A low-cost, DIY tourniquet simulator with built-in self-assessment for prehospital providers in Guatemala city.

BACKGROUND: Hemorrhage is the leading cause of preventable death after trauma. In high-income countries first responders are trained in hemorrhage control techniques but this is not the case for developing countries like Guatemala. We present a low-cost training model for tourniquet application using a combination of virtual and physical components. METHODS: The training program includes a mobile application with didactic materials, videos and a gamified virtual reality environment for learning. Additionally, a physical training model of a bleeding lower extremity is developed allowing learners to practice tourniquet application using inexpensive and accessible materials. Validation of the simulator occurred through content and construct validation. Content validation involved subjective assessments by novices and experts, construct validation compared pre-training novices with experts. Training validation compared pre and post training novices for improvement. RESULTS: Our findings indicate that users found the simulator useful, realistic, and satisfactory. We found significant differences in tourniquet application skills between pre-training novices and experts. When comparing pre- and post-training novices, we found a significantly lower bleeding control time between the groups. CONCLUSION: This study suggests that this training approach can enhance access to life-saving skills for prehospital personnel. The inclusion of self-assessment components enables self-regulated learning and reduces the need for continuous instructor presence. Future improvements involve refining the tourniquet model, validating it with first-responder end users, and expanding the training program to include other skills.

Protocol: identifying policy, system, and environment change interventions to enhance availability of blood for transfusion in Kenya, a mixed-methods study.

BACKGROUND: Safe blood is essential for the care of patients with life-threatening anemia and hemorrhage. Low blood donation rates, inefficient testing procedures, and other supply chain disruptions in blood administration affect patients in low-resource settings across Sub-Saharan countries, including Kenya. Most efforts to improve access to transfusion have been unidimensional, usually focusing on only point along the blood system continuum, and have excluded community stakeholders from early stages of intervention development. Context-appropriate interventions to improve the availability of safe blood at the point of use in low-resource settings are of paramount importance. Thus, this protocol proposes a multifaceted approach to characterize the Kenyan blood supply chain through quantitative and qualitative analyses as well as an industrial engineering approach. METHODS: This study will use a mixed-methods approach in addition to engineering process mapping, modeling and simulation of blood availability in Kenya. It will be guided by a multidimensional three-by-three-by-three matrix: three socioeconomic settings, three components of the blood system continuum, and three levels of urgency of blood transfusion. Qualitative data collection includes one-on-one interviews and focus group discussions with stakeholders across the continuum to characterize ground-level deficits and potential policy, systems, and environment (PSE) interventions. Prospectively-collected quantitative data will be used to estimate blood collection and transfusion of blood. We will create a process map of the blood system continuum to model the response to PSE changes proposed by stakeholders. Lastly, we will identify those PSE changes that may have the greatest impact on blood transfusion availability, accounting for differences across socioeconomic settings and levels of urgency. DISCUSSION: Identifying and prioritizing community-driven interventions to improve blood supply in low-resource settings are of utmost importance. Varied constraints in blood collection, processing, delivery, and use make each socioeconomic setting unique. Using a multifaceted approach to understand the Kenyan blood supply and model the response to stakeholder-proposed PSE changes may lead to identification of contextually appropriate intervention targets to meet the transfusion needs of the population.

The BLOODSAFE program: Building the future of access to safe blood in Sub-Saharan Africa.

BACKGROUND: The supply of blood in many low- and middle-income nations in Sub-Saharan Africa (SSA) does not meet the patient care needs. Lack and delay of blood transfusion cause harm to patients and slow the rate of progress in other parts of the health system. Recognizing the power of implementation science, the BLOODSAFE Program was initiated which supports three SSA research study teams and one data coordinating center (DCC) with the goal to improve access to safe blood transfusion in SSA. STUDY DESIGN AND METHODS: The study team in Ghana is focusing on studying and decreasing iron deficiency in blood donors and evaluating social engagement of blood donors through different approaches. The study team in Kenya is building a "vein to vein" workflow model to elucidate and devise strategies to overcome barriers to blood donation and improve infrastructural components of blood product production and use. The Malawi team is studying the infectious disease ramifications of blood donation as well as blood donor retention strategies aimed at blood donors who commence their donation career in secondary schools. RESULTS AND DISCUSSION: Together the project teams and the DCC work as a consortium to support each other through a shared study protocol that will study donor motivations, outcomes, and adverse events across all three countries. The BLOODSAFE Program has the potential to lead to generalizable improvement approaches for increasing access to safe blood in SSA as well as mentoring and building the research capacity and careers of many investigators.

