In sub-Saharan Africa, only 46% of births are attended by skilled personnel, compared to 96% in Europe (according to data for the African Region of the World Health Organization [WHO] from 2000 to 2008 ). In 2005, slightly over one quarter of a million women died from complications of childbirth ; most of these deaths could have been avoided by providing women with access to basic obstetric care and obstetric surgical care. On average, across sub-Saharan Africa, a population of 10,000 is served by two doctors and 11 nursing and midwifery personnel, compared to 32 and 79 respectively serving the same number of people in Europe (WHO data 2000–2007 ). A child born in sub-Saharan Africa in 2007 could expect to live only 52 years, which is 22 years less than its European counterpart . Such starkly contrasting figures drive national and international efforts to build health system capacity to save lives and increase life expectancies in Africa. We argue that these efforts should include surgical capacity, a neglected component of a functioning health system.
The overall disease burden associated with surgical conditions in sub-Saharan Africa is estimated at 38 DALYS (disability adjusted life years) lost per 1,000 population. This estimate is higher than in other regions of the world, and is mainly due to injuries (15/1,000), obstetric complications (6/1,000), malignancies (3/1,000), perinatal conditions (3/1,000), congenital anomalies (3/1,000), and cataracts and glaucoma (2/1,000) . The estimated cost per surgical DALY gained at a district hospital is in the range of US$19–102 . By comparison, the basic immunization program in Africa costs under US$10/DALY averted, malaria prevention and treatment costs US$2–24/DALY averted, and oral rehydration therapy for diarrheal disease can cost around US$1,062/DALY averted . Antiretroviral therapy for HIV infection in sub-Saharan Africa is estimated to be in the range of US$350–1,494/DALY averted . Yet, the global health community has largely neglected surgical diseases when supporting health interventions in sub-Saharan Africa ,.
The Bellagio Essential Surgery Group (BESG)—a network of surgeons, anesthesiologists, public health professionals, economists, and policy makers—was formed to advocate for increased access to surgery in Africa to reduce the surgical burden of disease (Box 1). The BESG builds on and collaborates with the significant work of the WHO in promoting surgical and trauma care. The WHO Global Initiative for Emergency and Essential Surgical Care is a multidisciplinary group of stakeholders committed to reducing death and disability in injuries, pregnancy-related complications, and congenital anomalies, and was the first coordinated effort on emergency and essential surgical care . WHO Essential Trauma Care Project aims to set reasonable, affordable minimum standards for the care of injured persons worldwide and defines the human and physical resources necessary to ensure these services .
Box 1. Bellagio Essential Surgery Group (BESG)
The BESG (http://www.essentialsurgery.org/bellagio/docs/2008_kampala_essential_surgery_report.pdf) is a multidisciplinary, international network focused on developing collaborative strategies to increase access to surgical services across sub-Saharan Africa. With support from the Rockefeller Foundation, the BESG first met in Bellagio, Italy in June 2007 and, with support from the Bill &Melinda Gates Foundation, the group met in Kampala, Uganda in July 2008 to develop specific cross-country strategies and implementation plans to address the large disease burden due to surgical conditions in sub-Saharan Africa. The BESG welcomes participation from all health professionals working to decrease disparities in access to health care and to reduce the burden of disease experienced by poor people living in sub-Saharan Africa.
We recommend four priority areas for national and international agencies to target in order to begin to address the surgical burden of disease in sub-Saharan Africa. The priority areas are based on the experience of projects in Ghana, Malawi, Mozambique, Niger, Tanzania, and Uganda and the WHO. The consensus statement from the 2008 BESG Kampala meeting can be found in Text S1. The context guiding our recommendations is the lack of even the most basic surgical services in rural areas and small towns throughout sub-Saharan Africa and our recognition of the broader role of surgery in strengthening health systems and fulfilling a basic human right to health care. Our definition of a surgical condition is one that “requires suture, incision, excision, manipulation, or other invasive procedure that usually, but not always, requires local, regional, or general anesthesia” as proposed by Debas et al. . This definition includes major obstetric interventions.