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Summary 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 affordability. 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. Funding None.

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Purpose Approximately 150 million individuals face catastrophic expenditure each year from medical costs alone, and many more from the nonmedical costs of accessing care. The proportion of this expenditure arising from surgical conditions is unknown. Because World Bank has proposed eliminating medical impoverishment by 2030, the impact of surgical conditions on financial catastrophe must be quantified so that any financial risk protection mechanisms can appropriately incorporate surgery. Methods To determine the global incidence of catastrophic expenditure due to surgery, a stochastic model was built. The income distribution of each country, the probability of requiring surgery, and the medical and nonmedical costs faced for surgery were incorporated. Sensitivity analyses were run to test model robustness. Findings 3.7 billion people risk catastrophic expenditure if they need surgery. Every year, 33 million of them are driven to financial catastrophe from the costs of surgery alone, and 48 million from nonmedical costs, leading to 81 million cases worldwide. The burden of catastrophic expenditure is highest in low- and middle-income countries; within any country, it falls on the poor. Estimates are sensitive to the definition of catastrophic expenditure and the costs of care. The inequitable burden distribution is robust to model assumptions. Interpretation Half the global population is at risk of financial catastrophe from surgery. Annually, 81 million individuals, especially the poor, face catastrophic expenditure due to surgical conditions, 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. Funding Partial funding for Dr. Shrime from NIH/NCI R25CA92203.

Object Evidence from the CURE Children's Hospital of Uganda (CCHU) suggests that treatment for hydrocephalus in infants can be effective and sustainable in a developing country. This model has not been broadly supported or implemented due in part to the absence of data on the economic burden of disease or any assessment of the cost and benefit of treatment. The authors used economic modeling to estimate the annual cost and benefit of treating hydrocephalus in infants at CCHU. These results were then extrapolated to the potential economic impact of treating all cases of hydrocephalus in infants in sub-Saharan Africa (SSA). Methods The authors conducted a retrospective review of all children initially treated for hydrocephalus at CCHU via endoscopic third ventriculostomy or shunt placement in 2005. A combination of data and explicit assumptions was used to determine the number of times each procedure was performed, the cost of performing each procedure, the number of disability-adjusted life years (DALYs) averted with neurosurgical intervention, and the economic benefit of the treatment. For CCHU and SSA, the cost per DALY averted and the benefit-cost ratio of 1 year's treatment of hydrocephalus in infants were determined. Results In 2005, 297 patients (median age 4 months) were treated at CCHU. The total cost of neurosurgical intervention was $350,410, and the cost per DALY averted ranged from $59 to $126. The CCHU's economic benefit to Uganda was estimated to be between $3.1 million and $5.2 million using a human capital approach and $4.6 million–$188 million using a value of a statistical life (VSL) approach. The total economic benefit of treating the conservatively estimated 82,000 annual cases of hydrocephalus in infants in SSA ranged from $930 million to $1.6 billion using a human capital approach and $1.4 billion–$56 billion using a VSL approach. The minimum benefit-cost ratio of treating hydrocephalus in infants was estimated to be 7:1. Conclusions Untreated hydrocephalus in infants exacts an enormous price from SSA. The results of this study suggest that neurosurgical intervention has a cost/DALY averted comparable to other surgical interventions that have been evaluated, as well as a favorable benefit-cost ratio. The prevention and treatment of hydrocephalus in SSA should be recognized as a major public health priority.