Mortality and Risk Factors in Isolated Traumatic Brain Injury Patients: A Prospective Cohort Study.

INTRODUCTION: Outcomes in patients with isolated traumatic brain injury (iTBI) have not been evaluated comprehensively in low-income and middle-income countries. We aimed to study the in-hospital iTBI mortality and its associated risk factors in a prospective multicenter Indian trauma registry. METHODS: Patients with iTBI (head and neck Abbreviated Injury Score ≥2 and other region Abbreviated Injury Score ≤2) were included. Study variables comprised age, gender, mechanism of injury, systolic blood pressure (SBP) at arrival, Glasgow Coma Scale (GCS) score - classified as mild (13-15), moderate (9-12), and severe (3-8), transfer status, and time to presentation at any participating hospital. A multivariable logistic regression was performed to assess the impact of these factors on 24-h and 30-d mortality following iTBI. RESULTS: Among 5042 included patients, 24-h and 30-d in-hospital mortalities were 5.9% and 22.4%. On a regression analysis, 30-d mortality was associated with age ≥45 y (odds ratio [OR] = 2.1 [1.6-2.7]), railway injury mechanisms (OR = 2.1 [1.3-3.5]), SBP <90 mmHg (OR = 2.6 [1.6-4.1]), and moderate (OR = 3.8 [3.0-5.0]) to severe (OR = 21.1 [16.8-26.7]) iTBI based on GCS scores. 24-h mortality showed similar trends. Patients transferred to the participating hospitals from other centers had higher odds of 30-d mortality (OR = 1.4 [1.2-1.8]) compared to those arriving directly. Those who received neurosurgical intervention had lower odds of 24-h mortality (0.3 [0.2-0.4]). CONCLUSIONS: Age ≥45 y, GCS score ≤12, and SBP <90 mmHg at arrival increased the risk of in-hospital mortality from iTBI.

Academic Output in Global Surgery after the Lancet Commission on Global Surgery: A Scoping Review.

BACKGROUND: The Lancet Commission on Global Surgery (LCoGS) published its seminal report in 2015, carving a niche for global surgery academia. Six years after the LCoGS, a scoping review was conducted to see how the term 'global surgery' is characterized by the literature and how it relates to LCoGS and its domains. METHODS: PubMed was searched for publications between January 2015 and February 2021 that used the term 'global surgery' in the title, abstract, or key words or cited the LCoGS. Variables extracted included LCoGS domains, authorship metrics, geographic scope, and clinical specialty. RESULTS: The search captured 938 articles that qualified for data extraction. Nearly 80% of first and last authors had high-income country affiliations. Africa was the most frequently investigated region, though many countries within the region were under-represented. The World Journal of Surgery was the most frequent journal, publishing 13.9% of all articles. General surgery, pediatric surgery, and neurosurgery were the most represented specialties. Of the LCoGS domains, healthcare delivery and management were the most studied, while economics and financing were the least studied. CONCLUSION: A lack of consensus on the definition of global surgery remains. Additional research is needed in economics and financing, while obstetrics and trauma are under-represented in literature using the term 'global surgery'. Efforts in academic global surgery must give a voice to those carrying the global surgery agenda forward on the frontlines. Focusing on research capacity-building and encouraging contribution by local partners will lead to a stronger, more cohesive global surgery community.

Different Crises, Different Patterns of Trauma. The Impact of a Social Crisis and the COVID-19 Health Pandemic on a High Violence Area.

