Issue 11 Volume 1
The seminal report published by the Lancet Commission on Global Surgery (LCoGS) in April 2015 highlighted that an estimated 5 billion people continue to lack access to safe and affordable surgical and anaesthetic care when required. Often, surgical care is associated with costly procedures and state-of-the-art equipment. While that might be true for a subset of procedures, there are many lifesaving procedures that are considered basic public health needs and can be performed cost-effectively with a simpler set of equipment. Through domains of research, education and advocacy, the relatively recent movement of Global Surgery endeavours to address and alleviate these vast disparities in surgical equity, particularly in low and middle-income countries (LMICs). Here, we would like to evaluate surgical care on a global scale from a basic public health standpoint.
Basic surgical care and safe surgery
Surgery is defined by the World Health Organization (WHO) as “any procedure occurring in the operating room involving the incision, excision, manipulation or suturing of tissue that usually requires regional or general anaesthesia or profound sedation to control pain”. Surgery is rendered across all disease categories, and is an indispensable component of health care. Essential surgical care is a distinct concept, meaning surgery necessary to prevent imminent death or disability. Without access to essential surgical care, readily treatable diseases can pose serious threats to health.
Safe surgery involves avoiding complications or adverse events that can arise before, during and after surgical procedures. Thus, safety measures are implemented before anaesthesia, before incision, during surgery and in the provision of post-operative care.
The WHO estimates that every year almost 7 million surgical patients suffer significant complications, most commonly including infection, bleeding and various complications of anaesthesia. More than half of these adverse events are preventable. In view of this, the WHO has implemented Guidelines for Safe Surgery (2009) to define core safety standards, with 10 essential objectives that can be implemented in any country and any surgical setting. These serve to reinforce the standardisation of safe practices, particularly in developing countries.
Cost of basic surgical care
Access to safe anaesthesia and surgery, or lack thereof, has a considerable economic impact on both patients and society.
Without sufficient public funding or health insurance, access to surgical services depends on the ability of patients and their family to pay. High death rates for surgically treatable conditions in LMICs are often due the financial barriers of accessing surgical care. Thus affordability, and not necessarily availability, of treatment is a major focus.
Surgically treatable causes of disease account for 28-32% of the global burden of disease; yet five billion people do not have access to the surgical care they need. There is a common misconception that surgical treatment of these conditions is expensive and not cost-effective. Beyond the incredible impact certain basic surgeries, including caesarean sections and hernia repairs, can have on an individual’s quality of life, their overall monetary cost over time is comparable to other global health initiatives.
The cost per DALY averted for basic surgeries is low in LMICs, in both small and large hospitals. Examples include emergency caesarean sections ($18 USD), elective inguinal hernia repair ($12.88 USD), and cleft lip repair ($15.44 USD). In contrast, other widely implemented public health initiatives can cost much more: oral rehydration therapy can cost over $1,000 USD per DALY averted, and HIV HAART therapy can cost over $900 USD per DALY averted.
Beyond economic measures, lack of access to treatment of surgically treatable diseases has a major impact on the lives of patients, their families, and their communities. A condition as easily addressed as a strangulated hernia can be life-threatening to an otherwise healthy adult. Such a loss of life or work productivity can have devastating impacts not only on the patient, but also on those who financially depend on them.
Surgery in low and middle income countries
In the past, the impact of surgical diseases has been vastly underestimated by global health experts, leading to its absence in the Sustainable Development Goals (SDGs). However, since the establishment of the LCoGS in 2015, there has been a shift in this paradigm. With 16.9 million annual deaths (32.9% of all deaths) attributed to surgical conditions, the total burden far outweighs that of tuberculosis (TB), HIV/AIDS and malaria combined. This is because easily treatable surgical diseases such as open fractures and obstructed labour cause significant morbidity and mortality due to lack of access to safe surgical care.
The LCoGS sheds light on the startling paucity of surgeries performed in LMICs. It found that a disproportionately low number of surgeries are performed in LMICs compared to the population size. A third of the world’s poorest population resides in LMICs, and yet only 6% of all surgical procedures worldwide are performed in these countries. An additional 143 million surgical procedures are required annually to overcome this present need.
Failure to address such basic health and surgical needs can potentially endanger the economic progress of these countries. This is particularly pertinent given the growing population and problem of uneven healthcare access in LMICs. Each year, 33 million individuals worldwide face immense expenditures due to out-of-pocket payment of medical and surgical costs, which can push them into poverty. The LCoGS found that workforce losses attributable to surgical conditions reduce GDP growth by up to 2%, particularly affecting growing nations. If no further is taken to address surgical needs in LMICs, it is estimated that the global economic loss in terms of international GDP could soar up to $12.3 trillion USD from 2015 to 2030.
These figures are alarming, and it is of utmost importance to recognise that these are not merely numbers and statistics, but that they represent real people affected every day. What must be stressed is that although the costs of providing surgery are high, investing in surgical services in LMICs is affordable, saves lives, and promotes economic growth. To improve the current conditions, there is a great need to gather data, identify gaps in data regarding surgical access, funding and resources, and monitor progress.
Global surgery in action
Advocacy in recent years has demonstrated new potential for advancements in global surgery. Since its establishment in 2015, the LCoGS has been ground-breaking in demonstrating the many opportunities for improvements in global health and global surgery over the next 15 years and beyond.
