Tracking global expenditures on surgery: gaps in knowledge hinder progress
Authors: Joseph L Dieleman, Gavin Yamey, Elizabeth K Johnson, Casey M Graves, Annie Haakenstad, John G Meara
Journal: The Lancet Global Health (2015)

Very little is known about how much is spent on surgical care delivery globally. Anecdotal evidence suggests that per-person expenditure on surgery varies enormously across countries. This cross-country and intervention-specific variation makes estimating global and country-level expenditure on surgery challenging; thus, these expenditure figures have not been produced to date. This gap in knowledge about funding to surgery is a major barrier to scale-up of surgical services, because it means that policymakers are unaware of the potential growth in expenditure associated with changes in care.In an attempt to estimate global surgical expenditure, we reviewed 958 country-generated National Health Accounts (NHAs) from 1996 to 2010.1Bui AL, Lavado RF, Brooks BP, et al. National Health Accounts data from 1996 to 2010: a systematic review. Bull World Health Organ (in press).Google Scholar NHA reports, completed annually by high-income countries and somewhat routinely by many low-income and middle-income countries, provide an accounting framework for national expenditure on health. They are the seminal tool for systematically tracking and comparing health expenditures.2Poullier J-P Hernandez P Kawabata K National Health Accounts: concepts, data sources, and methodology.in: Murray CJ Evans DB Health systems performance assessment: debates, methods and empiricism. WHO, Geneva2003: 185-193Google Scholar We found that only two countries, Georgia and Kyrgyzstan, have routinely reported expenditure on surgery in their NHAs. For the remaining countries, we know of no other comparable source for tracking funds for surgery.We also reviewed the Institute for Health Metrics and Evaluation's (IHME's) database on development assistance for health (DAH).3Dieleman JL Graves CM Templin T et al.Global health development assistance remained steady in 2013 but did not align with recipients' disease burden.Health Aff. 2014; (published online April 8.)http://dx.doi.org/10.1377/hlthaff.2013.1432Google Scholar DAH, at upwards of 50% of government health budgets in some low-income countries, can be an important means of financing health care.4Institute for Health Metrics and EvaluationFinancing global health 2013: transition in an age of austerity. IHME, Seattle2013Google Scholar Because no major donor or project-level database identifies projects related to surgery, we searched the IHME project-level database for projects that are described using keywords related to surgery—ie, “surgery”, “surgeon”, and “operating room”, including translations of these keywords into other languages used in the database. Correct identification, of course, depends on donors describing surgery-related projects with these precise terms. Nonetheless, we found that, in 2011, a total of just US$22 million was channelled from high-income countries to low-income and middle-income countries with the explicit purpose of supporting surgery; this is less than 1% of the US$30·6 billion of total DAH in 2011.Expenditure tracking is essential for strategic rather than incremental planning.5Global Health Resource Tracking Working GroupFollowing the money: toward better tracking of global health resources. Center for Global Development, Washington, DC2007Google Scholar Knowing how much is spent on health interventions, including surgery, allows policymakers, managers, and donors to assess the allocation of resources and identify gaps in financing that could have implications for coverage of vital health services. Accessing this information will become increasingly important as the need for these procedures grows with the anticipated increase in burden related to non-communicable diseases and injuries in developing countries.6Murray CJL Vos T Lozano R et al.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2197-2223Summary Full Text Full Text PDF PubMed Scopus (6188) Google Scholar Retrospective estimates of surgery expenditure, paired with burden, can feed into projections of the financing needed to deliver these services. Such information would allow decision-makers to efficiently manage resources, weighing crucial trade-offs and capitalising on important health-sector synergies. Disaggregating spending by types of surgery could also expose important areas of expenditure that could be reduced with health promotion and prevention activities. Overall, basic expenditure data allow for major improvements in the management and coordination of resources.Expenditure tracking highlights key financing gaps and shortfalls in funding in other areas of health and identifies whether resources are delivered as intended. For example, infectious diseases (HIV/AIDS, tuberculosis, and malaria) and maternal, newborn, and child health programmes have