 high income countries with a request for data on the number of specialist surgeons, anaesthesiologists, and obstetricians and their country of initial medical qualification….Half of all surgeons, anaesthesiologists, and obstetricians who had migrated from low‑income and middle‑income countries came from a country in workforce crisis…. Of 14 high‑income countries, the surgical workforce of 295,477 practitioners in these countries included 53,428 international medical graduates (18×1%), of whom 66.4% were from low‑income and middle‑income countries.


Holmer H, Shrime MG, Riesel JN, Meara JG, Hagander L. Towards closing the gap of the global surgeon, anaesthesiologist, and obstetrician workforce: thresholds and projections towards 2030. Lancet. 2015 Apr 27;385 Suppl 2: S40. PMID: 26313089


BACKGROUND: Billions of people are without access to surgical care, in part because of the inequitable distribution of the surgical workforce. Drawing on recently collected data for the number of surgeons, anaesthesiologists, and obstetricians worldwide, we sought to show their global maldistribution by identifying thresholds of surgical workforce densities, and by calculating the number of additional providers needed to reach those thresholds.

METHODS: From the WHO Global Surgical Workforce Database, national data for the number of specialist surgeons, anaesthesiologists, and obstetricians per 100 000 population (density) were compared with the number of maternal deaths per 100 000 live births (maternal mortality ratio; MMR) in WHO member countries. A regression line was fit between density of specialist surgeons, anaesthesiologists, and obstetricians and the logarithm of MMR, and we explored the correlation for an upper and a lower density threshold. Based on previous estimates of the global volume of surgical procedures, a global average productivity per specialist was derived. We then multiplied the average productivity with the derived upper and lower threshold densities, and compared these numbers to previously estimated global need of surgical procedures (4664 procedures per 100 000 population). Finally, the numbers of additional providers needed to reach the thresholds in countries with a density below the respective threshold were calculated.

FINDINGS: Each 10-unit increase in density of surgeons, anaesthesiologists, and obstetricians, corresponded to a 13·1% decrease in MMR (95% CI 11·3-14·8). We saw particularly steep improvements in MMR from 0 to roughly 20 per 100 000 population. Above roughly 40 per 100 000 population, higher density was associated with relatively smaller improvements in MMR. These arbitrary thresholds of 20 and 40 specialists per 100 000 corresponded with a volume of surgery of 2917 and 5834 procedures per 100 000 population, respectively, and were symmetrically distributed around the estimated global need of 4664 surgical procedures per 100 000 population. Our density thresholds are slightly higher than the current average in lower-middle income countries (16 per 100 000) and upper-middle-income countries (38 per 100 000), respectively. To reach the threshold of at least 20 per 100 000 in each country today, another 440 231 (IQR 438 900-443 245) providers would be needed. To reach 40 per 100 000, 1 110 610 (IQR 1 095 376-1 183 525) providers would be needed.

INTERPRETATION: Assuming uniform productivity, a global surgical workforce between 20 and 40 per 100 000 would suffice to provide the world’s missing surgical procedures. We concede that causality cannot be implied, but our results suggest that countries with a workforce density above certain thresholds have better health outcomes. Although the thresholds cannot be interpreted as a minimum standard, they are useful to characterise the global surgical workforce and its deficits. Such thresholds could also be used as markers for health system capacity.



Rose J, Weiser TG, Hider P, Wilson L, Gruen RL, Bickler SW. Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S13‑20. PMID: 25926315


BACKGROUND: Surgery is a foundational component of health‑care systems. However, previous efforts to integrate surgical services into global health initiatives do not reflect the scope of surgical need and many health systems do not provide essential interventions. We estimate the minimum global volume of surgical need to address prevalent diseases in 21 epidemiological regions from the Global Burden of Disease Study 2010 (GBD).

METHODS: Prevalence data were obtained from GBD 2010 and organised into 119 disease states according to the WHO’s Global Health Estimate (GHE). These data, representing 187 countries, were then apportioned into the 21 GBD epidemiological regions. Using previously defined values for the incident need for surgery for each of the 119 GHE disease states, we calculate minimum global need for surgery based on the prevalence of each condition in each region.

