ABSTRACT
INTRODUCTION: In the 5 months since it began, the COVID-19 pandemic has placed extraordinary demands on health systems around the world including surgery. Competing health objectives and resource redeployment threaten to retard the scale-up of surgical services in low- and middle-income countries where access to safe, affordable and timely care is low. The key aspiration of the Lancet Commission on global surgery was promotion of resilience in surgical systems. The current pandemic provides an opportunity to stress-test those systems and identify fault-lines that may not be easily apparent outside of times of crisis. METHODS: We endeavoured to explore vulnerable points in surgical systems learning from the experience of past outbreaks, using examples from the current pandemic, and make recommendations for future health emergencies. The 6-component framework for surgical systems planning was used to categorise the effects of COVID-19 on surgical systems, with a particular focus on low- and middle-income countries. Key vulnerabilities were identified and recommendations were made for the current pandemic and for the future. RESULTS: Multiple stress points were identified throughout all of the 6 components of surgical systems. The impact is expected to be highest in the workforce, service delivery and infrastructure domains. Innovative new technologies should be employed to allow consistent, high-quality surgical care to continue even in times of crisis. CONCLUSIONS: If robust progress towards global surgery goals for 2030 is to continue, the stress points identified should be reinforced. An ongoing process of reappraisal and fortification will keep surgical systems in low- and middle-income countries responsive to "old threats and new challenges". Multiple opportunities exist to help realise the dream of surgical systems resilient to external shocks.