Five years to the finish line: progress and unintended consequences since the Lancet Commission on Global Surgery

The year 2015 was a landmark year for global surgical care due to the publication of the 2030 targets of the Lancet Commission on Global Surgery. The Lancet report catalysed the global surgery movement amidst warnings of the movement's fragmentation, exclusivity, and leaning towards the Global North. Since then, there has been positive growth in academic global surgery programmes and centres, surgery coalitions, student advocacy, infrastructure, and task-sharing models, and a shift in the framing of global surgery from brief north-south mission trips to an academic discipline with burgeoning literature. Since 2016, four of the commission's six indicators have been integrated into the World Development Indicators. However, there has been a significant decline in the national reporting of these indicators (in some instances to 0% globally), making it difficult to objectively assess progress. The aim of this article is to discuss the progress and controversies surrounding the commission's benchmarks for specialist surgical workforce density, geographical access to surgical care, financial risk protection for surgical care, and surgical volume and reporting of perioperative mortality, as well as to discuss some unintended consequences since the commission, including the challenge of negative framing, the creation of a surgeon-focused movement, the expansion of a largely academic field with little focus on implementers, emphasis on high-level advocacy without a similar focus on grassroots advocacy, hyper-emphasis on surgical plans without appropriate focus on implementation capacity, relegation of community-based care and prevention as a component of global surgery, and the challenge of the use of 10-year-old data, 5 years to the finish line. Finally, broad recommendations for progress are suggested using a nine-pronged framework.