FINDINGS: We estimate that at least 321×5 million surgical procedures would be needed to address the burden of disease for a global population of 6×9 billion in 2010. Minimum rates of surgical need vary across regions, ranging from 3383 operations per 100?000 in central Latin America to 6495 operations per 100,000 in western sub‑Saharan Africa. Global surgical need also varied across subcategories of disease, ranging from 131,412 procedures for nutritionaldeficiencies to 45×8 million procedures for unintentional injuries.

INTERPRETATION: The estimated need for surgical procedures worldwide is large and addresses a broad spectrum of disease states. Surgical need varies between regions of the world according to disease prevalence and many countries do not meet the basic needs of their populations. These estimates could be useful for policy makers, funders, and ministries of health as they consider how to incorporate surgical capacity into health systems.



Verguet S, Alkire BC, Bickler SW, Lauer JA, Uribe‑Leitz T, Molina G, Weiser TG, Yamey G, Shrime MG. Timing and cost of scaling up surgical services in low‑income and middle‑income countries from 2012 to 2030: a modelling study. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S28‑37.PMID: 25926318


BACKGROUND: Given the large burden of surgical conditions and the crosscutting nature of surgery, scale‑up of basic surgical services is crucial to health‑system strengthening. The Lancet Commission on Global Surgery proposed that, to meet populations’ needs, countries should achieve 5000 major operations per 100?000 population per year. We modelled the possible scale‑up of surgical services in 88 low‑income and middle‑income countries with a population greater than 1 million from 2012 to 2030 at various rates and quantified the associated costs.

METHODS: Major surgery includes any intervention within an operating room involving tissue manipulation and anaesthesia. We used estimates for the number of major operations achieved per country annually and the number of operating rooms per region, and data from Mongolia and Mexico for trends in the number of operations. Unit costs included a cost per operation, proxied by caesarean section cost estimates; hospital construction data were used to estimate cost per operating room construction. We determined the year by which each country would achieve the Commission’s target. We modelled three scenarios for the scale‑up rate: actual rates (5×1% per year) and two “aspirational” rates, the rates achieved by Mongolia (8×9% annual) and Mexico (22×5% annual). We subsequently estimated the associated costs.

FINDINGS: About half of the 88 countries would achieve the target by 2030 at actual rates of improvements, with up to two‑thirds if the rate were increased to Mongolian rates. We estimate the total costs of achieving scale‑up at US$300‑420 billion (95% UI 190‑600 billion) over 2012‑30, which represents 4‑8% of total annual health expenditures among low‑income and lower middle‑income countries and 1% among upper middle‑income countries.

INTERPRETATION: Scale‑up of surgical services will not reach the target of 5000 operations per 100?000 by 2030 in about half of low‑income and middle‑income countries without increased funding, which countries and the international community must seek to achieve expansion of quality surgical services.



Dieleman JL, Yamey G, Johnson EK, Graves CM, Haakenstad A, Meara JG. Tracking global expenditures‑gaps in knowledge hinder progress [editorial]. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S2‑4. PMID: 25926316

Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S8‑9.

Mulla Z. Better brave than big [Editorial]. Lancet Glob Health. 2015 May;3(5): e240.

Lane R. John Meara: helping to make surgery truly global. Lancet. 2015 Aug 8;386(9993): 522. PMID: 25924838

Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, Nutt CT, Greenberg SL, Kotagal M, Diesel JN, Esquivel M, Uribe‑Leitz T, Molina G, Roy N, Meara JG, Farmer PE. Global access to surgical care: a modelling study. Lancet Glob Health. 2015 Jun;3(6): e316‑23.


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 afford ability. 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.

FINDINGS: 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.

INTERPRETATION: 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.



Chao TE, Sharma K, Mandigo M, Hagander L, Resch SC, Weiser TG, Meara JG. Cost‑effectiveness of surgery and its policy implications for global health: a systematic review and analysis. Lancet Glob Health. 2014 Jun;2(6): e334‑45. PMID: 25103302


BACKGROUND: The perception of surgery as expensive and complex might be a barrier to its widespread acceptance in global health efforts. We did a systematic review and analysis of cost‑effectiveness studies that assess surgical interventions in low‑income and middle‑income countries to help quantify the potential value of surgery.

METHODS: We searched Medline for all relevant articles published between Jan 1, 1996 and Jan 31, 2013, and searched the reference lists of retrieved articles. We converted all results to 2012 US$. We extracted cost‑effectiveness ratios (CERs) and appraised economic assessments for their methodological quality using the 10‑point Drummond checklist.

