Surgical intervention

Access to surgical and anaesthetic care is an essential, but often forgotten, component of health care in the developing world. 

An estimated five billion of the world’s population are unable to access safe surgery when they need it, and only six per cent of the 313 million procedures performed annually are done in the world’s poorest countries.

Access is defined by four criteria: safety, affordability, timeliness and capacity to deliver, the lack of which means 16.9 million lives are lost each year. These deaths represent 32.9 per cent of the annual global mortality.

For too long, health policy affecting the poorest and most vulnerable people in the world has ignored access to safe surgery and anaesthesia. But a concerted global effort is shifting policy at all levels, and a universal health goal is part of the Sustainable Development Goals.

Safe surgery and anaesthesia are vital to effectively treat much of the global burden of non-communicable diseases and injuries, and contribute to the provision of safe childbirth.

Photo by Armymedicine on flickr.

The major barriers to the delivery of essential surgical services in many low and middle income countries (LMICs) are the perceptions that surgery is unaffordable and too complicated to include in public health strategies. The result is a lack of global and national policies promoting safe surgery and anaesthesia, and a failure to develop the staff, infrastructure and capacity to deliver emergency and essential procedures.

In fact, recent work by the Lancet Commission on Global Surgery based on the New Zealand procedures database, suggests that almost 30 per cent of all conditions require surgery and anaesthesia. The treatment of most surgical conditions does not necessarily require complex surgical skills or equipment, and in some parts of the world, particularly Sub-Saharan Africa, trained providers of surgery and anaesthesia need not always be doctors or specialists.

Safe surgery and anaesthesia can be delivered cost-effectively in low and middle income countries but requires at least 20 surgery, anaesthesia and obstetric trained providers per 100,000 population.

There is a sound evidence base for the necessity of emergency and essential surgical care. The Global Initiative for Emergency and Essential Surgical Care (GIEESC) has succeeded in translating it into policy with the help of many countries, together with colleges, societies and non-government organisations representing surgeons and anaesthetists.

In 2015, the Millennium Development Goals, which never mentioned surgery, will be replaced by the Sustainable Development Goals. The health goal, Universal Health Coverage by 2030, includes surgery and the reporting of surgical indicators – a big win for the global surgical community.

A World Health Organization (WHO) World Health Assembly Resolution on strengthening emergency and essential surgical care was passed by 194 member nations in May 2015. This was critical because Ministers of Health are guided by the WHO recommendations when implementing healthcare decisions for their country. But it will require significant and sustained political commitment and substantial investment by individual countries to put policy into practice and improve surgical care at the country and regional level.

Countries need to work towards sustainable financing of surgical services. Current estimates in LMICs suggest 33 million individuals face catastrophic health expenditure due to payment for surgery and anaesthesia each year and a further 48 million are impoverished by additional costs from transport, food or loss of earnings.

Improving access to, and the quality and safety of surgical care requires resources (equipment and trained personnel) and well-managed hospitals with 24/7 capabilities. First level hospitals in LMICs need to have the capacity to perform a basic package of surgical procedures. They need trained providers in surgery and anaesthesia.

Photo by codnewsroom on flickr. https://www.flickr.com/photos/codnewsroom/14067359044/

This may mean task-sharing with clinician non-doctors, provided these clinicians are able to provide an extended scope of practice, are accredited through appropriate training, and are working in a supported, supervised system of care, with the ability to refer. Surgical and anaesthetic care must be integrated into the whole health system.

With expert input from Harvard Business School, the Lancet Commission calculated that the scaling up of surgical and anaesthesia care in 88 LMICs will cost approximately US$350 billion. Although this financial cost of surgical expansion is significant, the cost of inaction on national incomes is much greater. The lost output (total GDP losses) will cost LMICs a total of US$12.3 trillion dollars by 2030, or reducing annual global GDP growth as much as 2 per cent.

Substantial investment is required to boost the size and capacity of the surgical workforce and infrastructure. However, the GDP gained will progressively enable LMICs to invest in their own healthcare. A growing global economy, not impaired by lack of access to surgical and anaesthetic care, will benefit all countries and trading partners, not just the current LMICs.

And the financial and economic projections show that we can’t afford not to address this need, we must make the necessary investment.

Taken from an article written by Professor David Watters, OBE, and appearing in the College’s June 2015 edition of its Surgical News publication.

On 26 October 2015, the Royal Australasian College of Surgeons (RACS) and Lancet Commission on Global Surgery will convene a Global Health Symposium in Melbourne. The event will bring together health ministers, health practitioners and leaders from the Asia-Pacific and professional medical colleges to develop a roadmap to implement these recommendations in the region.