BACKGOUND: Santiago, Chile underwent two separate periods of crisis over the past year. The first period, the 'social crisis,' extended over thirteen weeks in late 2019 into early 2020 due to protests over income inequality and the government response to social unrest. The second period, the 'health crisis,' began in March 2020 with Chile's first case of COVID-19 and escalated rapidly to include 'stay at home orders,' traffic restrictions, and the shuttering of most businesses. We wished to evaluate the impact of these crisis periods on trauma epidemiology. METHODS: We performed a retrospective review of the South-East Metropolitan Health Service Trauma Registry. Trauma admissions, operative volume, and in-hospital mortality were evaluated during the crisis period and the year prior. RESULTS: The social crisis saw increased levels of trauma, both blunt and penetrating, relative to the time period immediately preceding. The health crisis saw an increase in penetrating trauma with a concomitant decline in blunt trauma. Both crisis periods had decreased levels of trauma, overall, compared to the year prior. There were no statistically significant differences in in-hospital trauma mortality. CONCLUSION: Different crises may have different patterns of trauma. Crisis periods that include extended periods of lockdown and curfew may lead to increasing penetrating trauma volume. Governments and health officials should anticipate the aggregate impact of these measures on public health and develop strategies to actively mitigate them. LEVEL OF EVIDENCE: III.

Outcomes of Renal Trauma in Indian Urban Tertiary Healthcare Centres: A Multicentre Cohort Study.

BACKGROUND: Renal trauma is present in 0.5-5% of patients admitted for trauma. Advancements in radiologic imaging and minimal-invasive techniques have led to decreased need for surgical intervention. We used a large trauma cohort to characterise renal trauma patients, their management and outcomes. METHODS: We analysed "Towards Improved Trauma Care Outcomes in India" cohort from four urban tertiary public hospitals in India between 1st September 2013 and 31st December 2015. The data of patients with renal trauma were extracted using International Classification of Diseases 10 codes and analysed for demographic and clinical details. RESULTS: A total of 16,047 trauma patients were included in this cohort. Abdominal trauma comprised 1119 (7%) cases, of which 144 (13%) had renal trauma. Renal trauma was present in 1% of all the patients admitted for trauma. The mean age was 28 years (SD-14.7). A total of 119 (83%) patients were male. Majority (93%) were due to blunt injuries. Road traffic injuries were the most common mechanism (53%) followed by falls (29%). Most renal injuries (89%) were associated with other organ injuries. Seven of the 144 (5%) patients required nephrectomy. Three patients had grade V trauma; all underwent nephrectomy. The 30-day in-hospital mortality, in patients with renal trauma, was 17% (24/144). CONCLUSION: Most renal trauma patients were managed nonoperatively. 89% of patients with renal trauma had concomitant injuries. The renal trauma profile from this large cohort may be generalisable to urban contexts in India and other low- and middle-income countries.

Quality of essential surgical care in low- and middle-income countries: a systematic review of the literature.

PURPOSE: Quality of care is an emerging area of focus in the surgical disciplines. However, much of the emphasis on quality is limited to high-income countries. To address this gap, we conducted a systematic review of the literature on the quality of essential surgical care in low- and middle- income countries (LMIC). DATA SOURCES: We searched PubMed, Cinahl, Embase and CAB Abstracts using three domains: quality of care, surgery and LMIC. STUDY SELECTION: We limited our review to studies of essential surgeries that pertained to all three search domains. DATA EXTRACTION: We extracted data on study characteristics, type of surgery and the way in which quality was studied. RESULTS OF DATA SYNTHESIS: 354 studies were included. 281 (79.4%) were single-center studies and nearly half (n = 169, 46.9%) did not specify the level of facility. 207 studies reported on mortality (58.47%) and 325 reported on a morbidity (91.81%), most commonly surgical site infection (n = 190, 53.67%). Of the Institute of Medicine domains of quality, studies were most commonly of safety (n = 310, 87.57%) and effectiveness (n = 180, 50.85%) and least commonly of equity (n = 21, 5.93%). CONCLUSION: We find that while there are numerous studies that report on some aspects of quality of care, much of the data is single center and observational. Additionally, there is variability on which outcomes are reported both within and across specialties. Finally, we find under-reporting of parameters of equity and timeliness, which may be critical areas for research moving forward.

Cured into Destitution: Catastrophic Health Expenditure Risk Among Uninsured Trauma Patients in the United States.

