Progress in achieving universal access to surgical care: An update and a path forward

More than 5 billion people worldwide lack access to safe, affordable, and timely surgical and anesthesia care.1 These global deficits in surgical and anesthesia care—and the means to alleviate them—moved into sharper focus in 2015, as the result of initiatives led by the World Bank, The Lancet Commission on Global Surgery, and the World Health Organization (WHO). Additionally, a new surgery-focused advocacy group called the G4 Alliance formed in May 2015, and the United Nations (UN) has adopted a new health systems framework that will set the global health agenda for the next 15 years. These initiatives are not merely the latest academic and political trends; rather, they represent a paradigm shift regarding the importance of quality health and surgical care access for resource-poor populations. This article summarizes these initiatives and offers a context for the future role of the American College of Surgeons (ACS) in making surgical care available to patient populations that are without access at present.

Disease Control Priorities

In March 2015, the World Bank released the first volume of its third edition of Disease Control Priorities.2 Disease Control Priorities in Developing Countries was published in 1993 against the backdrop of the growing human immunodeficiency virus (HIV) pandemic and a global malnutrition crisis.3 Along with the World Bank’s 1993 World Development Report, which focused on investing in health care (see Figure 1), the first edition of Disease Control Priorities provided policymakers with strategies that would produce the greatest benefits to the public welfare and promote economic growth with limited resources.4 Surgery was not mentioned in the first edition of the report. The second edition of Disease Control Priorities, however, included a chapter on the cost-effectiveness of surgery, in which Haile T. Debas, MD, FACS, and colleagues estimated that 11 percent of the global burden of disease could be addressed with surgical care.5 Until it was significantly revised upward in 2015, this estimate was one of the most widely cited statistics in global surgery.

Figure 1. Iterations of the Disease Control Priorities

global-surgery-1

The third edition of Disease Control Priorities, the first full volume of which is titled Essential Surgery, breaks with the past and recognizes recent evidence that proves that surgical care is cost-effective and essential for meeting health care targets in low-resource settings. The authors of the third edition describe the importance of assessing the cost-effectiveness of surgical care platforms, such as the rural, first-level hospital, which can provide a broad array of surgical and other health care services. The authors demonstrate that surgical care is cost-effective, with spending at only $10 to $100 per disability-adjusted life year (DALY) and deaths averted, a common measure used in public health to compare death and disability averted from interventions. This price tag compares favorably with some of the most accepted cost-effective interventions in public health, including vaccinations and antiretroviral therapy (see Figure 2).

Figure 2. Selected key findings of the Disease Control Priorities, Third Edition, volume on Essential Surgery

  • Essential procedures can avert more than 7 percent of preventable deaths in LMICs
  • Essential procedures are among the most cost-effective of all health procedures
  • First-level hospitals must be widely available and can provide most emergency surgery services
  • Substantial disparities exist in surgical safety, driven by high perioperative mortality and anesthesia deaths
  • Coverage of surgery should be financed early on the path to universal health coverage

Furthermore, the authors of the third edition of the report suggest that the universal provision of 44 essential surgical procedures could avert 1.5 million global deaths annually, or up to 7 percent of all avoidable deaths in low- and middle-income countries (LMICs) with a 10:1 benefit-cost ratio, making these surgical services a high-value investment rather than an expenditure.2 With the focus on cost-effectiveness, the World Bank, the document’s key sponsor, opens the door to attention from large-scale donors and policymakers who seek high return on investments in global health.

The Lancet Commission on Global Surgery

The Lancet periodically commissions reports on issues of global significance that require attention from policymakers. In the summer of 2013, The Lancet commissioned a report on the state of surgical care worldwide. This led to an 18-month deliberative process involving more than 500 clinicians, researchers, policymakers, and funders from more than 110 countries (see Figure 3). Commissioners, advisors, collaborators, and contributors engaged in interviews, online data and article submissions, and new primary research examining the current state of surgical care around the world. The end result of this process was the publication of the commission’s report, Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development.6

Figure 3. The process of The Lancet Commission on Global Surgery

Commissioneers, advisors, collaborators from over 110 countries

The Global Surgery 2030 report outlines important statistical information, including the fact that at least 5 billion people, or approximately 70 percent of the world’s population, lack access to safe, affordable, and timely surgical care (see Figure 4).6 This number represents a startling uptick and is more than double the previous estimates. Furthermore, patients in the world’s poorest countries will need to undergo 143 million additional procedures to meet minimum needs based on the global demand, requiring  the training of at least 1.25 million additional surgeons, anesthetists, and obstetricians.6 Notably, the scale-up of surgical care will require careful attention to financing models to prevent undue financial burden on individual patients. And although the challenges are daunting, the consequences of inaction are even more perilous. The world’s poorest economies will lose up to 2 percent of their gross domestic product annually by 2030 as a result of surgical illness.

