Lack of access to surgery: a public health problem.

Cad. Saúde Pública 2017; 33(10):e00151817 This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited. The report published in 2015 by the Lancet Commission on Global Surgery 1 considers the provision of surgical care an essential component of health systems and a major public health problem. The report defends the inclusion of access to surgical care on the health agenda, based on the principles of universal coverage, equity, and justice. Six indicators were selected, along with a structure for drafting a national plan to assess the current situation: access to timely essential surgery; specialist surgical workforce density; surgical volume; peri-operative mortality rate; risk of impoverishing expenditure; and risk of catastrophic expenditure. The application of these indicators in Brazil identified huge geographic inequality and regional differences in the supply of surgical care and the availability of qualified professionals, namely surgeons and anesthetists. Brazil’s hospital network is considered inefficient, with 57% of hospitals having 50 or fewer beds and 35.72% of hospitals concentrated in the Southeast region 2. The population in remote locations has to travel large distances to access a hospital that provides timely and effective care, including in emergency situations. Meanwhile, the number of beds in a hospital influences the quality of care provided, particularly surgical care, with a higher risk of adverse surgical events in small hospitals 3. Studies suggest an inverse relationship between volume of high-risk surgical procedures and mortality 4. The authors also emphasized the performance of simultaneous procedures by surgeons and anesthetists or by untrained professionals. Such practice definitely leads to negative results in the quality of surgical care and patient safety. The peculiarities of the Brazilian Unified National Health System (SUS) and the country’s large territory affect the supply of low, medium, and high-complexity surgical procedures. As highlighted by the authors, planning for increases in the coverage of low and medium-complexity surgeries should consider outpatient surgeries. Outpatient surgical centers should be designed to perform low and mediumcomplexity procedures in patients with good clinical status and who do not require staying more than 12 hours in the health service, leading to a reduction in operating costs. Adverse events, including deaths, raise concerns over patient safety and the need for government regulation. Quality improvement efforts in outpatient surgical care should seek adherence by surgeons and anesthetists to Brazilian Federal Board of Medicine (CFM) Resolution 1,886/2008 5, which sets minimum standards for functioning of medical offices and surgical centers for short-stay procedures. To guarantee that the patient can recover and be discharged within a reasonable time frame, standards 1 Instituto de Comunicação e Informação Científica e Tecnológica em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. 2 Unviersidade Federal Fluminense, Niterói, Brasil.