Appendix 1: World Bank region and income categories for countries taking part in the study*
Country/Economy Region Income group
Australia East Asia & Pacific High income
Azerbaijan Europe & Central Asia Upper middle income
Bangladesh South Asia Lower middle income
Belarus Europe & Central Asia Upper middle income
Belgium Europe & Central Asia High income
Botswana Sub-Saharan Africa Upper middle income
Brazil Latin America &
Caribbean Upper middle income
Cambodia East Asia & Pacific Lower middle income
Cameroon Sub-Saharan Africa Lower middle income
Canada North America High income
Chile Latin America &
Caribbean High income
Colombia Latin America &
Caribbean Upper middle income
Croatia Europe & Central Asia High income
Egypt, Arab Rep. Middle East & North
Africa Lower middle income
Ethiopia Sub-Saharan Africa Low income
France Europe & Central Asia High income
Germany Europe & Central Asia High income
Ghana Sub-Saharan Africa Lower middle income
Greece Europe & Central Asia High income
Greenland Europe & Central Asia High income
Guatemala Latin America &
Caribbean Upper middle income
Hungary Europe & Central Asia High income
India South Asia Lower middle income
Ireland Europe & Central Asia High income
Israel Middle East & North
Africa High income
Italy Europe & Central Asia High income
Kenya Sub-Saharan Africa Lower middle income
Libya Middle East & North
Africa Upper middle income
Lithuania Europe & Central Asia High income
Luxembourg Europe & Central Asia High income
Mexico Latin America &
Caribbean Upper middle income
Morocco Middle East & North
Africa Lower middle income
Myanmar East Asia & Pacific Lower middle income
Netherlands Europe & Central Asia High income
New Zealand East Asia & Pacific High income
Nicaragua Latin America &
Caribbean Lower middle income
Niger Sub-Saharan Africa Low income
Nigeria Sub-Saharan Africa Lower middle income
Norway Europe & Central Asia High income
Pakistan South Asia Lower middle income
Philippines East Asia & Pacific Lower middle income
Poland Europe & Central Asia High income
Portugal Europe & Central Asia High income
Romania Europe & Central Asia Upper middle income Russian Federation Europe & Central Asia Upper middle income
Rwanda Sub-Saharan Africa Low income
Saudi Arabia Middle East & North
Africa High income
Senegal Sub-Saharan Africa Lower middle income
Slovenia Europe & Central Asia High income
South Africa Sub-Saharan Africa Upper middle income
Spain Europe & Central Asia High income
St. Vincent and the Grenadines Latin America &
Caribbean Upper middle income
Sweden Europe & Central Asia High income
Syrian Arab Republic Middle East & North
Africa Low income
Turkey Europe & Central Asia Upper middle income
Uganda Sub-Saharan Africa Low income
Ukraine Europe & Central Asia Lower middle income
United Kingdom Europe & Central Asia High income
United States North America High income
Zambia Sub-Saharan Africa Lower middle income
Zimbabwe Sub-Saharan Africa Lower middle income
