If We Cannot Measure It, We Cannot Fix It: Why Global Surgery Needs Better Data

Across all 217 World Bank-classified countries, fewer than half have ever published an estimate for timely access to essential surgery, only a third have reported a perioperative mortality rate (an indicator where the global target is simply universal tracking rather than a specific numerical rate). Financial risk protection-arguably one of the indicator most relevant to patients-has been documented in just five countries.3 For the busy surgeon or anaesthetist, this is akin to running an operating theatre with no logbook and no morbidity audit: you cannot improve what you do not record.

Where data do exist, the inequity is stark. Almost all high-income countries meet the access and workforce benchmarks, yet not a single low-income country reaches the surgical workforce target of 20 specialist providers per 100 000 population, and no low- or lower-middle-income country achieves the surgical volume benchmark of 5000 procedures per 100 000.3,4 Furthermore, even though most high-income countries meet national access benchmarks, this broad compliance can mask substantial subnational inequities for different population groups. These are not incremental shortfalls; they represent order-of-magnitude gaps in surgical capacity that translate directly into preventable death and disability.3,5

When primary data are absent, researchers increasingly turn to modelling to generate national estimates.4,6 Our review identified 17 such studies and assessed their quality using a tool adapted from the GATHER statement,7 refined through expert consultation. The findings were concerning: only four studies met high-quality criteria across a majority of domains. Most lacked transparency in data sources, fewer than a fifth described prospective input data, and just 12% validated their models against observed data.3 If the global surgery community is to rely on modelled estimates to guide investment and policy, those estimates must be held to minimum standards of rigour. Without this, we risk building policy on foundations we cannot verify.

The contrast with other areas of global health is instructive. Maternal and newborn health programmes have made measurable gains through coordinated indicator frameworks, dedicated financing, and routine data collection via platforms like the Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Surgery does not need to build a new system from scratch-it needs integration into these existing, proven mechanisms. Platforms such as DHIS2, used by over 80 countries, and the WHO Operative Encounter Registry already offer practical infrastructure for embedding surgical metrics into national health information systems.8

For surgeons and anaesthetists working in low-resource settings, this is not an abstract data exercise. Without routine indicator reporting, surgical need remains invisible in universal health coverage benefit packages, official development assistance allocations, and Sustainable Development Goal progress reviews.9,10 This invisibility perpetuates a cycle: limited data leads to limited funding, which leads to limited capacity, which leads to limited data.

With fewer than five years until the 2030 deadline, the window for course correction is narrowing. Three actions could accelerate progress. First, the WHO should provide normative leadership by standardizing indicator definitions and establishing minimum reporting cycles.2 Second, multilateral development banks and bilateral funders should condition financing on reliable surgical data reporting, as they already do for immunization and infectious disease programmes.10 Third, the research community must adopt minimum quality standards for modelled estimates-the tool we developed in this review offers a starting point.3,7

The LCoGS indicators were designed as an accountability framework.1 Ten years on, the framework exists but the accountability infrastructure does not. If we are serious about achieving safe, affordable surgical care for all, we must first be serious about counting.