benefited from impressive increases in DAH commitments.3Dieleman JL Graves CM Templin T et al.Global health development assistance remained steady in 2013 but did not align with recipients' disease burden.Health Aff. 2014; (published online April 8.)http://dx.doi.org/10.1377/hlthaff.2013.1432Google Scholar Still, such commitments could go unrealised, merely replace domestic funding, or be wasted away inefficiently. Simultaneous investments in expenditure tracking mechanisms, such as NHA disease-specific subaccounts, UNAIDS National AIDS Spending Assessments, and the Partnership for Maternal, Newborn, and Child Health annual reports, have increased the likelihood that these new resources do not meet this fate, and are realised as additional to domestic expenditure.7Diener A Morgan D Deriving expenditures by disease under the System of Health Accounts (SHA) 2011 framework: a systematic analysis.Lancet. 2013; 381: S41Summary Full Text Full Text PDF Google Scholar, 8Joint United Nations Programme on HIV/AIDSNASA publications and tools.http://www.unaids.org/en/dataanalysis/knowyourresponse/nasacountryreportsGoogle Scholar, 9Partnership for MaternalNewbornChild HealthThe PMNCH 2013 Report.http://www.who.int/pmnch/knowledge/publications/2013_pmnch_report/en/Google Scholar Furthermore, tracking methods such as these have catalysed action in other sectors, including coalitions harnessing pooled resources, expertise, and political will for international action.10Reddy KS Yadav A Arora M Nazar GP Integrating tobacco control into health and development agendas.Tob Control. 2012; 21: 281-286Crossref PubMed Scopus (25) Google ScholarImportant strategic decisions must be made to accelerate the scale-up of surgical services in low-resource settings. Robust estimates of the currently available financial resources and funding gaps are the cornerstones of decision-making. Yet at the most basic level, we are unaware of how much is spent on surgical care delivery at the country and global levels. We find there is very little systematic tracking of expenditure on surgery in NHAs, and development assistance for surgery appears to be minimal. At a minimum, NHA reports should disaggregate health spending to track expenditure on surgery and development partners should code health projects to identify development assistance related to surgery. A robust accounting framework that disaggregates health expenditure by intervention, such as surgery, is a necessary input for systematic and efficient scale-up of such a crucial set of health interventions.We declare no competing interests. Very little is known about how much is spent on surgical care delivery globally. Anecdotal evidence suggests that per-person expenditure on surgery varies enormously across countries. This cross-country and intervention-specific variation makes estimating global and country-level expenditure on surgery challenging; thus, these expenditure figures have not been produced to date. This gap in knowledge about funding to surgery is a major barrier to scale-up of surgical services, because it means that policymakers are unaware of the potential growth in expenditure associated with changes in care. In an attempt to estimate global surgical expenditure, we reviewed 958 country-generated National Health Accounts (NHAs) from 1996 to 2010.1Bui AL, Lavado RF, Brooks BP, et al. National Health Accounts data from 1996 to 2010: a systematic review. Bull World Health Organ (in press).Google Scholar NHA reports, completed annually by high-income countries and somewhat routinely by many low-income and middle-income countries, provide an accounting framework for national expenditure on health. They are the seminal tool for systematically tracking and comparing health expenditures.2Poullier J-P Hernandez P Kawabata K National Health Accounts: concepts, data sources, and methodology.in: Murray CJ Evans DB Health systems performance assessment: debates, methods and empiricism. WHO, Geneva2003: 185-193Google Scholar We found that only two countries, Georgia and Kyrgyzstan, have routinely reported expenditure on surgery in their NHAs. For the remaining countries, we know of no other comparable source for tracking funds for surgery. We also reviewed the Institute for Health Metrics and Evaluation's (IHME's) database on development assistance for health (DAH).3Dieleman JL Graves CM Templin T et al.Global health development assistance remained steady in 2013 but did not align with recipients' disease burden.Health Aff. 2014; (published online April 8.)http://dx.doi.org/10.1377/hlthaff.2013.1432Google Scholar DAH, at upwards of 50% of government health budgets in some low-income countries, can be an important means of financing health care.4Institute for Health Metrics and EvaluationFinancing global health 2013: transition in an age of austerity. IHME, Seattle2013Google Scholar Because no major donor or project-level database identifies projects related to surgery, we