*(from https://datahelpdesk.worldbank.org/knowledgebase/articles/906519, accessed 4 June 2020)
Appendix 2: Delphi participant responses
First round N=269
Second round N=187
153 participated in round 1
34 new participants
Third round N=177
149 participated in
round 1 or 2
28 new
participants
Appendix 3: Characteristics of all participants in round 3 broken down by World Bank country income status (n = 177)
Characteristics High Income Upper middle income
Low and lower middle income
Total (n = 177) Sex
Male 80 (70.2) 18 (62.1) 25 (73.5) 123 (69.5)
Age
Mean (SD) 41.4 (11.0) 42.3 (10.0) 40.2 (8.8) 41.3 (10.4)
World Bank region***
East Asia and the Pacific 3 (2.6) 0 (0.0) 4 (11.8) 7 (3.9)
Europe and Central Asia 93 (81.6) 11 (37.9) 1 (2.9) 105 (59.3)
Latin America and the Caribbean 1 (0.9) 8 (27.6) 1 (2.9) 10 (5.6)
Middle east and North Africa 4 (3.5) 1 (3.4) 5 (14.7) 10 (5.6)
North America 13 (11.4) 0 (0.0) 0 (0.0) 13 (7.3)
South Asia 0 (0.0) 0 (0.0) 8 (23.5) 8 (4.5)
Sub-Saharan Africa 0 (0.0) 9 (31.0) 15 (44.1) 24 (13.6)
Rural or urban
Urban 101 (88.6) 26 (89.7) 28 (82.4) 155 (87.6)
Provider classification* (n=102) (n=28) (n=32) (n=164)
Surgeon 73 (71.6) 23 (82.2) 26 (78.1) 122 (74.4)
Anesthetist 17 (15.7) 2 (7.1) 4 (12.5) 23 (14.0)
Obstetrician/Gynecologist 9 (8.8) 0 (0.0) 0 (0.0) 9 (5.5)
Physician 3 (2.9) 2 (7.1) 2 (6.3) 7 (4.3)
Other* 1 (1.0) 1 (3.6) 1 (3.1) 3 (1.8)
Level of main facility where
practices (n=111) (n=29) (n=33) (n=172)
Tertiary/Central hospital 84 (75.7) 21 (72.4) 27 (79.4) 132 (76.8)
Secondary/District Hospital 23 (20.7) 7 (24.1) 4 (12.5) 34 (19.8)
Primary care 2 (1.8) 1 (3.4) 0 (0.0) 3 (1.7)
Other** 2 (1.8) 0 (0.0) 1 (3.1) 3 (1.7)
Surgical area of practice (non-
obstetric) (n=73) (n=23) (n=24) (n=121)
General 62 (84.9) 20 (87.0) 20 (83.3) 103 (85.1)
Pediatric 4 (5.5) 1 (4.3) 3 (12.5) 8 (6.6)
Orthopedic 2 (2.7) 1 (4.3) 0 (0.0) 3 (2.5)
Neuro 3 (4.1) 0 (0.0) 0 (0.0) 3 (2.5)
Plastic 1 (1.4) 0 (0.0) 0 (0.0) 1 (0.8)
Urology 1 (1.4) 0 (0.0) 0 (0.0) 1 (0.8)
Thoracic 0 (0.0) 0 (0.0) 1 (2.9) 1 (0.8)
Vascular 0 (0.0) 1 (4.3) 0 (0.0) 1 (0.8)
Otorhinolaryngology 0 (0.0) 0 (0.0) 0 (0.0) 0 (0)
Level of training*** (n=102) (n=27) (n=32) (n=161)
Attending/consultant 69 (67.6) 25 (92.6) 27 (84.4) 121 (72.2)
Resident/registrar/fellow 33 (32.4) 2 (7.4) 5 (15.6) 40 (24.8)
Additional duties
Teaching 102 (89.5) 26 (89.7) 31 (91.2) 159 (89.8)
Research*** 99 (86.8) 20 (69.0) 30 (88.2) 149 (84.2)
NGOs 18 (15.8) 1 (3.4) 6 (17.6) 25 (14.1)
Management 23 (20.2) 6 (20.7) 11 (32.4) 40 (22.6)
Ministry of Health 10 (8.8) 4 (13.8) 4 (11.8) 18 (10.2)
Public Health 20 (17.5) 9 (31.0) 7 (20.6) 36 (20.3)
Multilateral agency (e.g. WHO) 6 (5.3) 1 (3.4) 0 (0.0) 7 (4.0)
*Others include medical regulation and part time clinical, trauma, emergency medicine, pathology, general practice.
**Others include Mission Hospitals. non-governmental organizations (NGOs), private practice, private hospital, polyclinic and university affiliated elective hospitals.
