Health care leaders develop strategies for improving access to surgical care in Latin America

Centered on the vision of universal access to surgical and anesthesia care as articulated by The Lancet Commission on Global Surgery (LCoGS), the field of global surgery has achieved large advances through academic and political efforts in sub-Saharan Africa, south and east Asia, and the islands of the central and south Pacific, commonly known as Oceania.1-5

During a regional meeting on December 7, 2016, in São Paulo, Brazil, a diverse group of health care leaders from eight Latin American countries also demonstrated a commitment to systematically improving access to safe and affordable surgical care through a symposium titled Global Surgery Latin America: Findings, Recommendations, and Implementation of The Lancet Commission on Global Surgery (see Figure 1). This group was composed of 55 individuals, including regional leaders in acute care, colorectal, gynecologic, oncologic, pediatric, plastic, trauma, and vascular surgery, as well as anesthesia professionals and members of the American College of Surgeons (ACS).

Figure 1. Countries represented at the Global Surgery Latin America symposium

Figure 1. Countries represented at the Global Surgery Latin America symposium

 

Through prepared comments, interactive panels, and focused small-group discussions, participants identified priorities in Latin America for providing safe surgical care, conducting research, and driving policy. They identified challenges that are common to many regions of the world, as well as issues that are specific to Latin America (see photos below). Notably, during the meeting clinicians and policymakers in Latin America resolved to implement change and improve access to surgical care.

Unique Challenges in Latin America: Left: In Anamã, Amazonas, Brazil, the hospital doors are removed from their frames and labeled in preparation for annual flooding Right: Water levels in Careiro da Várzea; Photos by Dr. José Emerson dos Santos Souza, as part of a systematic assessment of the surgical capacity in the state of Amazonas, Brazil

Unique Challenges in Latin America:
Left: In Anamã, Amazonas, Brazil, the hospital doors are removed from their frames
and labeled in preparation for annual flooding; Right: Water levels in Careiro da Várzea
Photos by Dr. José Emerson dos Santos Souza, as part of a systematic assessment
of the surgical capacity in the state of Amazonas, Brazil

This article summarizes the contents of the symposium and describes strategies for further action. It is intended to serve as a call to action for members of the ACS, as well as for other health care providers to become more engaged in the global surgery movement.

Summary of symposium presentations

The opening comments at the symposium focused on core concepts in global surgery, including the surgical access gap, indicators for benchmarking progress, and a framework for evaluating and improving surgical systems. They pointed to the need to dedicate global resources to addressing surgical care as a public health concern. A summary of presenters and their topic areas are as follows:

  • Robert Riviello, MD, MPH, FACS, director of global surgery programs at the Center for Surgery and Public Health, associate surgeon, division of trauma, burns and surgical critical care, Brigham and Women’s Hospital; and assistant professor of surgery, Harvard Medical School, Boston, MA, presented the key messages of the LCoGS, providing specific data on the surgical access gap and the resources needed to close it.
  • Walter D. Johnson, MD, MPH, MBA, FACS, program lead, emergency and essential surgical care, World Health Organization, Geneva, Switzerland, discussed the World Health Assembly Resolution 68.15, which calls for “strengthening essential and emergency surgery as a component of universal health care.”6
  • John G. Meara, MD, DMD, MBA, FACS, chair, LCoGS, spoke of the need for national surgical planning on a state, national, and regional level to ensure coordination of efforts.
  • Nobhojit Roy, MD, MPH, of LCoGS–India, an organization that promotes global surgery in a large, disparate, emerging economy similar to Brazil or Mexico, provided another international perspective. Dr. Roy highlighted the role of the “essential surgeon,” which he defined as a health care provider who is equipped to take care of a broad array of surgical disease in austere environments—an idea that is being practiced in some regions of Latin America and North America.

Financial challenges in Latin America

A key topic of discussion among conference attendees was the harsh economic conditions of Latin America. Brazil in particular is struggling with difficult economic policies—for example, the government recently passed constitutional amendment PEC.55, Novo Regime Fiscal, which will cap social spending (with adjustments for inflation) for the next 20 years.7

Unlike Africa’s need for a large-scale infrastructure investment, Latin America’s greatest financial challenges relate to freezes on or a decline in public sector spending. Maureen Lewis, PhD, an economist and chief executive officer of Aceso Global, a not-for-profit organization committed to improving health care delivery and management in emerging markets, spoke on the need to prioritize effective management, efficiency, and quality reforms in order to do more, and to do better with less (see photos below).

Operating theaters in remote areas of the State of Amazonas: Functional but aging infrastructure exists even in remote areas of Brazil. The present concern is with workforce, upkeep, and ongoing operational expenditure.