searched the IHME project-level database for projects that are described using keywords related to surgery—ie, “surgery”, “surgeon”, and “operating room”, including translations of these keywords into other languages used in the database. Correct identification, of course, depends on donors describing surgery-related projects with these precise terms. Nonetheless, we found that, in 2011, a total of just US$22 million was channelled from high-income countries to low-income and middle-income countries with the explicit purpose of supporting surgery; this is less than 1% of the US$30·6 billion of total DAH in 2011. Expenditure tracking is essential for strategic rather than incremental planning.5Global Health Resource Tracking Working GroupFollowing the money: toward better tracking of global health resources. Center for Global Development, Washington, DC2007Google Scholar Knowing how much is spent on health interventions, including surgery, allows policymakers, managers, and donors to assess the allocation of resources and identify gaps in financing that could have implications for coverage of vital health services. Accessing this information will become increasingly important as the need for these procedures grows with the anticipated increase in burden related to non-communicable diseases and injuries in developing countries.6Murray CJL Vos T Lozano R et al.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2197-2223Summary Full Text Full Text PDF PubMed Scopus (6188) Google Scholar Retrospective estimates of surgery expenditure, paired with burden, can feed into projections of the financing needed to deliver these services. Such information would allow decision-makers to efficiently manage resources, weighing crucial trade-offs and capitalising on important health-sector synergies. Disaggregating spending by types of surgery could also expose important areas of expenditure that could be reduced with health promotion and prevention activities. Overall, basic expenditure data allow for major improvements in the management and coordination of resources. Expenditure tracking highlights key financing gaps and shortfalls in funding in other areas of health and identifies whether resources are delivered as intended. For example, infectious diseases (HIV/AIDS, tuberculosis, and malaria) and maternal, newborn, and child health programmes have benefited from impressive increases in DAH commitments.3Dieleman JL Graves CM Templin T et al.Global health development assistance remained steady in 2013 but did not align with recipients' disease burden.Health Aff. 2014; (published online April 8.)http://dx.doi.org/10.1377/hlthaff.2013.1432Google Scholar Still, such commitments could go unrealised, merely replace domestic funding, or be wasted away inefficiently. Simultaneous investments in expenditure tracking mechanisms, such as NHA disease-specific subaccounts, UNAIDS National AIDS Spending Assessments, and the Partnership for Maternal, Newborn, and Child Health annual reports, have increased the likelihood that these new resources do not meet this fate, and are realised as additional to domestic expenditure.7Diener A Morgan D Deriving expenditures by disease under the System of Health Accounts (SHA) 2011 framework: a systematic analysis.Lancet. 2013; 381: S41Summary Full Text Full Text PDF Google Scholar, 8Joint United Nations Programme on HIV/AIDSNASA publications and tools.http://www.unaids.org/en/dataanalysis/knowyourresponse/nasacountryreportsGoogle Scholar, 9Partnership for MaternalNewbornChild HealthThe PMNCH 2013 Report.http://www.who.int/pmnch/knowledge/publications/2013_pmnch_report/en/Google Scholar Furthermore, tracking methods such as these have catalysed action in other sectors, including coalitions harnessing pooled resources, expertise, and political will for international action.10Reddy KS Yadav A Arora M Nazar GP Integrating tobacco control into health and development agendas.Tob Control. 2012; 21: 281-286Crossref PubMed Scopus (25) Google Scholar Important strategic decisions must be made to accelerate the scale-up of surgical services in low-resource settings. Robust estimates of the currently available financial resources and funding gaps are the cornerstones of decision-making. Yet at the most basic level, we are unaware of how much is spent on surgical care delivery at the country and global levels. We find there is very little systematic tracking of expenditure on surgery in NHAs, and development assistance for surgery appears to be minimal. At a minimum, NHA reports should disaggregate health spending to track expenditure on surgery and development partners should code health projects to identify development assistance related to surgery. A robust accounting framework that disaggregates health expenditure by intervention, such as surgery, is a necessary input for systematic and efficient scale-up of such a crucial set of health interventions. We declare no competing interests.