*** Significant p<0.05 differences between country income status
Appendix 4a: Numbers and percentages of respondents that chose each procedure in the first round of the Delphi according to the category of Trauma surgery (n=269)
Surgical Procedure n (%) Income category n (%)
Trauma craniotomy 160 (59.5) Low income 16 (80)
Lower middle 31 (66)
Higher middle 25 (50)
High income 88 (57.9)
External fixation of femur 145 (53.9) Low income 15 (75)
Lower middle 31 (66)
Higher middle 23 (46)
High income 76 (50)
Internal fixation of femur 149 (55.4) Low income 17 (85)
Lower middle 28 (59.6)
Higher middle 23 (46)
High income 81 (53.3)
External fixation of tibia 152 (56.5) Low income 17 (85)
Lower middle 33 (70.2)
Higher middle 22 (44)
High income 80 (52.6)
Internal fixation of tibia 116 (43.1) Low income 15 (70)
Lower middle 27 (57.4)
Higher middle 16 (32)
High income 59 (38.8)
Fixation of mandible 82 (30.5) Low income 9 (45)
Lower middle 22 (53.2)
Higher middle 14 (28)
High income 37 (24.3)
Splenectomy 198 (73.6) Low income 17 (85)
Lower middle 42 (89.4)
Higher middle 37 (74)
High income 105 (69.1)
Trauma laparotomy 239 (88.8) Low income 19 (95)
Lower middle 42 (89.4)
Higher middle 44 (88)
High income 134 (88.2)
Tube thoracostomy 186 (69.1) Low income 16 (80)
Lower middle 36 (76.6)
Higher middle 37 (74)
High income 97 (63.8)
Skin grafting 121 (45.0) Low income 15 (75)
Lower middle 31 (66)
Higher middle 25 (50)
High income 50 (32.9)
Appendix 4b: Numbers and proportions of respondents that chose each procedure in the first round of the Delphi according to the category of Cancer surgery (n=269)
Surgical procedure n (%) Income Category n (%)
Modified radical mastectomy 190 (70.6) Low income 15 (75)
Lower middle 44 (93.6)
Higher middle 32 (64)
High income 99 (65.1)
Partial mastectomy with lymph node excision (including sentinel node biopsy)
180 (66.9) Low income 13 (65)
Lower middle 39 (83)
Higher middle 29 (58)
High income 99 (65.1)
Gastrectomy 195 (72.5) Low income 16 (80)
Lower middle 37 (78.7)
Higher middle 36 (72)
High income 106 (69.7)
Partial colectomy 238 (88.5) Low income 16 (80)
Lower middle 45 (95.7)
Higher middle 42 (84)
High income 135 (88.8)
Hepatectomy 122 (45.4) Low income 3 (15)
Lower middle 27 (57.4)
Higher middle 21 (42)
High income 71 (46.7)
Radical nephrectomy 153 (56.9) Low income 11 (55)
Lower middle 32 (68.1)
Higher middle 24 (48)
High income 86 (56.6)
Pancreatectomy 120 (44.6) Low income 5 (25)
Lower middle 26 (55.3)
Higher middle 23 (46)
High income 66 (43.4)
Esophagectomy 117 (43.5) Low income 8 (40)
Lower middle 26 (55.3)
Higher middle 21 (42)
High income 62 (40.8)
Thyroidectomy 197 (73.2) Low income 18 (90)
Lower middle 43 (91.5)
Higher middle 34 (68)
High income 102 (67.1)
Small bowel resection
(move to infection/inflammation) 202 (75.1)
Low income 15 (75)
Lower middle 41 (87.2)
Higher middle 39 (78)
High income 107 (70.4)
Stoma formation 218 (81.0) Low income 17 (85)
Lower middle 42 (89.4)
Higher middle 40 (80)
High income 119 (78.3)
Appendix 4c: Numbers and proportions of respondents that chose each procedure in the first round of the Delphi according to the category of Congenital procedures
Surgical procedure
n (%) Income category n (%)
Gastroschisis repair 143 (53.2) Low income 16 (80)
Lower middle 27 (57.4)
