When I was seven, I broke my nose in an accident. My family rushed me to the hospital where my mother worked as a retina surgeon, where, after understanding my injury, she was able to operate on me. My father was an anaesthesiologist but deemed anaesthesia to be unnecessary, and instead distracted me from the pain during the procedure. In my first encounter with surgical care in India, I was as at home as possible.
With the hindsight of 20 years, I realise my circumstances then were extraordinary. India’s Health Management Information System would classify what I underwent as a ‘minor surgery’ because it didn’t require general or spinal anaesthesia. In 2019-2020, the System, which covers most publicly owned health facilities in the country, recorded more than 14 million minor surgeries, which accounted for about a quarter of all surgeries.
LCoGS indicators
The Lancet Commission on Global Surgery (LCoGS) deems this to be much less than the actual need. In 2015, LCoGS researchers found that New Zealand, which has universal health coverage, had 5,000 surgeries per 100,000 people. With a population of about 1.4 billion, the rate of surgeries in India is somewhere between 166 and 3,646 surgeries per 100,000, depending on the setting, population, and other factors.
LCoGS has proposed that countries, particularly low- and middle-income countries, collect and monitor high-quality data for six indicators: 1. population within two hours of a surgical care facility (timely geographical access); 2. number of surgeons, obstetricians, and anaesthetists per 100,000 people (SOA workforce density); 3. number of essential and emergency surgeries per 100,000 people (surgical volumes/rates); 4. mortality within 30 days of surgery per 1,000 procedures (perioperative mortality rate); 5. population at risk of impoverishment due to seeking surgery; and 6. population at risk of catastrophic expenditure (over 10% of their annual household expenses) due to seeking surgery.
Together, these indicators build a picture of surgeries as a part of healthcare at the population level and on the ground. For example, for my ‘minor surgery’, I had to travel only a few minutes to reach the hospital. Both the surgeon and the anaesthetist were readily available and had the skills and resources for the surgery. I had close follow-up for about a month after without any fatal or non-fatal adverse outcomes. I could also easily afford the surgery. These circumstances are highly exceptional.
Right to access surgery
Millions of children and adults around India, regardless of the severity of their condition, injury, need or affordability, are forced to treat the basic right of surgery as a luxury.
In fact, five billion people around the world are deprived of the fundamental right to access surgery when required. More than 90% of rural Indians are estimated to not have access to surgery when required. India’s limited data on LCoGS indicators reveals several reasons for this.
First, many people are unable to reach the hospital on time. A lack of facilities, poor road network, lack of vehicles (including ambulances), etc. contribute to the lack of timely access. Such access problems are more common in rural, remote, and hilly areas that together house more than two-thirds of the population.
Second, even if someone is able to reach a facility, there might not be the necessary resources for treatment. A surgeon, an anaesthetist, and some other clinical staff are essential to perform surgery. The size of the SOA workforce is small in several parts of India, especially beyond metropolitan and tier-II cities, and at crisis-levels in the rural public health system.
Third, the capacity to perform enough surgeries is also undermined by disparities based on where one lives, how much one is able to pay, etc. The met need for major surgeries is less than 7% in rural India.
Fourth, the quality of surgical care determines whether someone will have safe outcomes. This depends on surgeons’ training, the availability of necessary equipment, and the presence of appropriate peri-operative care, among other factors. The mortality rate is a sensitive indicator of safety – but data on perioperative mortality is heterogeneous and missing in several instances.
Fifth, due to the absence of universal healthcare coverage and limited surgical-care capability among public health facilities that provide free or subsidised care, the financial impact on people forced to seek care in private hospitals can be devastating. More than 60% of surgery patients in rural India face catastrophic expenses and several thousand risk impoverishment.
So when it comes to lack of access to surgical care, India is not an anomaly but the archetype for low- and middle-income countries.
Gaps in surgical care
India’s current surgical system gets by on civilian initiatives and subnational programmes – including countless surgeon-led small private establishments and government teaching and public district hospitals – that plug systemic gaps in surgical care.
Noteworthy examples include rural surgeons gathered under the Association for Rural Surgeons of India; emergency and trauma care, including free ambulance services in multiple states, by the EMRI Green Health Services; and organisations such as the Society for Education, Action, and Research in Community Health (SEARCH) and Jan Swasthya Sahyog (JSS), which serve tribal populations in difficult-to-reach areas. Individual surgeons working on technological innovations and groups such as the Global Surgery India Hub, which strengthen research networks, have also contributed to improving surgical care.
But the systemic gaps persist, and they must be eliminated if India can improve its performance on the LCoGS indicators.
Surgical action plan
The way out requires us to know how we ended up here. The main issue is a lack of problem recognition. Lack of surgical care access, preventable disease burden due to surgery, and the economic toll of surgery on society are still not considered to be a part of public health in the mainstream. This neglect persists in health policymaking and planning.
Over the last seven decades, India’s focus on surgical care has been limited, with little attention in the most recent National Health Policy (2017). Since the publication of LCoGS, many countries in Africa and South Asia have initiated National Surgical Obstetric Anaesthesia Plans (NSOAPs) or equivalent policies. India currently has no NSOAP. The lack of investments in data for monitoring and evaluation of surgical care indicators has also been a major roadblock.
So, using existing data, integrating surgical care data in existing surveys and systems, and building new dedicated data collection mechanisms are the ways out.
Siddhesh Zadey is co-founder of the non-profit Association for Socially Applicable Research (ASAR) India and chair of the G4 Alliance SOTA Care in the South Asia Working Group.
- India’s Health Management Information System would classify what I underwent as a ‘minor surgery’ because it didn’t require general or spinal anaesthesia.
- The Lancet Commission on Global Surgery (LCoGS) deems this to be much less than the actual need.
- The way out requires us to know how we ended up here. The main issue is a lack of problem recognition. Lack of surgical care access, preventable disease burden due to surgery, and the economic toll of surgery on society are still not considered to be a part of public health in the mainstream.
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