Poverty and surgery: Is the deck still stacked against low-income and middle-income nations?

Despite the fundamental principle of equal access to health care, low-income individuals often face significant obstacles in accessing medical treatment, particularly when it comes to surgery. For individuals living in poverty, the expense of care and the standard of health care facilities may be substantial obstacles, creating moral and social questions regarding the justice and equity of our health care system. A vicious cycle of deteriorating poverty and poorer health care outcomes exists between surgery and poverty, with poverty raising the risk of surgical disease and allowing subpar access to health care1. Thus, the question of whether the deck is stacked against low-income patients when it comes to surgery is one that demands urgent attention. There are more than 5 billion individuals who do not have sufficient means of surgical care. Compared with 14.9% of persons in high-income countries (HICs), 94% of individuals in low-income and middle-income countries (LMICs) lack access to basic surgical care2. In addition, 143 million unmet surgical needs worldwide exist, the bulk of which is concentrated in the world’s most underdeveloped areas, especially in Africa2. Only ~6% of the 313 million procedures performed annually in the global context take place in the poorest countries, which house more than 40% of the world’s population2. The significant disparity in access to surgical procedures is consistent with previous research findings. Untreated surgical conditions persist in certain populations in LMICs, leading to a significant number of preventable morbidities and mortalities. For instance, despite attempts to raise awareness regarding the advantages of surgical interventions for public health, up to 25% of fatalities and up to 33% of preventable illnesses in Malawi alone are caused by untreated surgical disorders, respectively3. According to Moustafa and colleagues, Syrian refugees constitute a sizable populace of patients unable to receive standard surgical intervention due to financial restrictions. The study elucidated that with mortality rates above 50%, 25% of patients with surgically curable conditions did not obtain essential surgical care4. Patients residing in impoverished domiciles must pay for their own health care, which delays seeking treatment and allows multifaceted cases to advance in severity. Significant health risks are associated with serious surgical disorders like appendicitis, peritonitis, congenital malformations, tumors, strangulated hernias, intestinal obstructions, and obstetric fistulas in these regions3. Although surgical management may cure the majority of obstetric fistulas (~80%–95%), many young women (~2 million) in Asia and sub-Saharan Africa continue to suffer from the condition, in stark contrast to the negligible number of untreated fistulas in HICs5. This disparity highlights the inability of patients in LICs to afford necessary obstetric surgical means. A complicated and intricate issue is the observed disparities in surgical delivery between HICs and LMICs, where a considerable difference in health care expenditure per person is elucidated. In 2015, the average per capita health spending in low-income countries (LICs) was around $110, while it was $5551 in HICs6. The discrepancy is even more pronounced when considering government spending on health care. In LICs, the government accounts for <30% of total health care expenditure, whereas in HICs, it accounts for nearly 80%6. This highlights the significant resource gap between these 2 regions in terms of providing accessible and high-quality health care. Subsequently, poor governance and corruption within the health care systems of LMICs siphon off funds intended for health care services7. Surgical care personnel are understaffed and lack proper training due to little financing and investment in health care. The quality of surgical delivery in underdeveloped countries is greatly impacted by the significant shortage of trained surgeons, anesthesiologists, obstetricians, and other health care professionals. LMICs, which account for 48% of the global population, have a disproportionately small workforce8, where 20% of all surgeons, 15% of anesthesiologists, and 29% of obstetricians are observed. In terms of density, LICs (0.7) and LMICs (5.5) have fewer providers per 100,000 people than upper-middle-income countries (22.6) and HICs (56.9)8. Low provider-to-patient ratios lead to overworked and burned-out health care workers, which may lower the quality of care. Between HICs and LMICs, there are also considerable differences in the availability of facilities for specialist surgical care. When compared with HICs, LMICs have a much lower proportion of surgical clinics and operating rooms. While some HICs have more than 14 operating rooms per 100,000 individuals, many LMICs have fewer than one operating room per 100,000 persons9. This may be attributed to HICs possessing more expenditure to dedicate the development and maintenance of the health care infrastructure. Fewer operating rooms carry a higher danger of overcrowding, which may raise the risk of infection, compromise patient privacy, and lengthen recovery times. Furthermore, with less surgical capacity, there is a greater risk of overworked health care professionals and burnout, which may negatively impact the quality of surgical care. Rural areas in LMICS are almost totally neglected though that region hosts the majority of the region’s population. The provision of high-quality health care has been significantly hampered by poverty, demanding increasingly sophisticated approaches. In LMICs, there should be more financing for workforce development and health care infrastructure. This may aid with the building and maintenance of health care buildings as well as the hiring, retaining, and training of health care professionals, including surgeons, anesthesiologists, and obstetricians. Moreover, a substantial improvement would be to lower the cost of surgical care for individuals and groups living in disadvantaged locations. This may be conducted in a plethora of methodologies by improving accessibility to health care insurance, sustaining funding for travel and medical expenses, and establishing community-based health financing programs. More emphasis should be placed on the paramount importance of surgery in advancing public health and the negative consequences of neglected surgical disorders. In underdeveloped regions, implementing programs to address socioeconomic determinants of health, including income inequality and poverty, may be particularly beneficial. Policies must be devised and established to halt the exodus of medical workers from poor areas. This could entail offering incentives to encourage medical experts to remain in their home countries, such as better working conditions and greater salaries. Working with other organizations and stakeholders to build the capacity and resources for surgical treatment in underserved areas will be advantageous. Ethical approval Not applicable. Sources of funding None. Author contribution Conceptualization of Ideas: Wireko Andrew Awuah. Writing of Initial Draft, Review and Editing: Wireko Andrew Awuah, Favour Tope Adebusoye, Abdus Salam, Shankaneel Ghosh, Jack Wellington, Amal Olabisi Ahmad, Anastasia Fosuah Debrah, Toufik Abdul-Rahman, and Nikitina Iryna Mykolaivna. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Favour Tope Adebusoye.