FINDINGS: Of the 584 identified studies, 26 met full inclusion criteria. Together, these studies gave 121 independent CERs in seven categories of surgical interventions. The median CER of circumcision ($13×78 per disability‑adjusted life year [DALY]) was similar to that of standard vaccinations ($12×96‑25×93 per DALY) and bednets for malaria prevention ($6×48‑22×04 per DALY). Median CERs of cleft lip or palate repair ($47×74 per DALY), general surgery ($82×32 per DALY), hydrocephalus surgery ($108×74 per DALY), and ophthalmic surgery ($136 per DALY) were similar to that of the BCG vaccine ($51×86‑220×39 per DALY). Median CERs of caesarean sections ($315×12 per DALY) and orthopaedic surgery ($381×15 per DALY) are more favourable than those of medical treatment for ischaemic heart disease ($500×41‑706×54 per DALY) and HIV treatment with multidrug antiretroviral therapy ($453×74‑648×20 per DALY).

INTERPRETATION: Our findings suggest that many essential surgical interventions are cost‑effective or very cost‑effective in resource‑poor countries. Quantification of the economic value of surgery provides a strong argument for the expansion of global surgery’s role in the global health movement. However, economic value should not be the only argument for resource allocation‑‑other organisational, ethical, and political arguments can also be made for its inclusion.



Raykar NP, Kralievits K, Greenberg SL, Gillies RD, Roy N, Meara JG. The blood drought in context. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S4‑5. PMID: 25926320


Universal access to safe, affordable surgery when needed depends on a sufficient and safe blood supply. This is not the case in most of the world today. The average donation rate in low‑income countries (2.8 donations per 1,000 population) is an order of magnitude below that of high‑income countries (36.4 donations per 1,000 population). Knowing the patient will die without a transfusion…unbanked direct blood transfusions (UDBT) or commercial donations become necessary choices. Rather than disregarding or banning these practices, practical interim measures should be implemented to optimise their safety. …[furthermore, blood availability must be addressed as a global priority.



Marsh RH, Rouhani SA, Pierre P, Farmer PE. Strengthening emergency care: experience in central Haiti. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S5‑7.PMID: 25926321

Huber B. Finding surgery’s place on the global health agenda [editorial]. Lancet. 2015 May 9;385(9980): 1821‑2. PMID: 25924836

Shrime MG, Dare AJ, Alkire BC, O’Neill K, Meara JG. Catastrophic expenditure to pay for surgery worldwide: a modelling study. Lancet Glob Health. 2015 Apr 27;3 Suppl 2: S38‑44. PMID: 2592631


BACKGROUND: Approximately 150 million individuals worldwide face catastrophic expenditure each year from medical costs alone, and the non‑medical costs of accessing care increase that number. The proportion of this expenditure related to surgery is unknown. Because the World Bank has proposed elimination of medical impoverishment by 2030, the effect of surgical conditions on financial catastrophe should be quantified so that any financial risk protection mechanisms can appropriately incorporate surgery.

METHODS: To estimate the global incidence of catastrophic expenditure due to surgery, we built a stochastic model. The income distribution of each country, the probability of requiring surgery, and the medical and non‑medical costs faced for surgery were incorporated. Sensitivity analyses were run to test the robustness of the model.

FINDINGS: 3×7 billion people (posterior credible interval 3×2‑4×2 billion) risk catastrophic expenditure if they need surgery. Each year, 81×3 million people (80×8‑81×7 million) worldwide are driven to financial catastrophe‑32×8 million (32×4‑33×1 million) from the costs of surgery alone and 48×5 million (47×7‑49×3) from associated non‑medical costs. The burden of catastrophic expenditure is highest in countries of low and middle income; within any country, it falls on the poor. Estimates were sensitive to the definition of catastrophic expenditure and the costs of care. The inequitable burden distribution was robust to model assumptions.

INTERPRETATION: Half the global population is at risk of financial catastrophe from surgery. Each year, surgical conditions cause 81 million individuals to face catastrophic expenditure, of which less than half is attributable to medical costs. These findings highlight the need for financial risk protection for surgery in health‑system design.

∧Back to top