We are fragmented as a world. We are split among hundreds of nations, even more ethnicities, and seemingly innumerable political ideologies. Our health care, too, is fragmented, sliced into organ systems, disease categories, and regions of anatomy. Priorities for achieving health vary as well, often favoring those problems that readily engage our empathy, are visually striking, or carry the greatest funding.
It is no secret that surgery has often been left behind in this competitive arena. Often considered too complex and expensive, surgical care (surgery, obstetrics, and anesthesia) has been dismissed as a public health challenge only achievable after all other systems have been built. But financial support of surgery cannot be responsibly deferred and should be viewed by Ministries of Health as an investment, rather than a cost. Improved access to quality surgical, obstetrical, and anesthesia care should not be treated as merely a consequence, but rather as a driver of general health care needs.
Background: Improving access to surgical care worldwide
The World Health Organization (WHO) is the health care arm of the United Nations (UN). Since the WHO was first established in 1948, the organization has committed itself to the improvement of health around the globe, seeking to bridge the fragmentation created by geographic and political boundaries to promote wellness for all. But despite its best intentions, efforts may have suffered from a myopic focus on specific aspects of health care—a vertical approach to providing care—that have been deemed as most urgent and most achievable.
It is imperative that we no longer neglect surgical care when approaching overall public health programs. With robust economic, political, and needs data documented in the literature, researchers have amplified the evidence that an investment in surgery and anesthesia is both a health care and economic necessity. Providing timely access to safe and affordable surgical and anesthesia care to the 5 billion people without access worldwide not only curbs the detrimental consequences of surgical disease, it also boosts financially emerging economies and bolsters infrastructure.
In 2015, through the combination of four major events that occurred in quick succession, international demand for increasing surgical access gained significant momentum. In the span of months, the economic, political, and needs cases for prioritizing global surgery and anesthesia became clearly and publicly established.
The first crucial event was the UN transition from the millennium development goals to the era of sustainable development. The 17 sustainable development goals (SDGs)1 are notable for their specific inclusion of a number of surgical issues, specifically eight of the targets listed within SDG 3: “Ensure healthy lives and promote well-being for all at all ages.” Many of the itemized health targets directly involve surgically treatable disease, such as the reduction of maternal and neonatal mortality, death from road traffic accidents, and premature mortality from noncommunicable disease (NCD).
A second critical occurrence in 2015 was the publication of Essential Surgery,2 the first volume of the third edition of Disease Control Priorities (DCP3). Published by The World Bank, Essential Surgery establishes an economic and financial case for investment in surgical care. In addition, it specifically highlights 44 individual basic and essential surgical procedures that are cost-effective, deliverable, and address significant global need. The authors assert that providing essential surgery would prevent an estimated 1.5 million deaths annually, while providing a financial benefit-to-cost ratio of investment exceeding 10:1. With detailed financial data, the publication makes a clear assertion that “the large burden of surgical conditions, the cost effectiveness of essential surgery, and strong public demand for surgical services suggest that universal coverage of essential surgery should be financed early on the path to universal health coverage.”2
The third event occurring that year was the publication of the “Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development” report (GS 2030) by The Lancet Commission on Global Surgery (LCoGS).3 A collaborative effort by representatives from more than 110 countries, GS 2030 presents a robust economic case for global investment in surgical care, as well as an overwhelming needs case for surgical and anesthesia care delivery. The LCoGS estimates that surgical conditions are responsible for roughly 30 percent of the global burden of disease and that 5 billion people do not have timely access to safe and affordable surgical and anesthesia care.3 The report calls for an increase in surgical care to meet a goal of 80 percent coverage of essential surgical services by 2030, including 5,000 procedures per 100,000 population and 100 percent of countries exceeding 20 surgical, anesthesia, and obstetric licensed providers per 100,000 population. In addition, a data target was set for tracking perioperative mortality rate of 80 percent of countries by 2020 and 100 percent by 2030.
The LCoGS also investigated the monetary consequences for patients accessing surgical care, and as a result of that study seeks 100 percent protection globally against impoverishing and catastrophic out-of-pocket expenditures for surgical and anesthesia care by 2030. The LCoGS asserts that a critical investment of $350 billion (U.S.) until 2030 will prevent estimated losses of $12.3 trillion (U.S.) during this time in lost productivity and health care expenses.