Higher middle 25 (50)
High income 75 (49.3)
Imperforate anus repair 142 (52.8) Low income 18 (90)
Lower middle 33 (70.2)
Higher middle 21 (42)
High income 70 (46.1)
Pediatric colostomy 144 (53.5) Low income 17 (85)
Lower middle 35 (74.5)
Higher middle 25 (50)
High income 67 (44.1)
Repair congenital heart defect
112 (41.6) Low income 9 (45)
Lower middle 23 (48.9)
Higher middle 14 (28)
High income 66 (43.4)
Repair cleft lip/palate 158 (58.7) Low income 16 (80)
Lower middle 31 (66.0)
Higher middle 20 (40)
High income 91 (59.9)
Pediatric Inguinal hernia
repair 204 (75.8)
Low income 18 (90)
Lower middle 37 (78.7)
Higher middle 35 (70)
High income 114 (75)
VP shunt placement 106 (39.4) Low income 12 (60)
Lower middle 24 (51.1)
Higher middle 14 (28)
High income 56 (36.8)
Orchidopexy 163 (60.6) Low income 15 (75)
Lower middle 32 (68.1)
Higher middle 24 (48)
High income 92 (60.5)
Pyeloplasty 94 (34.9) Low income 8 (40)
Lower middle 25 (53.2)
Higher middle 13 (26)
High income 48 (31.6)
Pyloroplasty 155 (57.6) Low income 16 (80)
Lower middle 29 (61.7)
Higher middle 24 (48)
High income 86 (56.6)
Hypospadias 124 (46.1) Low income 12 (60)
Lower middle 29 (61.7)
Higher middle 18 (36)
High income 65 (42.8)
Appendix 4d: Numbers and proportions of respondents that chose each procedure in the first round of the Delphi according to the category of Maternal/reproductive
Surgical procedure
n (%) Income category n (%)
Cesarean delivery 221 (82.2) Low income 19 (95)
Lower middle 39 (83)
Higher middle 32 (64)
High income 131 (86.2)
Uterine evacuation 170 (63.2) Low income 18 (90)
Lower middle 32 (68.1)
Higher middle 25 (50)
High income 95 (62.5)
Salpingo-oophorectomy
(adding oophorectomy) 153 (56.9)
Low income 14 (70)
Lower middle 33 (70.2)
Higher middle 26 (52.0)
High income 80 (52.6)
Vasectomy 133 (49.4) Low income 14 (70)
Lower middle 25 (53.2)
Higher middle 21 (42)
High income 73 (48)
Tubal ligation 144 (53.5) Low income 14 (70)
Lower middle 32 (68.1)
Higher middle 27 (54)
High income 71 (46.7)
Hysterectomy 209 (77.7) Low income 18 (90)
Lower middle 38 (80.9)
Higher middle 33 (66)
High income 12 (78.9)
Repair obstetric fistula 141 (52.4) Low income 16 (80)
Lower middle 29 (61.7)
Higher middle 18 (36)
High income 78 (51.3)
Male circumcision 152 (56.5) Low income 14 (70)
Lower middle 34 (72.3)
Higher middle 33 (66)
High income 71 (46.7)
Appendix 4e: Numbers and proportions of respondents that chose each procedure in the first round of the Delphi according to the category of Aging/Degeneration
Surgical procedure
n (%) Income Category n (%)
Prostatectomy 160 (59.5) Low income 18 (90)
Lower middle 32 (68.1)
Higher middle 26 (52)
High income 84 (55.3)
Knee arthroplasty 122 (45.4) Low income 9 (45)
Lower middle 25 (53.2)
Higher middle 17 (34)
High income 71 (46.7)
Hip arthroplasty 153 (56.9) Low income 13 (65)
Lower middle 28 (59.6)
Higher middle 19 (38)
High income 93 (61.2)
Coronary artery bypass graft 131 (51.3) Low income 3 (15)
Lower middle 24 (51.1)
Higher middle 17 (24)
High income 87 (57.2)
Cataract surgery 182 (67.7) Low income 12 (60)
Lower middle 34 (72.3)
Higher middle 21 (42)
High income 115 (75.7)
Inguinal hernia repair 217 (80.7) Low income 18 (90)
Lower middle 38 (80.9)
Higher middle 41 (82.0)
High income 120 (78.9)