OBJECTIVE: To characterize the economic hardship for uninsured patients admitted for trauma using catastrophic health expenditure (CHE) risk. BACKGROUND: Medical debts are the greatest cause of bankruptcies in the United States. Injuries are often unpredictable, expensive to treat, and disproportionally affect uninsured patients. Current measures of economic hardship are insufficient and exclude those at greatest risk. METHODS: We performed a retrospective review, using data from the 2007-2011 Nationwide Inpatient Samples of all uninsured nonelderly adults (18-64 yrs) admitted with primary diagnoses of trauma. We used US Census data to estimate annual postsubsistence income and inhospital charges for trauma-related admission. Our primary outcome measure was catastrophic health expenditure risk, defined as any charges ≥40% of annual postsubsistence income. RESULTS: Our sample represented 579,683 admissions for uninsured nonelderly adults over the 5-year study period. Median estimated annual income was $40,867 (interquartile range: $21,286-$71.733). Median inpatient charges were $27,420 (interquartile range: $15,196-$49,694). Overall, 70.8% (95% posterior confidence interval: 70.7%-71.1%) of patients were at risk for CHE. The risk of CHE was similar across most demographic subgroups. The greatest risk, however, was concentrated among patients from low-income communities (77.5% among patients in the lowest community income quartile) and among patients with severe injuries (81.8% among those with ISS ≥ 16). CONCLUSIONS: Over 7 in 10 uninsured patients admitted for trauma are at risk of catastrophic health expenditures. This analysis is the first application of CHE to a US trauma population and will be an important measure to evaluate the effectiveness of health care and coverage strategies to improve financial risk protection.

An Evaluation of Preparedness, Delivery and Impact of Surgical and Anesthesia Care in Madagascar: A Framework for a National Surgical Plan.

BACKGROUND: The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework. METHOD: Mercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators. RESULTS: In Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135-191 procedures per 100,000 with a perioperative mortality rate of 2.5-3.3%. Patients requiring surgery have a 77.4-86.3 and 78.8-95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate. CONCLUSION: Compared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.

A systematic review of quantitative research on traumatic brain injury in India.

INTRODUCTION: Over a quarter of the world's trauma deaths occur in India, with traumatic brain injury (TBI) as the leading cause of death and disability within trauma. With little known about TBI in India, we set out to do a systematic review to characterize the quantitative literature on TBI in India. MATERIALS AND METHODS: The following databases were searched from their inception to December 31, 2015: PubMed, Cochrane, Web of Science, and the World Health Organization's Global Health Library, using the keywords: neurotrauma, brain injury, traumatic brain injury, TBI, head injury, and India. Articles were screened by two independent reviewers, with disagreements arbitrated by discussion or a third reviewer. RESULTS: A total of 72 manuscripts were included, encapsulating 19962 patients over 27 years in 14 states of India. The sample-size-weighted mean age was 31.3 years, male-to-female ratio was 3.8:1, and sample-size-weighted mean in-hospital mortality was 24.6%. Age and mortality did not change significantly over time. Road traffic accidents (55.5%) and falls (29.2%) were the most commonly reported mechanisms of injury for TBI in India. The mean quality of reporting on TBI in India was 65.7%, according to the appropriate EQUATOR guideline score. CONCLUSION: The quality of reporting of quantitative studies published on TBI in India is low, and future methodological excellence should be ensured. The demographics and outcomes identified can be used as an epidemiological baseline for future research on TBI in India. Future research can build upon this platform to develop and refine context-appropriate policy recommendations and treatment protocols.

Waiting at the hospital door: a prospective, multicentre assessment of third delay in four tertiary hospitals in India.