global-surgery-4Figure 4. Key messages of The Lancet Commission on Global Surgery

  • 5 billion people lack access to safe, affordable surgical and anesthesia care
  • 143 million additional procedures are needed yearly
  • 33 million people face catastrophic expense after surgical care yearly
  • Investment in surgical and anesthesia care saves lives, is affordable, and promotes economic growth
  • Surgery is an indivisible, indispensable part of health care

In addition to assigning numbers to the problem, the report provides more than 100 recommendations and six surgery-specific indicators to stimulate and measure systems improvement. The WHO and World Bank—the global agenda-setting institutions for health metrics and monitoring—have endorsed the six surgical indicators by incorporating them into their respective frameworks, and, in April, the World Bank published the first set of surgical indicators in its World Development Indicators dataset. Together, the commission’s recommendations and indicators create a framework for the systematic strengthening of surgical systems in low-resource environments for the first time in this emerging field of global health.

WHA resolution 68.15

The WHO, formed in 1948 out of the groundswell of global cooperation following World War II, is tasked with monitoring and improving global public health. Its policymaking body, the World Health Assembly (WHA), is composed of health ministers from the UN’s 194 member states and is responsible for setting the budget and electing WHO leadership (see Figure 5). In May 2015, the 68th WHA passed resolution 68.15, “Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage,” which officially declares surgical care a priority initiative for the WHO (see Figure 6).7

Figure 5. The WHA

The WHA

Figure 6. The core recommendations of WHA resolution 68.15

  • Urges member states to identify core set of procedures, integrate emergency care into primary care and first-level hospitals, promote intersectoral financing mechanisms, carry out monitoring and evaluation, and develop national policies to scale workforce
  • Requests director general to advance delivery of science in surgery and anesthesia, raise awareness of cost-effective options, collect and report data, support member states in developing policies, and raise resources for WHO and surgery

The resolution calls for a $23 million investment over five years for implementation, with the primary aim of enhancing surgical systems in the areas of advocacy, governance, data collection, essential medicines, and training. The office within the WHO responsible for the effort will expand from a staff of one to a seven-person operation and will spread its reach beyond the WHO’s Geneva, Switzerland, headquarters to regional offices.

As a capstone to this sequence of events, in December the WHO hosted its 10th anniversary meeting of the Global Initiative for Emergency and Essential Surgical Care in Geneva, during which a plan for implementing the WHA resolution was developed. Participants from six continents and more than 40 countries approved this initiative, which calls for a strong focus on global indicator collection and monitoring and coordinated support for national surgical planning.

Global alliance

More than 60 surgical, anesthetic, obstetric, and trauma federations, professional societies, academic entities, and nongovernmental organizations have signed on to support the Global Alliance for Surgical, Obstetric, Trauma, and Anesthesia Care (the G4 Alliance).8 The G4 Alliance is the first professional advocacy-based organization “dedicated to building political priority for surgical care as part of the global development agenda.” Holding its first executive board meeting in Geneva in May 2015, and various webinars and regional events throughout the year, the G4 Alliance will play an important role in keeping surgery and anesthesia at the forefront of the global public health conversation.

Sustainable development goals

The Millennium Development Goals (MDGs) established by the UN in 2000 (see Figure 7) included eight anti-poverty targets to be achieved by 2015. Significant progress has been made toward reducing the number of people living in poverty. Last year, the UN Member States adopted the Sustainable Development Goals (SDGs) to extend these efforts through the next 15 years (see Figure 8).9

Figure 7. The Millennium Development Goals

The Millennium Development Goals

Figure 8. The Sustainable Development Goals

The Sustainable Development Goals

In contrast to the MDGs, which focused on disease-specific interventions, the 17 SDGs emphasize “horizontal” development, which entails investing in broad-based health systems and universal health care instead of a narrow, “vertical” focus. With the latest estimate suggesting that one-third of the world’s burden of disease requires some form of surgical care, it is clear that the SDGs cannot be fully realized without an emphasis on improving surgical access and quality. The third SDG calls for ensuring healthy lives and promoting well-being for all.

Within this goal, the UN set a target of reducing the global maternal mortality rate to less than 70 per 100,000 live births, cutting by one-third the rate of premature death from non-communicable diseases, and halving the number of deaths due to road traffic accidents. The link between achieving the third SDG and surgical care is most direct, but the role of surgery in development extends far beyond this milestone. Strengthening the world’s surgical systems will be an important step toward achieving targets for many other SDGs. For example, the first SDG calls for ending poverty, the eighth SDG for promoting economic growth, and the 10th for reducing inequality. The third edition of the Disease Control Priorities and The Lancet Commission both suggest that a lack of a strong surgical system inhibits economic growth, hitting the lowest-income countries the hardest with a cumulative loss of $12.3 trillion across LMICs from the burden of surgical disease.6 Achieving each of the SDGs will require interventions that include both prevention and treatment and that fundamentally rely on robust hospital systems offering comprehensive health care, including surgery.