Appendix 4f: Numbers and percentages of respondents that chose each procedure in the first round of the Delphi according to the category of Infection/Inflammation
Surgical Procedure n (%) Income category n (%)
Open Appendectomy 231 (85.9) Low income 18 (90)
Lower middle 42 (89.4)
Higher middle 44 (88)
High income 127 (83.6)
Laparoscopic Appendectomy 191 (71.0) Low income 8 (40)
Lower middle 31 (66)
Higher middle 34 (68)
High income 118 (77.6)
Open Cholecystectomy 201 (74.7) Low income 17 (85)
Lower middle 41 (87.2)
Higher middle 37 (74)
High income 106 (69.7)
Laparoscopic Cholecystectomy
217 (80.7) Low income 10 (50)
Lower middle 35 (74.5)
Higher middle 41 (82)
High income 131 (86)
Extremity Amputation (Above level of ankle or wrist)
197 (73.2) Low income 17 (85)
Lower middle 36 (76.6)
Higher middle 34 (68)
High income 110 (72.4)
Appendix 5: Numbers and percentages of respondents who found procedures
extremely/very important, moderately important or slightly/not important in round two of the Delphi exercise
Surgical procedures
Extremely important n (%)
Importance N (%)
Cesarean delivery 148 (78.7)
Extremely/very 177 (94.7)
Moderately 7 (3.7)
Slightly/not 3 (1.6)
Trauma laparotomy 130 (69.1)
Extremely/very 176 (94.1)
Moderately 6 (3.2)
Slightly/not 5 (2.7)
Open appendectomy 104 (55.3)
Extremely/very 162 (86.6)
Moderately 18 (9.6)
Slightly/not 7 (3.7)
Stoma formation 80 (42.6)
Extremely/very 161 (86.1)
Moderately 21 (11.2)
Slightly/not 5 (2.7)
Inguinal hernia repair 89 (47.3)
Extremely/very 160 (85.6)
Moderately 17 (9.1)
Slightly/not 10 (5.3)
Partial colectomy 64 (34.0)
Extremely/very 159 (85.0)
Moderately 20 (10.7)
Slightly/not 8 (4.3)
Modified radical
mastectomy 54 (28.7)
Extremely/very 151 (80.7)
Moderately 30 (16.0)
Slightly/not 6 (3.2)
Cataract surgery 61 (32.4)
Extremely/very 147 (78.6)
Moderately 33 (17.6)
Slightly/not 7 (3.7)
Extremity amputation 73 (38.8)
Extremely/very 146 (78.1)
Moderately 30 (16.0)
Slightly/not 11 (5.9)
Small bowel resection 64 (34.0)
Extremely/very 143 (76.9)
Moderately 32 (17.2)
Slightly/not 11 (5.9)
Tracheostomy 85 (45.2)
Extremely/very 142 (75.9)
Moderately 36 (19.3)
Slightly/not 9 (4.8)
Splenectomy 59 (31.4)
Extremely/very 142 (75.9)
Moderately 34 (18.2)
Slightly/not 11 (5.9)
Hysterectomy 56 (29.8)
Extremely/very 141 (75.8)
Moderately 35 (18.8)
Slightly/not 10 (5.4)
Trauma thoracotomy 81 (43.3)
Extremely/very 141 (75.4)
Moderately 36 (19.3)
Slightly/not 10 (5.3)
Tube thoracostomy 80 (42.6)
Extremely/very 139 (75.1)
Moderately 34 (18.4)
Slightly/not 12 (6.5)
Partial mastectomy with
lymph node excision 42 (22.3)
Extremely/very 131 (70.8)
Moderately 39 (21.1)
Slightly/not 15 (8.1)
Uterine evacuation 63 (33.5)
Extremely/very 132 (70.6)
Moderately 39 (20.9)
Slightly/not 16 (8.6)
Open cholecystectomy 55 (29.3)
Extremely/very 130 (69.5)
Moderately 34 (18.2)
Slightly/not 23 (12.3)
Laparoscopic
cholecystectomy 52 (27.7)
Extremely/very 130 (69.5)
Moderately 30 (16.0)
Slightly/not 27 (14.4)
Trauma craniotomy 50 (26.6)
Extremely/very 125 (66.8)
Moderately 46 (24.6)
Slightly/not 16 (8.6)
External fixation of femur 55 (29.3)
Extremely/very 120 (64.2)
Moderately 51 (27.3)
Slightly/not 16 (8.6)
Obstetric fistula repair 47 (25.0)
Extremely/very 119 (63.6)
Moderately 44 (23.5)
Slightly/not 24 (12.8)
Laparoscopic
appendectomy 41 (21.8)
Extremely/very 114 (61.6)
