Armed conflict disrupts health systems in ways that extend far beyond the destruction of hospitals or shortages of medical supplies. The ability of patients to access care depends on whether health systems can sustain referral pathways, coordinate services across different levels of care, and maintain continuity despite insecurity, displacement, and fragmented governance. Yet these dimensions of health-system performance remain poorly captured by conventional humanitarian indicators.

Surgical access under prolonged occupation, war, and fragmented health governance offers a particularly revealing lens. In Palestine, movement restrictions, referral governance, territorial fragmentation, place of residence, and the availability of functioning health facilities shape who reaches care, when they reach it, and whether care can continue. Research from the West Bank has documented the relationship between checkpoints, road closures and other movement restrictions and reduced access to healthcare. These barriers matter particularly for patients whose care requires movement between facilities or jurisdictions. And of course,  the war in Gaza sadly demonstrated in the past few years what happens when disruption of surgical pathways becomes systemic rather than episodic. 

Surgery: a neat tracer with nevertheless room for improvement

Global health responses to conflict commonly rely on indicators such as mortality, communicable disease control, maternal health outcomes, and facility functionality to understand crisis impact. These measures remain essential, but they tell us less about whether patients are able to progress through referral pathways or recover functional capacity after injury. Studies of surgical referral systems, for example, have documented how failures in transport, coordination, communication and referral processes can disrupt continuity of care across different levels of the health system.

Surgery is particularly useful as a tracer because surgical care depends on multiple components of the health system functioning together. Access to safe surgery requires transportation, referral coordination, diagnostics, anesthesia, specialist teams, operating theatre capacity, blood products, postoperative care and, frequently, rehabilitation and repeated patient mobility. The Lancet Commission on Global Surgery (2015) established timely access, surgical capacity, safety and affordability as some of the core dimensions of surgical access. In conflict settings, however, even nominally available services may become unreachable when the pathways connecting patients to them break down.

The horrendous war in Gaza showed what happens when disruption of surgical pathways becomes systemic. A longitudinal analysis of 35 hospitals during the first 13 months of the current war found that overall hospital-system functionality fell to 13.9% at its lowest point and remained below one-third after December 2023. No hospital was reported as fully functional after 18 October 2023. Such collapse does more than reduce the number of operations that can be performed. It also disrupts the continuum connecting injury to definitive treatment, postoperative care, reconstruction and rehabilitation. A hospital’s nominal operational status therefore tells us only part of whether a patient can actually complete a surgical pathway. In Palestine, the surgical pathway itself can therefore become a geography of inequity, shaped not only by clinical need but by where a patient lives, which facility remains reachable, and whether movement between stages of care is possible.

The consequences become particularly visible after the acute phase of injury. Fractures, burns, complex soft-tissue injuries and injuries requiring reconstructive procedures may remain treatable, yet delays or interruptions in care can translate into chronic pain, impaired mobility and preventable disability. These outcomes influence independence, education, employment and participation in community life long after the immediate violence has passed. Humanitarian responses understandably prioritize preventing mortality, but survival alone cannot tell us whether recovery has been equitable.

Two patients may therefore survive similar injuries while experiencing profoundly different futures. One may receive definitive surgery, reconstruction, rehabilitation and follow-up; another may survive but remain with avoidable disability because a referral could not be completed, a facility ceased functioning, or repeated travel became impossible. The difference between these trajectories exposes a dimension of health equity that mortality statistics alone cannot show.

Suggestion for a way forward

This suggests a practical shift in how surgical care should be monitored during conflict. Alongside facility functionality and mortality, humanitarian health systems could document referral completion, time from injury or referral to definitive surgery, reasons for interruption or delay, continuity of postoperative and reconstructive care, and access to rehabilitation. These indicators should, where possible, be disaggregated by geography, displacement status, gender, age and disability. Existing research on timely surgical access already highlights the need for more consistent outcome measures; conflict settings make this gap particularly consequential.

Surgical pathways should therefore not simply be understood as a measure of surgical service delivery, but also as a tracer of health equity and health-system continuity during conflict. Following the pathway of an injured patient makes visible where systems fracture, which populations become stranded between levels of care, and whose recovery remains possible.

Ultimately, asking “Who gets surgery in war?” refers to a broader question: not only who survives conflict, but who is afforded the possibility of recovery, mobility and continued participation in society?