BACKGROUND: A common framework to assess delays in health-care in countries with low-income and middle-income (LMICs) defines three time periods that add to the interval between onset of symptoms and treatment; the time it takes to receive care after hospital arrival is known as the third delay. Tertiary centres in LMICs are known to be overcrowded and under-capacity, but few studies have formally assessed the third delay. This study aims to quantify the third delay in LMIC tertiary centres and identify contributing factors at the facility level. METHODS: A prospective multicentre study was conducted from July, 2013, to July, 2014, in four tertiary care hospitals in the three largest cities in India: Mumbai, Delhi, and Kolkata. The time from patient arrival to the time when vital signs were first recorded was used as a proxy for the third delay. This delay was recorded by the research officers for those patients who were directly observed. For the rest of the patients the data were collected from patient records. Qualitative interviews were conducted with a subset of patients exploring reasons for the delay. FINDINGS: Data were collected for 5087 patients (1664 from Delhi, 469 from Mumbai centre-1, 711 from Mumbai centre-2, and 2243 from Kolkatta); median age was 30 years (IQR 20-45), 3944 (78%) were men, 3372 (66%) were transfers from other facilities, and 3424 (67·3%) arrived in an ambulance. Researchers directly observed 1392 (27·4%) patients from arrival to time of vital signs. There were wide variations in delays between groups, transferred versus direct presentation (0 min vs 20 min) and in between hospitals (median time 0·0 min in Mumbai to 1·5 h in Kolkatta) and in groups within each hospital. The reasons for delay were multifactorial: administrative (police case recordings, admission paper registration), logistical (no vacant beds, no physician available), and process-based (investigations before vitals, multiple patients at one time, junior physicians in-charge); process based reasons were the most common (80%). INTERPRETATION: Delays in care persist in tertiary centres in LMICs for a variety of reasons. Low-cost but context-specific changes that optimise care processes like prioritisation and transfer protocols could yield major reductions in third delay. Adoption of best practices of the better performing hospitals in the Indian setting will help to improve the trauma quality practices in India. FUNDING: The Laerdal Foundation for Acute Medicine and the Swedish National Board of Health and Welfare.

The global blood supply: a literature review.

BACKGROUND: A safe and sufficient blood supply is requisite for a functional surgical system. Although the disparity in blood donation rates between low-income and middle-income countries (LMICs) and high-income countries is well documented, less is known about the reasons for this inequity, which compromises efforts to remedy it. We aimed to review the state of the blood supply and elucidate unique country-specific challenges in each of the world's 196 countries. METHODS: We searched PubMed, MEDLINE, Google Scholar, and WHO reports using the search terms "blood donor", "blood donation","blood safety", "blood bank", "transfusion safety", and "blood services". After an initial review of existing literature, we did a comprehensive country-by-country search of the aforementioned electronic databases, WHO regional reports, Ministry of Health websites, and National Blood Transfusion Services data for specific indicators and data points used to compare blood supply and safety across countries. These included donation rate per 1000 population, percent of donations from voluntary non-remunerated donors, number of blood banks or centres, and national blood policies. Both quantitative and descriptive data are included in a summary table in the appendix of the Lancet Commission on Global Surgery. FINDINGS: Our review yielded 117 publications with data for 188 countries: 101 peer-reviewed manuscripts with 13 reporting data for high-income countries and 88 for LMICs, 16 WHO publications, and a subsequent search of select websites to collect additional country-specific indicator data. Generally, blood donation is limited because of poor health infrastructure (28 LMIC and four high-income country manuscripts), low public awareness of donation practices and safety (22 LMIC manuscripts), and stigmas surrounding voluntary blood donations, especially in LMICs. Most blood banks and donation centres are located in urban centres, inaccessible to those in rural areas. The prevalence of transfusion-transmissible infections in the blood supply is higher in LMICs (30 LMIC manuscripts), resulting in high discard rates and increased transfusion risks. Two-thirds of countries have a national blood policy in place, but are often unable to efficiently coordinate and regulate blood services nationwide. To overcome these barriers, some countries have developed innovative solutions. INTERPRETATION: The blood supply in LMICs is of insufficient quantity and safety, and the reasons for these deficits are multifactorial. Addressing blood supply inadequacies requires focused attention at both local and global levels. Political prioritisation and innovative solutions to the blood crisis will be necessary to improve this situation and will require a culturally cognizant, pro-poor, pro-equity approach. Reviewing successful approaches to this crisis employed by some countries can be helpful in charting a way forward. FUNDING: None.

A qualitative study exploring contextual challenges to surgical care provision in 21 LMICs.

