Our History

Surgery, anesthesia, and pain management have historically not been included in the broader global health agenda. In 2006 around the time that GPAS formed, it was estimated that 11% of the global burden of disease could be treated by surgical intervention with a larger but uncertain proportion of disease burden treatable with pain and palliative care services.

Roughly seven years later data became available that demonstrate inadequate access to surgical and anesthesia services is a much larger problem than initially predicted. Current estimates demonstrate that 30% of the global burden of disease is surgically treatable, with the burden from trauma alone being more than that for HIV, tuberculosis, and malaria, combined.

A global epidemiologic transition is currently underway with decreases in infectious and childhood diseases, and an increasing burden of non-communicable diseases.  Many of these conditions, especially injury and cancer, also require surgical and anesthesia care, either for cure or palliation.

Most of the world’s seven billion people live in low and middle-income countries (LMICs) and lack access to surgical and anesthesia services. Of the 235 million operations performed worldwide each year, only 4% are performed in LMICs. Despite having the largest proportion of disease burden, regions like Sub-Saharan Africa have the fewest healthcare resources including healthcare workers. Equitable access to pain management and palliative care services are also sorely lacking, with 15% of the world’s population consuming 94% of the world’s opiates.

  • 5 billion people lack access to safe, affordable surgical and anesthesia care
  • 32 million receive anesthesia without adequate monitoring annually
  • 143 million additional surgical procedures needed each year
  • 3 million people face catastrophic health expenditure due to surgery and anesthesia each year
  • $12.3 trillion of economic productivity will be lost without scale-up of surgical and anesthesia services between now and 2030

Despite these statistics, surgical and anesthesia care continue to be overshadowed by infectious diseases and other global health topics. Additional factors that have contributed to the relative neglect of global surgery and anesthesia include the misperception that all surgery is complex, expensive and resource-intense; and a historical focus on vertical public health programs with the false assumption that infrastructure for other services would indirectly be strengthened.

Recent cost-effectiveness studies have estimated that surgical services are more cost effective than well-established and heavily supported antiretroviral therapy for HIV. As it turns out, surgery ranks comparably with more cost-effective public health interventions, such as vaccines.

There are many factors contributing to this projected rise in the burden of surgical disease, including a critical surgical workforce shortage especially in LMICs. Sub-Saharan Africa carries a disproportionate 25% of the world’s total disease burden with only 2% of the global health care workforce to address it. Similar disparities exist for the surgical disease burden. Sub-Saharan Africa has the highest concentration of surgical disease burden though the fewest surgery and anesthesia providers per capita.

The situation in Uganda is no different. At the time of GPAS formation, there were only 13 physician anesthesiologists and fewer than 100 surgeons for the population of 30 million. With five physicians per 100,000 people, an average annual per capita income of ~US$510 , and a life expectancy of 58 years, Uganda is among the poorest and most medically underserved countries in the world.

  • In 2003 the surgery departments at the University of California San Francisco (UCSF) and Makerere University (MU) Kampala, Uganda formed a partnership that focused on faculty and trainee exchange as a first step toward addressing the surgical care crisis in Uganda. Based on lessons learned from the initial 5-year partnership and shifting local priorities in Uganda, it became clear that clinical service, donations and teaching through short trips had limited long-term impact, and thus the GPAS model began to emerge.
  • In 2006, Ugandan surgeons conducted a survey of faculty and trainees at MU to help identify challenges and potential solutions to improve surgery and anesthesia care in Uganda. Problems identified included the low number of trainees, high costs of training, “brain drain,” inadequate post-graduate job opportunities, perceived increased risk of HIV exposure, and a poor learning environment.
  • In 2007, based on these concerns, a locally developed “task force” formed and adopted the name GPAS. The group met regularly at Mulago Hospital and expanded in subsequent years to include representatives from multiple departments (Emergency Medicine, Internal Medicine, Obstetrics, Orthopedics) from several collaborating institutions (UBC, Duke, UW Seattle, Harvard) and organizations (AAGBI – Association of Anaesthetists of Great Britain and Ireland).
  • Also in 2007, the Bellagio Essential Surgery Group was formed as a multidisciplinary, international network focused on developing collaborative strategies to increase access to surgical services across sub-Saharan Africa. Several of the founding members of GPAS participated in the BESG.
  • In 2008, The Bellagio Essential Surgery Group met in Kampala, Uganda to develop specific cross-country strategies and implementation plans for global surgery:  Bellagio Essential Surgery Group Report (Uganda 2008).
  • 2016 – At the present time GPAS is an international, multidisciplinary collaboration focused on developing, implementing, and evaluating strategies that improve surgical and perioperative care in resource-poor settings. Our recent annual conference in Uganda hosted more than 230 collaborators from > 10 countries.


    Our projects fall into three main categories:

      • Capacity Building
              • Education
              • Workforce
              • Infrastructure
              • Research training
      • Research
            • Collecting epidemiological data to quantify the need, both met and unmet
            • Measuring the (potential) disability averted by surgical services
            • Establishing quality of care and quality of training standards
            • Determining cost-effectiveness of interventions
      • Harmonization
            • Collaborating with stakeholders
            • Avoiding duplication of efforts

    We actively seek new partners with similar missions and believe harmonization of global surgical efforts across disciplines and institutions is critical to successfully addressing the surgical disease crisis at hand.

    To date, GPAS projects have been primarily based in Uganda, though collaboration with other partner sites are underway.