Moderately 33 (17.8)
Slightly/not 38 (20.5)
External fixation of tibia 50 (26.6)
Extremely/very 111 (59.4)
Moderately 57 (30.5)
Slightly/not 19 (10.2)
Internal fixation of femur 33 (17.6)
Extremely/very 111 (59.4)
Moderately 55 (29.4)
Slightly/not 21 (11.2)
Thyroidectomy 33 (17.6)
Extremely/very 110 (58.8)
Moderately 62 (33.2)
Slightly/not 15 (8.0)
Salpingectomy 29 (15.4)
Extremely/very 104 (55.6)
Moderately 64 (34.2)
Slightly/not 19 (10.2)
Gastrectomy 23 (12.2)
Extremely/very 101 (54.0)
Moderately 56 (29.9)
Slightly/not 30 (16.0)
Imperforate anus repair 38 (20.2)
Extremely/very 99 (52.9)
Moderately 51 (27.3)
Slightly/not 37 (19.8)
Pediatric colostomy 37 (19.7)
Extremely/very 97 (52.4)
Moderately 57 (30.8)
Slightly/not 31 (16.8)
Skin grafting 33 (17.6)
Extremely/very 97 (52.2)
Moderately 54 (29.0)
Slightly/not 35 (18.8)
Cleft lip/palate repair 33 (17.6)
Extremely/very 96 (51.3)
Moderately 65 (34.8)
Slightly/not 26 (13.9)
Coronary artery bypass 32 (17.0) Extremely/very 92 (49.2)
graft Moderately 65 (34.8)
Slightly/not 30 (16.0)
Internal fixation of tibia 24 (12.8)
Extremely/very 91 (48.7)
Moderately 61 (32.6)
Slightly/not 35 (18.7)
Prostatectomy 21 (11.2)
Extremely/very 91 (48.7)
Moderately 57 (30.5)
Slightly/not 39 (20.9)
Percutaneous coronary
angioplasty 40 (21.3)
Extremely/very 91 (48.7)
Moderately 43 (23.0)
Slightly/not 53 (28.3)
Orchidopexy 29 (15.4)
Extremely/very 83 (44.4)
Moderately 75 (40.1)
Slightly/not 29 (15.5)
Radical nephrectomy 20 (10.6)
Extremely/very 83 (44.4)
Moderately 71 (38.0)
Slightly/not 33 (17.6)
Hip arthroplasty 28 (14.9)
Extremely/very 81 (43.3)
Moderately 66 (35.3)
Slightly/not 40 (21.4)
Tubal ligation 30 (16.0)
Extremely/very 80 (42.8)
Moderately 54 (28.9)
Slightly/not 53 (28.3)
Gastroschisis repair 26 (13.8)
Extremely/very 77 (41.2)
Moderately 71 (38.0)
Slightly/not 39 (20.9)
Omphalocele repair 20 (10.6)
Extremely/very 76 (40.6)
Moderately 70 (37.4)
Slightly/not 41 (21.9)
Pyloroplasty 13 (6.9)
Extremely/very 67 (35.8)
Moderately 72 (38.5)
Slightly/not 48 (25.7)
VP shunt placement 18 (9.6)
Extremely/very 62 (33.2)
Moderately 57 (30.5)
Slightly/not 68 (36.4)
Meningomyelocele repair 18 (9.6)
Extremely/very 61 (32.8)
Moderately 56 (30.1)
Slightly/not 69 (37.1)
Hypospadias 12 (6.4)
Extremely/very 58 (31.0)
Moderately 65 (34.8)
Slightly/not 64 (34.2)
Male circumcision 24 (12.8)
Extremely/very 57 (30.5)
Moderately 52 (27.8)
Slightly/not 78 (41.7)
Esophagectomy 11 (5.9)
Extremely/very 56 (29.9)
Moderately 60 (32.1)
Slightly/not 71 (38.0)
Hepatectomy 15 (8.0)
Extremely/very 55 (29.4)
Moderately 56 (29.9)
Slightly/not 76 (40.6)
Vasectomy 23 (12.2) Extremely/very 52 (27.8)
Moderately 48 (25.7)
Slightly/not 87 (46.8)
Lower extremity bypass
graft 12 (6.4)
Extremely/very 52 (27.8)
Moderately 71 (38.0)
Slightly/not 64 (34.2)
Fixation of mandible 10 (5.3)
Extremely/very 49 (26.2)
Moderately 58 (31.0)
Slightly/not 80 (42.8)
Knee arthroplasty 12 (6.4)
Extremely/very 48 (25.7)
Moderately 70 (37.4)
Slightly/not 69 (36.9)
Pyeloplasty 7 (3.7)
Extremely/very 43 (23.0)
Moderately 71 (38.0)
Slightly/not 73 (39.0)
Pancreatectomy 11 (5.9)
Extremely/very 40 (21.5)
Moderately 51 (27.4)
Slightly/not 95 (51.1)
Greyed out procedures were not prioritised by ≥75% in any income categories and were not brought forwards to Round 3.
