Global Surgery Day, which was celebrated on 25th May, marked the 10th anniversary of the Global Surgery movement, advocating for safe, timely, and affordable surgical care for everyone globally. A decade ago, it was established that over 30% of the global disease burden can be treated surgically. However, the World Health Summit Regional (WHS) Meeting held in April 2025 at Delhi, which saw great momentum on several health, social, and developmental issues, had one area lacking: Surgical care. It only had one session that talked about access to surgical care as a public health, health systems, and health policy challenge. As India concluded its National Surgery Week last month on 15th June, we highlight why surgery needs to be prioritized in its public health systems.
How India falls short on surgical access and safety
Surgery is lifesaving in several essential and emergency conditions, and unavailability, delay, or poor quality can lead to mortality and morbidity, which is otherwise completely preventable. The lack of access to safe surgical care results in four times more deaths annually than HIV/AIDS, tuberculosis, and malaria combined around the world.
India can reduce this burden by strengthening its healthcare system to ensure safe and affordable surgical care. Yet, surgical care has remained a low priority in policies and programs over the last several decades around the world, and more specifically in Asia and India.
One way of evaluating the status of India’s surgical systems is through indicators proposed by the Lancet Commission on Global Surgery (LCoGS). These include timely access, workforce density, surgical volume, perioperative mortality, and the financial risk due to surgical procedures. Unfortunately, India lags on nearly every measure.
Timely access: Even though geospatial modeling evidence (a method used to measure distance and travel time) suggests that over 95% of patients can access surgery at the medical college hospitals, this access is often not meaningful. Many centres provide a narrow range of procedures due to workforce, infrastructure, and financial constraints. For instance, many community health centres and sub-district hospitals cannot provide surgical care due to a shortage of anesthesiologists, inadequate diagnostic facilities, and a severe lack of basic infrastructure like electricity and oxygen. Blood banks and anesthesia machines are often missing or non-functional in smaller hospitals.
Workforce: According to LCoGS, India’s surgical workforce density was 6.5 per 100,000 population in 2009. To reach the density target of 20 by 2030, an additional 2,91,824 providers are required. Despite increasing the number of MBBS seats by more than 100% in the last decade, the scale-up rate of specialty seats for surgical branches remains inadequate. There is also a severe rural-urban disparity, with more than 67% of registered physicians and surgeons practising in urban areas while 70% of the country’s population lives in rural areas.
Surgical volume: Lack of workforce translates to fewer surgeries. In 2019, India recorded 1385 surgeries per 100,000 population, far below the global target of 5,000. Only five Union Territories (UTs) met the benchmark, possibly due to their small population size. Five states from the eastern and northeastern regions, with predominantly rural populations, accounted for almost two-thirds of the unmet need for surgical procedures.
Safety: India continues to struggle with surgical safety. The perioperative mortality rate (POMR) (the percentage of patients who die within 30 days after surgery) in India is higher compared to other LMICs. A study published in BMJ Global Health compared the POMR in India with the average in other low- and middle-income countries (LMICs). In their report, maternal deaths after cesarean sections in India ranged from 0.1% to 0.3%, deaths after abdominal surgeries ranged from 4.9% to 12.5%, and for trauma surgeries, the rate ranged from 0% to 4.7%.
Although POMR is a key indicator of surgical safety, its use remains limited due to inconsistent reporting practices and vulnerability to information and publication biases. The timeframe used to calculate POMR differs across studies, and in some cases, the metric itself lacks a clear definition. Some studies suggest that surgical safety in India is a serious issue contributing to adverse outcomes such as increased postoperative complications, prolonged hospital stays, and preventable mortality.
Financing: A key barrier to surgical care is the lack of investment. In a stark contrast to its population size, India has one of the world’s lowest healthcare budgets. Although research indicates that surgery is as cost-effective as immunization programs for conditions requiring surgical management, medically manageable conditions like infectious diseases often get greater attention and funding. Moreover, most infrastructural investments are concentrated on tertiary hospitals, while first referral units like district hospitals and community health centres remain neglected. For patients, this means a grim choice: paying out-of-pocket for expensive private care or skipping surgery altogether.
How PMJAY has impacted surgical care in India
Schemes like the Pradhan Mantri Jan Arogya Yojana (PMJAY) have made surgeries more accessible for the bottom 40% of the country’s population by subsidizing surgical care in the private sector. Under this scheme, patients can get free treatment up to ₹5 lakh per year per family in empanelled hospitals, including surgical procedures such as caesarean sections, hernia repair, cataract surgery, and even a few cancer surgeries. While PMJAY is the world’s largest government-funded health insurance program, covering over 500 million individuals, it reflects the pre-existing health inequalities in India.
Nearly two-thirds of all surgical procedures under PMJAY occur in private facilities, predominantly in urban regions. In states like Bihar, Madhya Pradesh, and Uttar Pradesh, surgical needs are high, but PMJAY utilization is low. Only 7% of hospitals in India’s Aspirational Districts identified for urgent development offer specialized surgeries compared to 17% in other districts.
Even within the scheme, disparities exist in gender, geography, and specialty uptake. Men raised more claims for high-value surgeries, and states with better infrastructure dominate surgical specialties such as neurosurgery and cardiothoracic surgery. Meanwhile, rural patients are often forced to travel to other states to seek care. Without strong and functional district hospitals, PMJAY risks becoming a referral pipeline to private hospitals, leaving rural India behind.
Path forward: Financing, infrastructure, and changing public perception
India can no longer afford to neglect surgical care. Treatable conditions are causing preventable deaths and pushing families into poverty. While PMJAY can serve as India’s way of financing surgical care, much remains undone. For PMJAY to truly succeed, the government must strengthen the public health infrastructure, particularly district hospitals and community health centers that serve as first points of surgical referral.
While expanding infrastructure and financing are essential, public health literacy is key to improving health-seeking behaviour. State-led public awareness campaigns can address fear and stigma around surgery. This requires strong community participation, including engagement of local leaders, collaboration with grassroots health workers, culturally sensitive messaging, and the use of regional languages and media channels to build trust and encourage informed decision-making. A pilot survey conducted in the urban slums of Ahmedabad, Gujarat, by SATHI found that 57% of households did not undergo surgery due to the fear of surgical procedures and trust deficit. Reframing surgery as safe, necessary, and often life-saving is essential.
Another major gap is data. India’s data on surgical indicators is nearly a decade old, with recent updates limited to small-scale studies that lack national representativeness and generalizability. Recently, the Data Innovation, Program Implementation, and Community Action (DIPICA) Observatory brought together several stakeholders from global surgery, public health, health policy, and clinical practice to address planned challenges in SAO care, focusing on data-driven approaches, sustainable financing, and workforce development.
The DIPICA observatory will serve as a platform for continuous dialogue and knowledge exchange, focusing on grassroots-level studies, qualitative data collection from interest holders, and real-time monitoring resources in the future. DIPICA is a promising start to a long-term collaboration, aimed at paving the way for better surgical care in India.
Ultimately, surgical care is not a luxury but a fundamental right. India must act now to ensure that every citizen has access to safe and affordable surgical care.
(The authors have written this on behalf of the DIPICA collaborative.)
Edited by Parth Sharma
Image by Janvi Bokoliya