Operating theaters in remote areas of the State of Amazonas: Functional but aging infrastructure exists even in remote areas of Brazil. The present concern is with workforce, upkeep, and ongoing operational expenditure.

Dr. Lewis noted that quality and efficiency extend well beyond the walls of the operating room and highlighted the need to address the continuum of surgical patient care from initial presentation to follow-up. Symposium participants concluded that three pillars should underpin efficiency efforts: strong management, appropriate incentives, and robust data.

The issue of strong management was of particular importance, and some delegates were concerned that management professionals in Latin America’s complex health care domain are under-trained for the role they serve.

The second pillar requires a restructuring of appropriate incentives for quality measures at both the facility and staff level. As an example of misaligned incentives, participants spoke of public systems throughout the region in which providers receive below-cost reimbursements. As a result, if the hospital takes on more volume it actually loses money because the per procedure reimbursement is less than the per procedure cost.

The third pillar, data, was referenced repeatedly throughout the day as a major barrier to efficient and effective surgical practice. Although health care data are regularly collected in Latin America—even digitally, in some cases—the quality and management of these data varies and they are rarely leveraged for system-level decision making. As a result, participants called for the establishment of a basic, consensus-driven, streamlined set of minimum data requirements. All delegates agreed that the most important part of collecting data is leveraging it to guide management decisions.

Surgical workforce maldistribution

Another broad challenge for global surgery is how the surgical, anesthesia, and obstetrics (SAO) workforce can adequately meet the demands of underserved populations. Mário Scheffer, PhD, from the Departamento de Medicina Preventiva, Universidade de São Paulo, Brazil, and a co-author of this article, highlighted the maldistribution of health care professionals in Brazil. Although the national average of SAO specialists meets the LCoGS’ target of 20 to 40 SAO professionals per 100,000 patients, there are marked disparities between the well-served south and the underserved north and northeast areas of Brazil (see Figure 2).8,9

Figure 2. Geographic representations of the SAO workforce distribution in Brazil as of July 2014

Source: Demografia Médica

Source: Demografia Médica

Referring to 2014 data, Dr. Scheffer noted that most Brazilian physicians work in the private sector (78.4 percent, with 26.9 percent working exclusively in the private sector), whereas only 25 percent of the population receives its care in the private sector. He also observed that while women are making gains in the health care workforce in Brazil (43 percent of physicians are women), the surgical professions have been less successful in attracting women; only 16 percent of surgeons and 37 percent of anesthesiologists are women (see Figure 3).

Figure 3. Women in the SAO workforce in Brazil

Source: Demografia Médica

Source: Demografia Médica

To address workforce geographic maldistribution, symposium delegates offered several solutions, including a program tested at the Universidade do Estado do Amazonas (UEA), where students from remote areas are recruited into “quota” seats. In accepting these university seats, students agree to one year of service in their home town after graduation. The first cohort of 16 students is scheduled for graduation later in 2017.

Surgical workforce shortages, particularly in resource-poor environments, often lead to health care providers performing procedures without adequate training. José Emerson dos Santos Souza, MD, of the UEA and co-author of this article, described his research carrying out an on-the-ground evaluation in the Brazilian state of Amazonas. He described a situation in which nonsurgeons routinely practice surgery and nonphysicians perform procedures, often without adequate training or supervision. Likewise Sandra Leal, MD, an anesthesiologist from El Salvador, noted a lack of training among the nonphysician providers who are often tasked with delivering anesthesia care in El Salvador.

Telemedicine is one viable strategy for improving the skills of under-trained staff, as is telementoring. Cleinaldo Costa, rector/chancellor of UEA, noted that telemedicine should start as a means to support physicians in the periphery through continuing professional development of these surgeons. Professional development, a low-risk and less logistically complicated activity, would be a first step in telementoring, before progressing to assistance with triage or even live surgical training. Another delegate described the experience of using neurosurgical teleconsultations at a trauma hospital in São Paulo, with remote neurosurgeons evaluating computed tomography scans in order to minimize patient transfers to higher care.

Implementing change in Latin America

Although symposium participants discussed key barriers to providing surgical care in the region, they also identified strategies that can address these challenges, including the following:

  • Continued collaboration at the regional level, including regular meetings to share ideas and progress
  • Dissemination of global surgery data and research by engaging with national, state, and municipal governments and professional societies
  • New or improved mechanisms for surgical data collection at the facility and national level
  • Expansion and formalization of global surgery research within Latin America to develop effective policy

At a state level, in Amazonas, Brazil, Dr. dos Santos Souza and Rodrigo Vaz Ferreira, MD, a co-author of this article, plan to bring the results of an on-the-ground surgical capacity assessment to the state government later this year. This initiative would demonstrate how surgical systems research can create potential for health care improvement even at the grassroots level.