Appendix 6: Percentage score for each procedure [score = (sum of all participants' scores/maximal potential score)*100] by participants in high income countries (HIC). upper middle income countries
(UMIC). and lower and lower middle income countries (LLMIC).
Procedures HICs UMICs LLMIC
Trauma laparotomy 96.0 95.2 81.2
C-section 95.1 93.1 94.7
Open appendectomy 88.2 86.9 89.4
Inguinal hernia repair 84.4 90.3 90.0
Tracheostomy 86.8 86.9 72.9
Trauma thoracotomy 84.6 93.1 71.2
Stoma formation 84.0 88.3 74.1
Cataract surgery 86.0 76.6 71.8
Partial colectomy 84.7 80.7 81.2
Extremity amputation 81.9 83.4 85.9
Modified radical mastectomy 82.1 83.4 83.5
Tube thoracostomy 81.8 89.0 72.4
Small bowel resection 80.7 82.8 72.4
Splenectomy 80.4 82.1 69.4
Hysterectomy 80.2 80.0 82.9
Uterine evacuation 81.6 81.4 67.1
Partial mastectomy 79.5 77.2 77.1
Trauma craniotomy 77.0 81.4 80.0
External fixation of tibia 76.7 75.2 80.0
Laparoscopic cholecystectomy 77.5 80.7 69.4
External fixation of femur 76.3 73.8 78.8
Obstetric fistula repair 76.7 69.0 79.4
Internal fixation femur 72.5 72.4 74.1
Salpingectomy 70.5 73.8 74.7
Open cholecystectomy 70.2 73.8 75.3
Pediatric colostomy 68.9 72.4 79.4
Imperforate anus repair 71.2 65.5 74.7
Laparoscopic appendectomy 74.2 69.0 59.4
Cleft lip palate repair 70.4 63.4 75.3
Skin grafting 69.6 71.7 61.8
Thyroidectomy 67.5 69.7 64.7
Coronary artery bypass graft 67.7 73.8 67.1
Internal fixation tibia 66.1 70.3 71.2
Gastrectomy 66.1 66.2 68.8
Percutaneous coronary angioplasty 66.0 71.0 65.3
Prostatectomy 64.9 64.1 69.4
Radical nephrectomy 64.9 61.4 70.0
Gastroschisis repair 65.6 60.0 61.2
Orchidopexy 62.6 60.0 69.4
Omphalocele repair 62.8 59.3 68.8
Hip arthroplasty 64.2 63.4 58.2
Tubal ligation 58.6 66.2 58.2
Appendix 7: Procedures which more than 75% of respondents thought were extremely, very, or moderately important.
