Health Systems Strengthening

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Polythelia is defined as presence of a third or more nipples in a human being, this term polythelia is derived from the Greek language, meaning many nipples. At times this term is used interchangeably with the term polymastia which means presence of more than two breasts in an individual, however these two conditions can occur concurrently. We report a case of a 13-year-old girl who presented with history of having been born with extra nipples, which were noticed at birth by the mother the mother was not bothered because the girl was growing normally compared to other girls who were born in the same period. Nevertheless, the mother began getting worried about the girl's condition when the girl, started complaining to her that her breasts were different from those of other girls, she further reported that her peers and pupils in upper primary classes were telling that her condition was associated with things like curses, and fertility. Subsequently these complaints were followed by self-isolation from the peers, putting on overfitting clothes and reduced participation in classroom activities and this tremendously affected her performance in academics. The polythelia was treated by simple bilateral excitons without intra or post operative complications, the tissue was subjected to histology and tissue showed ducts within stroma with normal epidermis overlying the stroma which confirmed a diagnosis of polythelia. In subsequent follow-up, abdominal ultrasound showed no associated abdominal abnormalities and had improved happily associating with peers and active in class activities.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background: Health system strengthening is critical to ensure the integration and scaling-up of priority health promotion, disease prevention and control programs. Normative guidelines are available to address health system function imbalances while strategic and analytical frameworks address critical functions in complex systems. Tacit knowledge-based health system constructs can help identify actors' perspectives, contributing to improve strengthening strategies. Using maternal health as an example, this paper maps and analyses the health system functions that critical actors charged with formulating and delivering priority health programs consider important for their success. Methods: Using concept mapping qualitative and statistical methods, health system functions were mapped for different categories of actors in high maternal mortality states of Mexico and at the federal level. Functions within and across maps were analyzed for degree of classification, importance, feasibility and coding. Results: Hospital infrastructure and human resource training are the most prominent functions in the maternal health system, associated to federal efforts to support emergency obstetric care. Health policy is a highly diffuse function while program development, intercultural and community participation and social networks are clearly stated although less focused and with lower perceived importance. The importance of functions is less correlated between federal and state decision makers, between federal decision makers and reproductive health/local health area program officers and between state decision makers and system-wide support officers. Two sets of oppositions can be observed in coding across functions: health sector vs. social context; and given structures vs. manageable processes. Conclusions: Concept mapping enabled the identification of critical functions constituting adaptive maternal health systems, including aspects of actor perspectives that are seldom included in normative and analytical frameworks. Important areas of divergence across actors' perceptions were identified to target capacity strengthening efforts towards better integrated, performing health systems.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background: This study aimed to gather insights in physicians' considerations for decisions to either refer for-or to withhold additional diagnostic investigations in nursing home patients with a suspicion of venous thromboembolism. Methods: Our study was nested in an observational study on diagnostic strategies for suspected venous thromboembolism in nursing home patients. Patient characteristics, bleeding-complications and mortality were related to the decision to withhold investigations. For a better understanding of the physicians' decisions, 21 individual face-to-face in-depth interviews were performed and analysed using the grounded theory approach. Results: Referal for additional diagnostic investigations was forgone in 126/322 (39.1%) patients with an indication for diagnostic work-up. 'Blind' anticoagulant treatment was initiated in 95 (75.4%) of these patients. The 3month mortality rates were higher for patients in whom investigations were withheld than in the referred patients, irrespective of anticoagulant treatment (odds ratio 2.45; 95% confidence interval 1.40 to 4.29) but when adjusted for the probability of being referred (i.e. the propensity score), there was no relation of non-diagnosis decisions to mortality (odds ratio 1.75; 0.98 to 3.11). In their decisions to forgo diagnostic investigations, physicians incorporated the estimated relative impact of the potential disease; the potential net-benefits of diagnostic investigations and whether performing investigations agreed with established management goals in advance care planning. Referral for additional diagnostic investigations is withheld in almost 40% of Dutch nursing home patients with suspected venous thromboembolism and an indication for diagnostic work-up. We propose that, given the complexity of these decisions and the uncertainty regarding their indirect effects on patient outcome, more attention should be focused on the decision to either use or withhold additional diagnostic tests.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