BACKGROUND: Billions of people worldwide are without access to safe, affordable, and timely surgical care. The Lancet Commission on Global Surgery (LCoGS) conducted a qualitative study to understand the contextual challenges to surgical care provision in low-income and middle-income countries (LMICs), and how providers overcome them. METHODS: A semi-structured interview was administered to 143 care providers in 21 LMICs using stratified purposive sampling to include both urban and rural areas and reputational case selection to identify individual providers. Interviews were conducted in Argentina (n=5), Botswana (3), Brazil (10), Cape Verde (4), China (14), Colombia (4), Ecuador (6), Ethiopia (10), India (15), Indonesia (1), Mexico (9), Mongolia (4), Namibia (2), Pakistan (13), Peru (5), Philippines (1), Sierra Leone (11), Tanzania (5), Thailand (2), Uganda (9), and Zimbabwe (15). Local collaborators of LCoGS conducted interviews using a standardised implementation manual and interview guide. Questions revolved around challenges or barriers in the area of access to care for patients; challenges or barriers in the area of in-hospital care for patients; and challenges or barriers in the area of governance or health policy. De-identified interviews were coded and interpreted by an independent analyst. FINDINGS: Providers across continent and context noted significant geographical, financial, and educational barriers to access. Surgical care provision in the rural hospital setting was hindered by a paucity of trained workforce, and inadequacies in basic infrastructure, equipment, supplies, and access to banked blood. In urban areas, providers face high patient volumes combined with staff shortages, minimal administrative support, and poor interhospital care coordination. At a policy level, providers identified regulations that were inconsistent with the realities of low-resource care provision (eg, a requirement to provide 'free' care to certain populations but without any guarantee for funding). Regional variation did exist on some matters, particularly related to prevalence of patient-provider mistrust and supply chain failures. Everywhere, providers have created innovative workarounds to overcome some of these barriers, such as clever financing mechanisms for planned surgery (eg, raising donated farm animals for cash in Zimbabwe, Ethiopia, and India), provision in scheduling and accommodations to facilitate patients from afar, reduction of cost and waste through re-sterilisation of disposable supplies, and locally sourcing consumables (eg, hand cleaning solution made of alcohol from the local distillery in India). INTERPRETATION: Although some variation exists between countries, the challenges to surgical care provision are largely consistent and based on local resource availability; underfunded rural hospitals faced similar challenges worldwide. Global efforts to scale-up surgical services can focus on these commonalities (eg, investments in infrastructure, workforce), while local governments can tailor solutions to key contextual differences (eg, community-based outreach, supply chains, professional management, and interhospital coordination). FUNDING: None.

Geospatial mapping to estimate timely access to surgical care in nine low-income and middle-income countries.

BACKGROUND: The Lancet Commission on Global Surgery calls for universal access to safe, affordable, and timely surgical care. Two requisite components of timely access are (1) the ability to reach a surgical provider in a given timeframe, and (2) the ability to receive appropriately prompt care from that provider. We chose a threshold of 2 h in view of its relevance in time-to-death in post-partum haemorrhage. Here, we use geospatial mapping to enumerate the percentage of a nation's population living within 2 h of a surgeon and the surgeon-to-population ratio for each provider. METHODS: Geospatial mapping was used to identify the population living within a 2-h driving distance (access zone) of a health-care facility staffed by a surgeon. Surgeon locations were extracted from Ministries of Health, professional society databases, and published literature for countries which had available data. Data were reviewed by individuals knowledgeable of in-country distribution. Spatial distribution of providers was mapped with Google Maps engine. Access zones were constructed around every provider through estimation of driving times in Google Maps. The number of people living within zones was estimated with the Socioeconomic Data and Applications Center Population Estimation Service. Surgeon-to-population ratios were constructed for every individual access zone and averaged to report a single ratio. FINDINGS: Results (% country's population living within an access zone; average surgeon:population ratio within all access zones) are reported for nine countries with available data: Somaliland (16·9%; 1:118 306), Botswana (31·0%; 1:64 635), Ethiopia (39·6%; 1:229 696), Rwanda (41·3%; 1:158 484), Namibia (43·4%; 1:69 385), Zimbabwe (54%; 1:148 292), Mongolia (55·5%; 1:10 500), Sierra Leone (70·3%; 1:106 742), and Pakistan (84·4%, 1:139 299). Surgeon-to-population ratios vary substantially even within countries; in Sierra Leone, urban access zones have a ratio of 1:45 058 and rural access zones have a ratio of 1:467 929. INTERPRETATION: Surgical access is poor in many low-income and middle-income countries, even when using a narrow definition of surgical access consisting only of timeliness. Living outside of an access zone makes timely access to surgical care highly unlikely, and in view of low surgeon-to-population ratios and poor prehospital transport, even living within a 2-h access zone might not confer 2-h access. Investments in infrastructure and training must be prioritised to address widespread disparity in access to timely surgery. FUNDING: None.