# Systematic review of the Lancet Commission on Global Surgery indicators with quality assessment of modelled estimates

## TL;DR

This paper reviews global progress on surgical system benchmarks and finds significant gaps in data reporting and quality, especially in low-income countries.

## Contribution

The study systematically evaluates the extent to which countries have met surgical system benchmarks and the quality of data used to estimate these metrics.

## Key findings

- Only 39% of countries met the benchmark for access to timely essential surgery.
- High-income countries were more likely to meet surgical system benchmarks than low-income countries.
- Modelled estimates often lacked transparency and validation, limiting their reliability.

## Abstract

The Lancet Commission on Global Surgery (LCoGS) defined six indicators with 2030 targets to track national surgical system performance. The aim of this systematic review was to evaluate national reporting and attainment of benchmarks for each indicator and to assess the quality of modelling studies used to fill data gaps.

Seven bibliographic databases (1 April 2015–24 July 2024) and government domains of 48 countries committed to National Surgical, Obstetric, and Anaesthesia Plans were searched. Records providing national estimates of any LCoGS indicator were eligible. The primary outcome was the proportion of World Bank-classified countries meeting indicator benchmarks and the secondary outcome was the quality of modelled national estimates. This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD420250650890).

Of 4245 records retrieved, 44 studies were included (35 research articles and 9 policy documents). Among 217 World Bank-classified countries, access to timely essential surgery (indicator 1) was reported for 94 countries (39% meeting benchmark), specialist surgical workforce density (indicator 2) was reported for 167 countries (50.3% meeting benchmark), surgical volume (indicator 3) was reported for 124 countries (31.5% meeting benchmark), perioperative mortality (indicator 4) was reported for 74 countries (no benchmark was set at country level), and financial risk protection indicators (indicators 5 and 6) were reported for five countries, with none meeting either benchmark. Across indicators, high-income countries were more likely to meet benchmarks. Most modelled studies lacked transparency in data sources, statistical methods, or model validation.

Reporting of LCoGS indicators remains sparse and uneven, particularly in low- and middle-income countries. Without standardized, routine measurement and minimum quality standards for modelled estimates, progress towards 2030 cannot be credibly tracked. Integrating surgical metrics into national health information systems should be a policy priority.

This systematic review evaluated national reporting and benchmark attainment for all six Lancet Commission on Global Surgery indicators (2015–2024) across 217 World Bank-classified countries and assessed the methodological quality of modelled estimates used to fill data gaps. Reporting was sparse, particularly for financial risk protection (≤3% of countries), and benchmark achievement was strongly stratified by income, with no low-income country meeting workforce and surgical volume targets. Modelled estimates were frequently limited by poor transparency and lack of validation, underscoring the need for standardized reporting and integration of surgical metrics into national health information systems.