The fourth turning point that occurred in 2015 was the unanimous passage of the World Health Assembly (WHA) Resolution 68.15,4 which calls for strengthening of emergency and essential surgical care and anesthesia as a component of universal health coverage. This landmark resolution for surgical prioritization emphasizes that a significant portion of the global burden of disease can be successfully treated with surgical intervention and specifically notes the beneficial effect of surgery on morbidity and mortality rates due to obstructed labor, cancer, road traffic accidents, and violence, all of which disproportionately affect low- and middle-income countries (LMICs).
WHA 68.15 identifies five key surgical areas of focus: surgical and anesthesia workforce, information management, service delivery, essential medicines, and advocacy and resource development. Establishment of an adequate surgical and anesthesia workforce in LMICs requires not only an increase in workforce volume, but also an enhancement of training programs, increased efforts by credentialing bodies, and possibly support by mid-level providers. Meeting these workforce needs worldwide relies heavily on strong partnerships between regional surgical organizations and professional societies, as well as the development of mutually beneficial twinning partnerships. The leadership of associations—such as the College of Surgeons of East, Central and Southern Africa (COSECSA); the West African College of Surgeons; the Royal Colleges in the U.K., Ireland, and Australasia; and the American College of Surgeons, among others—is foundational for building and maintaining a skilled surgical global workforce. In addition, Ministries of Health, Finance, and Education are key partners, uniting involved governmental and nongovernmental organizations (NGOs) toward common goals. In collaboration with regional societies and governments, NGOs also provide training for medical professionals. One example is the Pan-African Academy of Christian Surgeons, which, through an affiliation with COSECSA and Loma Linda University, CA, has provided residency training to more than 100 surgeons across Africa. Teamwork and communication between these organizations is critical to meet the overwhelming need for surgeons, anesthesiologists, and obstetrician/gynecologists.
A second essential focus of WHA 68.15 is information management. The WHO list of 100 Core Health Indicators provides a starting place for data collection in the areas of health status, risk factors, service coverage, and health systems. This list includes the LCoGS six surgical indicators, as follows:
- Perioperative mortality rate
- Total surgical volume
- Geographic access of surgical facility
- Licensed surgical, obstetric, and anesthesia health workforce density
- Catastrophic surgical and anesthesia care-related expenditures
- Impoverishing expenditures
All of these indicators, taken together, allow for more accurate needs assessment by location and ability to track improvements or changes in surgical capacity.3
Improved data collection facilitates quality service delivery. In highlighting service delivery, WHA 68.15 acknowledges that surgical access must not be confined to urban centers. Often limited by geographic boundaries, transportation infrastructure, and insufficient health care providers and facilities, the accessibility of care is a significant barrier to treatment of surgical disease. To reduce delay in surgical access, improvement in systems integration is a necessity.
A fourth major aim of WHA 68.15 is to emphasize the need for access to essential medicines. Though often restricted by governmental agencies due to a potential for abuse, narcotic medications and anesthetics such as ketamine are crucial for the daily, sustained function of surgical systems, particularly in resource-limited settings. Appropriate anesthesia during surgical interventions and quality pain control both for the acute postoperative setting and for long-term palliative care for adults and children are integral to the total spectrum of surgical disease management and treatment. With necessary safeguards in place to limit illegal use, these essential medicines must be made available for appropriate access to surgical patients.
Finally, the resolution highlights advocacy and resource development. With a staggering global burden of disease and disproportionately poor availability of financial and human resources, surgical, obstetric, and anesthesia care is in great need of international champions. To adequately improve access to care requires a global effort by physicians, patients, government agents, economists, epidemiologists, and those in the public eye. Advocacy efforts by these key stakeholders is essential for building the capacity of essential surgical and anesthesia service delivery to all.
As we further develop strategies for global surgical development, continuation of accurate and thorough data collection and progress reporting has become increasingly vital. In 2017, WHA Decision 70.22 was passed, calling for the continued biennial reporting of emergency and essential surgery and anesthesia progress by Member States coinciding with NCD reporting until the expiration of the SDGs in 2030.5 More robust data collection will allow for a more detailed understanding of the status of surgical care around the world, which, in turn, will allow more targeted goal setting.
