Assessing the Brazilian surgical system with six surgical indicators: a descriptive and modelling study

BACKGROUND: Brazil boasts a health scheme that aspires to provide universal coverage, but its surgical system has rarely been analysed. In an effort to strengthen surgical systems worldwide, the Lancet Commission on Global Surgery proposed a collection of 6 standardised indicators: 2-hour access to surgery, surgical workforce density, surgical volume, perioperative mortality rate (POMR) and protection against impoverishing and catastrophic expenditure. This study aims to characterise the Brazilian surgical health system with these newly devised indicators while gaining understanding on the complexity of the indicators themselves. METHODS: Using Brazil's national healthcare database, commonly reported healthcare variables were used to calculate or simulate the 6 surgical indicators. Access to surgery was calculated using hospital locations, surgical workforce density was calculated using locations of surgeons, anaesthesiologists and obstetricians (SAO), and surgical volume and POMR were identified with surgical procedure codes. The rates of protection against impoverishing and catastrophic expenditure were modelled using cost of surgical inpatient hospitalisations and a γ distribution of incomes based on Gini and gross domestic product/capita. FINDINGS: In 2014, SAO density was 34.7/100 000 population, surgical volume was 4433 procedures/100 000 people and POMR was 1.71%. 79.4% of surgical patients were protected against impoverishing expenditure and 84.6% were protected against catastrophic expenditure due to surgery each year. 2-hour access to surgery was not able to be calculated from national health data, but a proxy measure suggested that 97.2% of the population has 2-hour access to a hospital that may be able to provide surgery. Geographic disparities were seen in all indicators. INTERPRETATION: Brazil's public surgical system meets several key benchmarks. Geographic disparities, however, are substantial and raise concerns of equity. Policies should focus on stimulating appropriate geographic allocation of the surgical workforce and better distribution of surgical volume. In some cases, where benchmarks for each indicator are met, supplemental analysis can further inform our understanding of health systems. This measured and systematic evaluation should be encouraged for all nations seeking to better understand their surgical systems.