Before analyzing discrepancies in surgical care between HIC and LMICs, the framework utilized to make these comparisons must be understood. The WHO classifies member countries depending on both Gross National Income and Region, based on World Bank criteria [13].

WHO Member States are grouped into six regions (2012) including the African Region, the Region of the Americas, the Eastern Mediterranean Region, the European Region, the South-East Asia Region, and the Western Pacific Region. WHO Member States are grouped into four gross annual income groups (GNI) per capita (low, lower middle, upper middle, and high) based on the World Bank list of economies for the year 2011 (released July 2012) (Table 4.2).

In the USA, annual per capita healthcare spending (2011) is on the order of $8,608 [14, 15]. Of this, roughly US$4,400 is spent by the government. At the other extreme Eritrea, Ethiopia, Central African Republic, Madagascar, the Democratic Republic of the Congo and Niger all spend less than $20 USD per capita annually on health care (Table 4.3), which is extremely low, even when calculated in terms of purchasing power parity (PPP).

Data from the World Bank [16]. PPP is used in international comparisons based on currencies to estimate what market basket of goods a currency could purchase. They are used in economics to eliminate distortions that can occur when comparisons are made on the basis of market exchange rates.

As the above tables show, there are dramatic funding disparities from country to country. However, even if funding were to be increased in sub-Saharan Africa—the most concentrated, impoverished region—there would be major issues of healthcare delivery because there is no established infrastructure coupled with a large deficit of healthcare providers here and in other LMICs. In Table 4.4, we also see the significant variation in the distribution of physicians, nurses, and available hospital beds when countries are ranked by PPP. Regional variation again is striking, with sub-Saharan Africa having the greatest shortages in all categories.

As seen in Table 4.4, LMICs have fewer physicians, nurses and midwives, and hospital beds per capita compared to more affluent countries. Exacerbating this discrepancy however is the fact that compared to population growth rates, most-sub-Saharan African nations have an actual negative annual growth rate in the number of physicians produced [17]. Because of the hardships of practice in these locations, better reimbursement for competing professions (engineering) and the employment opportunities in countries which spend more money per capita on healthcare, many individuals in LMICs either choose alternative professions or if they do enter medicine, they are induced to migrate elsewhere for better wages and living conditions.

A study of healthcare workers in Ghana revealed a marked preference for migration to ODEC countries [95]. For healthcare workers, this was of particular concern because their training is generally publically funded. One model found that for the United Kingdom, the country had a net overall gain by the importing of foreign physicians, the exact opposite was seen in the exporting country. Although only 1.91 % of the total population migrated, this was reflective of 8.07 % of the total expenditure on education of the current population.

Access to surgery, operating suites, and trained anesthesia personnel is even more starkly imbalanced between HI countries and those of sub-Saharan and other LI countries. Weiser et al. [18] found that the global volume of major surgery was between 187 and 281 million cases, which is equivalent to one operation for every 25 people living in 2004. These researchers further found that countries spending less than USD $100 (2004) per person only had 295 major surgeries per 100,000 people. In contrast, countries spending more than USD $1,000 (2004) per person had surgical incidences of 11,110 per 100,000 people.

Weiser et al. also showed that MI and HI countries accounted for 30.2 % of the world’s population but received 73.6 % of the surgical operations, whereas poor expenditure countries (less than or equal to USD $100 per person) accounted for 34.8 % of the global population and received only 3.5 % of all surgical procedures. This striking difference is not primarily due to nonessential surgical care. For example, in the USA in 2010 there were 51.4 million procedures performed on inpatients. Some of these procedures were endoscopies and cardiac catheterizations, but for the most part the procedures are those typically associated as “surgical” [19]. The number of aesthetic surgical procedures performed in the USA in 2012 was 289,000 [20]. Consequently, it can be seen that even with cosmetic and other procedures, the bulk of surgical interventions in the USA and other HI countries is not solely the result of nonessential intervention. Rather, what these data emphasize is that the extremely low volume of surgery performed in LMICs underscores a lack of access to surgical services in these locations. With this large, unaddressed surgical disease burden worldwide, measurement of surgical outcomes and public health evaluations in surgical disease are warranted.

In HI countries, mortality from anesthesia was found to be on the order of 6.4 deaths per 10,000 anesthetics by Beecher and Todd in 1954. By 1980, the mortality rate from anesthesia had decreased to 2 deaths per 10,000 anesthetics and current data indicates that anesthetic mortality is on the order of 1 death per 100,000–200,000 [21]. Major morbidity occurs in 3–16 % of cases. In contrast, in developing countries, the death rate remains 5–10 %, which is 500–1,000 deaths per 10,000 administered anesthetics [22] (Table 4.5). These data suggest that while affluent portions of the world have benefited from advances in anesthesia over the past six decades, with risk from dying from anesthesia being on the order of 1:200,000 anesthetics, LMICs have not seen any improvement. Anesthetic-related mortality in these environments is worse than experienced in the developed world since the inauguration of the age of anesthesia in the nineteenth century [23].

Differences in frequency of surgical procedures could perhaps be explained by availability of surgical resources. Funk et al. [24] noted that there are more than 14 operating theaters per 100,000 people in high-income countries and 1–25 per 100,000 in middle to low-income countries. Moreover, almost 20 % of operating rooms worldwide were not equipped with pulse oximeters and this was not the case in high-income countries. Pulse oximeters are not the only equipment-related resources missing in LMICs. As seen below, simple things such as functional operating table are frequently not available. And, basic infrastructure requirement—such as electricity and water—cannot be guaranteed (Table 4.6).

In general, three types of clinical personnel administer anesthesia globally: anesthesiologists, anesthesia assistants, and nurse anesthetists or surgical nurses. Anesthesiologists are medical professionals who have received medical degrees and appropriate training. Anesthesia assistants are trained professionals that specifically assist anesthesiologists. Nurse anesthetists are nurses who receive specialized training related to anesthesia, which may include drug administration. In certain countries, surgical nurses are trained to administer and/or monitor anesthesia. Thus, the specialty of nurse anesthetist does not exist. Each country has various restrictions that govern the practice of each type of clinical personnel.