Member States’ desire to track improvements and set national goals for surgical and anesthesia care has led to the creation and popularization of the National Surgical, Obstetric, and Anesthesia Plan (NSOAP).6 In 2017, the Republic of Zambia became one of the first countries to develop an NSOAP that is fully embedded in the National Health Strategic Plan 2017–2021.7 Subsequently, numerous Member States have begun preparing and designing their own national plans. High demand for strategic NSOAPs soon exceeded capacity for individual country-specific development. In partnership with the Harvard Program in Global Surgery and Social Change (PGSSC), Boston, MA, the WHO Emergency and Essential Surgical Care (EESC) program has begun to plan multiple regional workshops to assist Member States and encourage groups to share their successes and challenges so that each may learn from the experiences of others.
WHO continues to bring together countries of varying resource levels and contexts in collaboration toward quality health care for all people. Strategies for achieving this goal are ever-evolving in response to changing needs and data, but always rely on healthy partnerships and international communication. The diplomatic involvement of the UN permanent mission health attachés in advocating for surgical access to political, business, educational, and trade organizations remains vital.
In addition, WHO has approved five official collaborating centers (CCs), each dedicated to particular niches of research and expertise in surgical care and anesthesia, and is in the process of developing three additional centers. These WHO CCs are beginning to transition from bilateral relationships with WHO toward multilateral networks of integration and support. The Mongolia WHO CC is located in a country with one of the lowest population densities. It is housed within the department of surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, and specializes in distance surgical education. At Lund University, Sweden, the CC focuses on global density of surgeons, anesthesiologists, and obstetricians, including migration patterns, whereas the CC located at the University of Western Ontario, London, is dedicated to perioperative issues and anesthesia in low-resource settings. The Mumbai, India, WHO CC specializes in innovative methods for building rural surgery capacity, and the PGSSC focuses on development of national surgical plans.
The WHO EESC is in official discussions with a number of NGOs, such as the International College of Surgeons, the World Federation of Societies of Anesthesiologists, the World Federation of Neurosurgical Societies, the International Society of Orthopaedic Surgery and Traumatology, and the International Federation of Surgical Colleges. These relationships bring important global leadership, contribute vision and personnel, and assist with quality improvement through educational programming.
The WHO strives to bridge the fragmented relationship between medicine and politics to achieve quality health care for all. By responding to medical needs, convening international partners, and leading worldwide initiatives, WHO works to meet health care challenges on both a global and local scale. It is time for global recognition of surgery and anesthesia as necessary components of universal health care and to help the world meet the challenge of providing surgical access to its people.
For years, anecdotal needs cases for surgery have existed; we have known that access to safe surgical care has not been a reality for much of the world’s population. But with the impact of the LCoGS and DCP3 now showing the depth of the economic case and the WHA resolution and transition to SDGs demonstrating the political case, we are able to see the full extent of the need for access to quality surgery, and obstetric and anesthesia care. We now know that it is critical to integrate and promote all aspects of surgery—including pediatric surgery, orthopaedics, urology, obstetrics, gynecology, neurosurgery, and many others—to improve global health infrastructure and well-being. In collaboration with governments and NGOs around the world, the WHO EESC program will continue working for safe, timely, and affordable surgical and anesthesia care until it is available to all people, everywhere.
- United Nations. Sustainable development knowledge platform. Transforming our world: The 2030 agenda for sustainable development. 2015. Available at: https://sustainabledevelopment.un.org/post2015/transformingourworld/publication. Accessed March 13, 2018.
- 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.
- 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.
- 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.
- World Health Organization. World Health Assembly Resolution 70.22: Progress in the implementation of the 2030 agenda for sustainable development. Seventieth World Health Assembly. Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_35-en.pdf. Accessed March 20, 2018.
- World Health Organization. Surgical care systems strengthening: Developing national surgical, obstetric and anaesthesia plans. Geneva, Switzerland: World Health Organization; 2017. Available at: www.who.int/surgery/publications/scss/en/. Accessed March 20, 2018.
- Republic of Zambia Ministry of Health. National Surgical, Obstetric, and Anaesthesia Strategic Plan (NSOASP): Year 2017–2021. Available at: www.cosecsa.org/sites/default/files/NSOAP_May%202017.pdf. Accessed March 6, 2018.