Surgical procedure n %
C-section 176 98.9
Open appendectomy 176 98.9
Partial colectomy 176 98.9
Trauma laparotomy 176 98.9
Cataract surgery 173 98.3
Stoma formation 174 97.8
Tracheostomy 174 97.8
Hysterectomy 173 97.2
Modified radical mastectomy 173 97.2
Inguinal hernia repair 172 96.6
Splenectomy 172 96.6
Small bowel resection 171 96.1
Extremity amputation 170 95.5
Trauma craniotomy 169 94.9
External fixation of tibia 169 94.9
Partial mastectomy 169 94.9
External fixation of femur 165 94.8
Trauma thoracotomy 168 94.4
Tube thoracostomy 167 93.8
Uterine evacuation 167 93.8
Obstetric fistula repair 165 92.7
Internal fixation of femur 164 92.1
Thyroidectomy 162 91.0
Cleft lip palate repair 161 90.4
Laparoscopic cholecystectomy 158 88.8
Salpingectomy 158 88.8
Pediatric colostomy 154 86.5
Internal fixation of tibia 153 86.0
Skin grafting 151 85.8
Open cholecystectomy 152 85.4
Imperforate anus repair 150 84.3
Prostatectomy 148 83.1
Coronary artery bypass graft 146 82.0
Gastrectomy 146 82.0
Laparoscopic appendectomy 145 81.5
Radical nephrectomy 144 80.9
Percutaneous coronary angioplasty 140 79.1
Omphalocele repair 136 76.8
Note this has not been broken down by income group as all but 4 procedures are included
Appendix 8: Results round 3 in high income countries (HIC) and upper middle countries (UMIC) and lower middle and low income countries together (UMIC and LLMICs)
HIC UMICs and
LLMICs
(n=114) (n=63)
Condition n (%) n (%)
Trauma laparotomy 111 (97.4) 61 (96.8)
C-section 108 (94.7) 61 (96.8)
Cataract surgery 104 (91.2) 53 (85.5)
Inguinalhernia repair 96 (84.2) 61 (96.8)
Stoma formation 98 (86.0) 59 (93.7)
Tracheostomy 101 (88.6) 53 (84.1)
Open appendectomy 100 (87.7) 54 (85.7)
Partial colectomy 100 (87.7) 49 (77.8)
Modified radical mastectomy 96 (84.2) 52 (82.5)
Trauma Thoracotomy 93 (81.6) 53 (84.1)
Extremity amputation 95 (83.3) 51 (81.0)
Small bowel resection 89 (78.1) 53 (84.1)
Hysterectomy 91 (79.8) 51 (81.0) External fixation femur 88 (79.3) 45 (72.6)
Uterine evacuation 91 (79.8) 44 (69.8)
Partial mastectomy 90 (78.9) 43 (68.3)
Splenectomy 85 (74.6) 47 (74.6)
Trauma craniotomy 80 (70.2) 51 (81.0) External fixation tibia 85 (74.6) 43 (68.3) Tube thoracostomy 81 (71.1) 46
(73.0) Laparascopic
cholecystectomy 80 (70.2)
38 (60.3) Obstetric fistula repair 75 (65.8) 36
(57.1) Internal fixation femur 68 (59.6) 36 (57.1) Laparascopic appendectomy 73 (64.0) 28 (44.4)
Pediatric colostomy 59 (51.8) 41 (65.1)
Salpingectomy 64 (56.1) 35 (55.6)
Imperforate anus repair 62 (54.4) 34 (54.0)
Open cholecystectomy 61 (53.5) 35 (55.6)
Coronary artery bypass graft 48 (42.1) 34 (54.0)
Thyroidectomy 49 (43.0) 34 (54.0)
Appendix 9: Estimated 2015 specialist surgical workforce and participants in the round 3 Delphi, by WHO region and World Bank Income region (ref Holmer et al. Lancet)
Surgeons, obstetricians and anaesthetist globally
Round 3 Delphi (n=177)
% of total % of total
WHO Region
African Region 1% 15.1%
Eastern Mediterranean Region 5% 6.1%
European Region 34% 58.7%
Region of the Americas 20% 12.8%
South-East Asia Region 8% 3.9%
Western Pacific Region 32% 3.4%
World Bank Income Category
High income 40% 64.4%
Upper middle income 44% 16.4%
Lower middle income 15% 14.7%
Low income 1% 4.5%