BaCkground According to the World Health Organization (WHO), the essential key building block of a health system is the health workforce, which, when competent, motivated, and empowered, delivers quality health services which are appropriate and acceptable to the population. [1] Health workforce pertains to clinical and non-clinical domains which cater to individual and public health care interventions across sectors such as environmental, occupational health personnel, laboratory scientists, community health workforce, and so on. [2,3] Particularly in the clinical aspect, the role of specialized healthcare providers becomes significant in delivering specialized healthcare services to persons in need, thus improving the health outcomes. [4] The density ratio of human resource for heath (HRH) has a significant impact on improving the vital health indicators such as maternal mortality rate, infant mortality rate, total fertility rate, and so on. [5] The WHO report published in 2019 states that India needs at least 1.8 million doctors, nurses, and midwives to achieve the minimum threshold of 44.5 health workers per 10,000 population by 2030. [6] A study conducted by analyzing the data on registered qualified health professionals and the 68 th round (July 2011 to June 2012) of NSSO data on The World Health Organization (WHO) recommends the requirement of human resource for health (HRH) stands at 44.5 skilled health workers per 10,000 population. WHO recognizes India as one of the countries which has HRH crisis. Karnataka, a southern state in India, has the highest number of medical colleges yet faces the shortage of specialists in the public hospitals. We conducted desk review to understand the HRH crisis, particularly the medical specialists in India. Simultaneously, we conducted secondary research to explore the initiatives taken by the Government of Karnataka (GoK) to mitigate the shortage of medical specialists in the rural areas. GoK scaled up the National Board of Examination in Medical Sciences (NBEMS) postgraduate and super-speciality courses such as Diplomate of National Board (DNB), Diploma, and Doctorate of National Board (DrNB) in district hospitals (minimum 250-500 bedded) and taluk hospitals (minimum 100 bedded) by utilizing the existing resources. Karnataka is the first state in India to expand the NBEMS (DNB and Diploma) courses in taluk hospitals and to begin DrNB courses in district hospitals. The paper documents the process of implementation of the NBEMS courses at district and taluk hospitals of Karnataka, which has supported in strengthening these hospitals in the state.

The study investigated the factors affecting the state of availability of sports, leisure and recreational facilities and equipment in University of Benin. The research design used for this study was the descriptive survey research design. The population for this study was 40,000 students of University of Benin. The random sampling technique was used to select 400 students for the study. A correlation coefficient of 0.76 was obtained using Pearson's product movement correlation coefficient method. The data collected was analysed using simple percentages, tables and frequency counts. The finding from the study revealed that the time allotted for sports, recreation and leisure was not enough. It was also discovered that there were not enough facilities and equipment to carryout the activities. It also revealed that there was no general time for students to participate in these activities. It was therefore, recommended that both the University authorities and Government at all levels should provide adequate and functional facilities and equipment for the activities to take its proper place. Also that a general day and time should be approved by the university management for these activities to take place. It was also recommended that the time should be enough for these activities.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background: India, with a population of more than 1.21 billion, has the highest maternal mortality in the world (estimated to be 56000 in 2010); and adolescent (aged 15-19) mortality shares 9% of total maternal deaths. Addressing the maternity care needs of adolescents may have considerable ramifications for achieving the Millennium Development Goal (MDG)-5. This paper assesses the socioeconomic differentials in accessing full antenatal care and professional attendance at delivery by adolescent mothers (aged 15-19) in India during 1990-2006. Methods and Findings: Data from three rounds of the National Family Health Survey of India conducted during 1992-93, 1998-99, and 2005-06 were analyzed. The Cochran-Armitage and Chi-squared test for linear and non-linear time trends were applied, respectively, to understand the trend in the proportion of adolescent mothers utilizing select maternity care services during 1990-2006. Using pooled multivariate logistic regression models, the probability of select maternal healthcare utilization among women by key socioeconomic characteristics was appraised. After adjusting for potential socio-demographic and economic characteristics, the likelihood of adolescents accessing full antenatal care increased by only 4% from 1990 to 2006. However, the probability of adolescent women availing themselves of professional attendance at delivery increased by 79% during the same period. The study also highlights the desolate disparities in maternity care services among adolescents across the most and the least favoured groups. Conclusion: Maternal care interventions in India need focused programs for rural, uneducated, poor adolescent women so that they can avail themselves of measures to delay child bearing, and for better antenatal consultation and delivery care in case of pregnancy. This study strongly advocates the promotion of a comprehensive 'adolescent scheme' along the lines of 'Continuum of Maternal, Newborn and Child health Care' to address the unmet need of reproductive and maternal healthcare services among adolescent women in India.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