Role of surgical organizations

At the North American launch of Global Surgery 2030, ACS Executive Director David B. Hoyt, MD, FACS, noted that the Commission’s report represents a call to action for surgeons to recognize the deficits in global surgical care and to accept responsibility for resolving this problem. Extending access to surgical care beyond the world’s wealthiest 2 billion people will require the coordinated action of international agencies, national governments, and clinicians. It also will necessitate the attention and commitment of influential surgical organizations, particularly those in high-income countries.

Many surgical organizations have already begun to heed this call to action. The ACS, the Royal Australasian College of Surgeons (RACS), and the Royal College of Surgeons of Ireland (RCSI) are already playing an important role in this process.

The ACS Operation Giving Back (OGB) program started in 2004 as a portal to coordinate American surgical volunteerism around the globe.10 Its mission is to leverage the passion, skills, and humanitarian ethos of the surgical community to effectively meet the needs of medically underserved populations. OGB seeks to provide the necessary tools to facilitate humanitarian outreach among surgeons of all specialties at all stages in their professional careers and with emphasis on both domestic and international service.

The RACS Pacific Islands Project, established in 1995, is a longitudinal program that focuses on strengthening workforce and clinical support capacity across the Asia-Pacific region. Meanwhile, the RCSI has long-standing training collaborations with the College of Surgeons of East, Central, and Southern Africa (COSECSA).11,12 These initiatives have appropriately garnered accolades as models of collaboration between partners in high-income and LMICs.

But more can be done. One important strategy is to continue to foster direct collaboration between surgical organizations in high- and low-income countries, particularly in the context of systematic national surgical planning. To address long-term workforce strengthening, surgical organizations in low-resource settings should have direct channels to their high-income partners for financial, technical, and material support for education, training, and research. National and regional surgery societies, such as the West African College of Surgeons and COSECSA, provide the bulk of surgical training for the African continent. Their success hinges on maintaining long-term training programs that fit the needs of their populations while creating local practice environments that will retain graduates. As the world’s leading surgical organization, the ACS is well-positioned to play a major role in supporting the global community of surgeons in advocating for the underserved surgical patient, both domestically and internationally.

The landmark events and publications of 2015 reveal a moral imperative for all surgeons to meaningfully support the research, advocacy, and training that is a part of the growing field of global surgery. The health care community can no longer turn a blind eye to the gross inequities in access to surgical care. For more information or to get involved, go to The Lancet Commission on Global Surgery website and the Operation Giving Back website.


References

  1. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: A modelling study. Lancet Glob Heal. 2015;3(6):e316–323.
  2. Mock CN, Donkor P, Gawande A, Jamison DT, Kruk ME, Debas HT. Essential surgery: Key messages from Disease Control Priorities, 3rd edition. Lancet. 2015;385(9983):2209-2219.
  3. Jamison D, Moshley W, Measham A, Bobadilla J. Disease Control Priorities in Developing Countries. New York, NY: Oxford University Press; 1993.
  4. The World Bank. World Development Report 1993: Investing in Health. New York NY: Oxford University Press; 1993.
  5. Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: Jamison DT, Breman JG, Measham AR, et al, eds. Disease Control Priorities in Developing Countries, 2nd edition. New York, NY: Oxford University Press; 2006.
  6. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
  7. World Health Organization. The 68th World Health Assembly. Strengthening emergency and essential surgical services as a component of universal health coverage. Report by the Secretariat. March 20, 2015. Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_31-en.pdf. Accessed April 12, 2016.
  8. A Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care. About us. Available at: www.theg4alliance.org/aboutg4alliance/. Accessed April 12, 2016.
  9. United Nations. The Millennium Development Goals Report 2015 Summary. Available at: www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20Summary%20web_english.pdf. Accessed April 12, 2016.
  10. The American College of Surgeons. Operation Giving Back. Available at: facs.org/ogb/. Accessed April 17, 2016.
  11. Watters DA, Ewing H, McCaig E. Three phases of the Pacific Islands Project (1995–2010). ANZ J Surg. 2012;82(5):318-324.
  12. Royal College of Surgeons in Ireland. RCSI-COSECSA Collaboration Programme. Developing surgical skills in sub-Saharan Africa. Introduction. Available at: www.rcsi.ie/cosecsa. Accessed April 12, 2016.

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