At the national level, participants from Operation Smile and Nicaragua described the early phases of a partnership with the government of Nicaragua. Jordan Swanson, MD, a plastic surgeon working with Operation Smile, explained the goal of increasing access to quality and timely surgical care for patients, in particular underserved patients who live in communities away from large urban centers. This proposal includes a plan to improve rural emergency and essential surgery, nurse training, and the development of a framework for scale-up of surgery.

Beyond the national level commitments, symposium participants reached consensus on the value of regional collaboration and agreed that the global surgery Latin America group should reconvene approximately one year after the symposium, possibly in Mexico City, Mexico, in November. The goals of reconvening are to move beyond the broad overview of global surgery, transition from individual to collective efforts in the region, measure progress, and share ideas.

Organizational support

For these efforts to succeed, institutions and networks across Latin America need to be leveraged. Paulo Corsi, MD, president of the Colégio Brasileiro de Cirurgiões, pledged his organization’s support. An invitation was extended to present the findings of the LCoGS at the Congreso Latinoamericano de Cirugia General in March 2017 in Lima, Peru. These opportunities could attract broader participation and may lead to policy development and position statements from professional societies.

Recognizing the role of universities in creating global surgery research centers outside of the U.S. and Europe also is a way to help promote global surgery efforts; in fact, a symposium participant initiated a proposal to develop the first global surgery research center at UEA in Manaus, Brazil. These centers will enhance the sustainability of global surgery efforts by allowing trainees to build longitudinal careers in global surgery and to act as hubs that support surgeons in the periphery. Additionally, by using global surgery research projects as part of work toward advanced degrees—for example, toward earning a doutorado in Brazil—global surgery research can be recognized and incentivized.

Through this symposium, Latin America has joined Europe, North America, Africa, Asia, and Oceania in uniting and committing to systematically improving access to safe and affordable surgical care—a goal that the ACS supports. The connections made via this meeting will spark new initiatives and collaborations in the region and will ideally inspire continued support from members of the College. (See photo below.)

Meeting attendees representing eight Latin American countries

Meeting attendees representing eight Latin American countries

Acknowledgement

The symposium was made possible through contributions from Johnson & Johnson Medical Innovation Institute, Globomed, Mending Kids, the Program in Global Surgery and Social Change at Harvard Medical School, and Rutgers Global Surgery. Industry and not-for-profit sponsors did not have input into the academic or other content of the symposium.


References

  1. Meara JG, Leather AJM, Hagander L. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. The Lancet. 2015;386(9993):569-624.
  2. Saluja S, Makuhopadhyay S, Raykar NP, et al. Global surgery: Towards equitable surgical systems. 2016. Harvard Center for Global Health Delivery–Dubai. Available at: ghd-dubai.hms.harvard.edu/files/ghd_dubai/files/globalsurgery_towardsequitablesurgicalsystems.pdf. Accessed January 11, 2017.
  3. Stewart BT, Tansley G, Gyedu A, et al. Mapping population-level spatial access to essential surgical care in Ghana using availability of bellwether procedures. JAMA Surg. 2016;151(8):e161239.
  4. Massenburg BB, Raykar NP, Pawaskar A, et al. Collaboration and innovation in rural surgery. Int Health. 2016;8(6):367-368.
  5. Stokes MA, Guest GD, Mamadi P. Measuring the burden of surgical disease averted by emergency and essential surgical care in a district hospital in Papua New Guinea. World J Surg. 2017;41(3):650-659.
  6. World Health Assembly. Strengthening emergency and essential surgical care as a part of universal health coverage. WHA68.15. Agenda item 17.1. May 26, 2015. Available at: apps.who.int/gb/ebwha/pdf_files/WHA68/A68_R15-en.pdf. Accessed March 15, 2017.
  7. Boadle A, Marcela Ayres M. Brazil Senate passes spending cap in win for Temer. Reuters. December 13, 2016. Available at: www.reuters.com/article/us-brazil-politics-idUSKBN142203. Accessed March 23, 2017.
  8. Scheffer MC, Guilloux A, Matijasevich A, et al. The state of the surgical workforce in Brazil. Surgery. 2017;161(2):556-561.
  9. Scheffer M. Demografia Médica No Brasil. São Paulo: Conselho Federal de Medicina, 2011–2015. Available at: www.usp.br/agen/wp-content/uploads/DemografiaMedica30nov2015.pdf. Accessed March 20, 2017.

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