The aim of the study was to assess the impact of health systems strengthening on the consumption of public healthcare services in Northern Namibia. The study assessed how the following components of health systems strengthening influence the consumption of public health care services; (1) timeliness and readiness of services rendered, (2) health workforce competence, (3) health information systems, (4) availability of essential medicines, (5) healthcare financing and lastly (6) leadership and governance. We used a quantitative descriptive cross-sectional study design. 672 respondents were identified using the purposive sampling technique and a well-structured Likert-scaled questionnaire was used for the interviews. Collected information was entered into data sets and analysis was done using Excel and Statistical Package for Social Sciences (SPSS) version 23.0 software. The results were that over 95% of the respondents strongly agreed with each of the factors assessed. Health systems strengthening remains an important factor in the delivery of health services. This was taken note of when 48% of the participants agreed that a good competent health workforce determines their choice of healthcare facility when they are not feeling well. This was further augmented when 49% of the participants agreed that healthcare financing influences people's choice to go and seek healthcare services from government facilities. It was concluded that health systems strengthening is the cornerstone for improved consumption of public health care services in Northern Namibia. We recommend that governments should develop strong health systems at all levels of health service delivery.

the GAVI Alliance (GAVI) Health Systems Strengthening (HSS) window has offered predictable funding to developing countries, based on a combined population and economic formula. This is intended to assist them to address system constraints to improved immunization coverage and health care delivery, needed to meet the Millennium Development Goals. The application process invites countries to prioritize specific system constraints not adequately addressed by other donors, and allows them to allocate their eligible funds accordingly. This article presents an analysis of the first four rounds of countries' funding applications. These requested funding for a variety of health system initiatives that reflected country-specific requirements, and were not limited to improving immunization coverage. Analyses identified a dominance of operationallevel health service provision activities, and an absence of interventions related to demand and financing. While the proposed activities are only now being implemented, the results of this study provide evidence that the open application process employed by the HSS window has led to a shift in analysis and planning-from the programmatic to the systemic-in the countries whose applications have been approved. However, the proposed responses to identified constraints are dominated by short-term operational responses, rather than more complex, longer term approaches to health system strengthening.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Global immunization programs have been instrumental in reducing morbidity and mortality from vaccine-preventable diseases, yet disparities persist in coverage due to socioeconomic , cultural, and geographic factors. This journal explores the role of diversity and inclusion in public health immunization efforts, highlighting successes and challenges from global campaigns such as those led by the World Health Organization (WHO) and other global health partners. It emphasizes the importance of culturally responsive strategies and inclusive policies that address the unique needs of marginalized populations, and how these approaches can enhance the effectiveness of immunization programs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Purpose: To develop a clinical staging system based on the PIRO concept (Predisposition, Infection, Response and Organ dysfunction) for hospitalized patients with infection. Methods: One year prospective cohort study of all hospitalized patients with infection (n = 1035), admitted into a large tertiary care, university hospital. Variables associated with hospital mortality were selected using logistic regressions. Based on the regression coefficients, a score for each PIRO component was developed and a classification tree was used to stratify patients into four stages of increased risk of hospital mortality. The final clinical staging system was then validated using an independent cohort (n = 186). Results: Factors significantly associated with hospital mortality were N for Predisposition: age, sex, previous antibiotic therapy, chronic hepatic disease, chronic hematologic disease, cancer, atherosclerosis and a Karnofsky index,70; N for Insult/Infection: type of infection N for Response: abnormal temperature, tachypnea, hyperglycemia and severity of infection and N for Organ dysfunction: hypotension and SOFA score$1. The area under the ROC curve (CI 95%) for the combined PIRO model as a predictor for mortality was 0.85 (0.82-0.88). Based on the scores for each of the PIRO components and on the cutoffs estimated from the classification tree, patients were stratified into four stages of increased mortality rates: stage I: #5%, stage II: 6-20%, stage III: 21-50% and stage IV: .50%. Finally, this new clinical staging system was studied in a validation cohort, which provided similar results (0%, 9%, 31% and 67%, in each stage, respectively). Conclusions: Based on the PIRO concept, a new clinical staging system was developed for hospitalized patients with infection, allowing stratification into four stages of increased mortality, using the different scores obtained in Predisposition, Response, Infection and Organ dysfunction. The proposed system will likely help to define inclusion criteria in clinical trials as well as tailoring individual management plans for patients with infection.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.