Looking forward – May 2018

David B. Hoyt

David B. Hoyt, MD, FACS

The feature section of this issue of the Bulletin focuses largely on global efforts to improve access to surgical, obstetric, and anesthesia care, and I am proud to say it will be distributed at the World Health Assembly (WHA) 71, May 21−26 in Geneva, Switzerland. The idea for this special issue originated with John G. Meara, MD, DMD, MBA, FACS, co-chair of The Lancet Commission on Global Surgery (LCoGS); director, Program in Global Surgery and Social Change, Harvard Medical School, Boston; and chair, department of plastic and oral surgery, Boston Children’s Hospital, MA, in collaboration with Girma Tefera, MD, FACS, Director, American College of Surgeons (ACS) Operation Giving Back program.

In this issue, you will find a collection of provocative and informative articles submitted by professional societies and colleges from around the world. These articles highlight not only the organizations’ important efforts, but also their recommendations for moving forward and a call to action for the surgery, obstetrics, and anesthesia communities to work together toward a common goal of universal access to safe, affordable essential care. Both Dr. Meara and Dr. Tefera worked tirelessly to solicit articles from the leaders of the organizations that have committed to this goal. My hat is off to them.

Watershed moments

Efforts to promote access to surgical care as essential to the well-being of all people began in 1980, when Halfdan Mahler, MD, then director-general of the World Health Organization (WHO), addressed the XXII Biennial World Congress of the International College of Surgeons with his lecture Surgery and Health for All. In a speech that was ahead of its time, Dr. Mahler alluded to the Alma-Ata International Conference, calling for health equity and social justice, and, most notably, for the inclusion of surgical care in the pursuit of health care for all. Including surgery in the realm of global health was somewhat of an anathema at that time. What ensued after his bold speech was relative silence—a 28-year lapse in the development of global surgery policy.1

The standstill ended in 2008, when Paul E. Farmer, MD, PhD, Kolokotrones University Professor, Global Health and Social Medicine, Harvard Medical School, and Jim Yong Kim, MD, PhD, president of The World Bank, called surgery “the neglected stepchild of global health” in their article, “Surgery and global health: A view from beyond the OR.”2 This vivid metaphor brought to the forefront the reality that in low- and middle-income countries, access to surgical care eluded the poor, yet for decades the public health community had written off surgical care as expensive and unnecessary. Drs. Farmer and Kim countered these arguments with data and drove home the message that without a holistic approach to health system strengthening—a paradigm shift from the age-old vertical approach to siloed, disease-specific global programs—health care equity and social justice were unattainable.

The tipping point for global surgery, obstetrics, and anesthesia occurred in 2015. Three events aligned that focused the global health community on surgical care. The third edition of The World Bank’s Disease Control Priorities (DCP3) was published in early 2015, and the first of nine volumes was devoted to “Essential Surgery.”3 DCP3 made a strong case for the cost-effectiveness of basic surgical procedures in low-resource settings, identified district hospitals as key to providing acute and lifesaving surgical care, and proposed a list of 44 essential operations to prioritize in scaling up surgical systems.

Later that same year, the LCoGS released a report that defined the extent of global surgical need and quantified the human and financial implications of inaction. The report also outlined a surgical, obstetric, and anesthesia planning process that would allow Ministries of Health to map national needs and plan system-level interventions. Finally, the commission proposed a set of six key performance indicators to enable standardized global assessments of surgical systems and to track the progress of health system strengthening programs that included surgical, anesthesia, and obstetric care.4

The final watershed moment occurred during the WHA in May 2015 with the adoption of Resolution 68.15, a formal WHO declaration and commitment to “emergency and essential surgical care and anesthesia as a component of universal health coverage.”5 This resolution was a call for all Member States to commit to the following actions:

  • Develop adequate infrastructure and equipment in district hospitals
  • Train appropriate surgical health care workforce
  • Ensure surgical information management for data to drive informed health policy
  • Provide essential medicines and medical devices
  • Mobilize adequate financial resources to surgical service delivery
  • Avoid catastrophic expenditures by citizens on surgical services
  • Improve referral systems

The WHO made a permanent commitment to surgery in 2017 with WHA Decision Point 70.22, which required submission of biennial progress reports on the status of global surgery to the WHO director-general.

Looking to the future

We are now in an era in which global health care is defined by sustainable development goals (SDGs), with a renewed focus on universal health coverage and an acknowledgment of health care as a human right.6 In the context of the SDGs and WHA 68.15, countries have a mandate to acknowledge access to safe, affordable surgical, obstetric, and anesthesia care as part of this right.

The WHO also has a new director-general—Tedros Adhanom Ghebreyesus, PhD, MSc—a proven health care reformer from Ethiopia who enthusiastically welcomes surgery, anesthesia, and obstetrics to the global health care community. With the recognition of surgery and anesthesia as an integral component of universal health coverage, data collection systems and national surgical, obstetric, and anesthesia plans (NSOAPs) are critical next steps in surgical system strengthening. Managing complex health systems requires measurement, and national surgical data that is beginning to be collected must flow each year from Ministers of Health to WHO to The World Bank to promote transparent accountability. NSOAPs need to be created and integrated into national health care agendas.7

The concept of surgery as a vertical program is gone. Surgery, anesthesia, and obstetrics harmoniously woven into national health and wellness planning efforts must become the norm. The implementation of these plans will need solid financial support that likely will stem from new funding models, including a symbiotic partnership between the private and public sectors, as seen with The World Bank’s new Global Financing Facility.8

All of these changes bring about new opportunities. In recognition of the responsibility we as clinician-advocates have of supporting health equity and social justice, the ACS is pleased to offer this issue of the Bulletin for dissemination at the WHA 71. We wish you all a productive and fruitful meeting that will lead to improved health care for surgical patients around the world.


References

  1. Mahler H. Surgery and Health for All. Address from the director-general, World Health Organization, to the XXII Biennial World Congress of the International College of Surgeons, Mexico City, Mexico, June 1980.
  2. Farmer PE, Kim JY. Surgery and global health: A view from beyond the OR. World J Surg. 2008;32(4):533-536.
  3. Debas HT, Donkor P, Gawande A, Jamison T, Kruk  M, Mock CN (eds). Disease Control Priorities, Third Edition: Volume 1. Essential Surgery. Washington, DC: World Bank; 2015. Available at: http://dcp-3.org/surgery. Accessed April 12, 2018.
  4. 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.
  5. World Health Organization. World Health Assembly Resolution 68.15: Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Sixty-Eighth World Health Assembly. Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_R15-en.pdf. Accessed March 20, 2018.
  6. United Nations. Sustainable development goals. Available at: www.un.org/sustainabledevelopment/sustainable-development-goals/. Accessed March 19, 2018.
  7. Harvard Medical School Program in Global Surgery and Social Change. National Surgical, Obstetrics and Anesthesia Planning. Available at: www.pgssc.org/national-surgical-planning. Accessed March 19, 2018.
  8. World Bank Group. Global Financing Facility. Available at: www.globalfinancingfacility.org/. Accessed March 19, 2018.

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