Progress has also been made in surgical safety. For instance, the sustained use of the “WHO Surgical Safety Checklist” led to continued improvements in surgical processes and reductions in 30-day surgical complications in Moldova, a LMIC, almost 2 years after its implementation. Such improvements were seen despite the absence of continued oversight by the research team, demonstrating the important role that local leaders play in the success of quality improvement initiatives, especially in resource-limited settings.
Moreover, opportunities to address health inequity and reset the global health agenda have arisen. These include global commitments to achieve Universal Health Coverage and the establishment of the Sustainable Development Goals. Realisation of the various goals to end poverty, ensure health for all, and promote sustainable economic growth, will be more achievable by ensuring delivery of safe, affordable and timely surgical care.
However, more improvements can still be made to further the provision of surgery worldwide. Currently, a global fund for surgery does not exist, and only a few foundations are willing to support surgery. Indeed, it took decades of advocacy to demonstrate the huge disease burden of other global health issues such as HIV/AIDs, tuberculosis and malaria, and then to develop funding mechanisms for them. With surgeons and leaders in global health advocating for patients in LMICs, we can hope to push for financial support in the coming years in order to improve the infrastructure and access to safe surgical care.
In order to improve training and facilitate sharing of resources, there should also be further collaboration between hospitals in high income countries and LMICs (“twinning programs”). However, donor hospitals, surgeons, and all those involved in efforts to redistribute surgical supplies need to exercise due diligence by ensuring that their partner institutions, including hospitals, clinics and medical schools, commit to reaching the poorest populations. Additionally, it is important to integrate vertical surgical programs into broader efforts to improve public health. In doing so, several important questions need to be raised: how effectively are the partner institutions providing care? Are they meeting broader goals of public health and global health equity?[3,7,8]
Finally, professional interest groups starting at the level of medical students and residents can foster interest and educate others about surgery in a global healthcare setting. One such entity is the International Student Surgical Network (InciSioN). This international team of medical students and young doctors, began as a small working group within the International Federation of Medical Student Associations (IFMSA) in 2014. Since its initiation, members of InciSioN have been passionately active in global surgery research, advocacy and education.
Considering the significant economic and disease burden of lack of access to safe surgical care, surgery is truly a necessity and not a luxury. Put simply, essential surgical care should be made accessible and available to everyone in the public sector. Whilst the challenges are huge, progress in global surgery can be made with patience, determination and devotion to the cause. There is much hope that, through international movements led by various organisations, and with involvement of medical students, doctors, and leaders in global health, the landscape of safe surgical care will change. As members of InciSioN international team, we dream of a world where no life is lost due to lack of access to safe surgery and anaesthesia.
Maryam Ali Khan (Pakistan), Zineb Bentounsi (Morocco), Nayan Bhindi (Australia), Helena Franco (Australia), Tebian Hassanein Ahmed Ali (Sudan), Katayoun Seyedmadani (Grenada/USA), Ruby Vassar (Grenada), Dominique Vervoort (Belgium) -InciSioN international team members
InciSioN, the International Student Surgical Network, is a student-led organisation of medical students and young doctors from around the globe with one shared passion, Global Surgery. InciSioN embodies the aim of educating about, advocating for, and performing research in Global Surgery. Among the 33 members of InciSioN, we share 23 countries spanning over 12 time zones, in 5 continents, and speak over 15 languages.
- Lancet Commission on Global Surgery. Global surgery 2030 report overview [Internet]. 2015. Available from: https://www.surgeons.org/media/21831010/Lancet-Commission-Policy-Briefs.pdf
- World Health Organization. WHO guidelines for safe surgery 2009 [Internet]. World Health Organisation; 2009. Available from: http://apps.who.int/iris/bitstream/10665/44185/1/9789241598552_eng.pdf
- Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg [Internet]. 2008 Mar [cited 2017 May 28];32(4):533-536. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2267857/pdf/ DOI: 10.1007/s00268-008-9525-9
- Meara, JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet [Internet]. 2015 Apr [cited 2017 May 28];386:569-624. Available from: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)60160-X.pdf DOI: 10.1016/S0140-6736(15)60160-X
- Grimes, CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Cost-effectiveness of surgery in low- and middle-income countries: a systematic review. World J Surg [Internet]. 2013 Oct [cited 2017 May 28];38:252-263. Available from: http://www.brighamandwomens.org/Research/labs/CenterforSurgeryandPublicHealth/Documents/AGSF/2014/December/Grimes%20CE%20CE%20of%20Surgery%20in%20LMICs%20systematic%20review%20WJS%202014.pdf DOI: 10.1007/s00268-013-2243-y
- Kim RY, Kwakye G, Kwok AC, Baltaga R, Ciobanu G, Merry AF et al. Sustainability and long-term effectiveness of the WHO surgical safety checklist combined with pulse oximetry in a resource-limited setting. JAMA Surg [Internet]. 2015 Mar [cited 2017 May 28];150(5):473-479. Available from: http://jamanetwork.com/journals/jamasurgery/fullarticle/2207940 DOI: 10.1001/jamasurg.2014.3848.
- Walton DA, Farmer PE, Lambert W, Léandre F, Koenig SP, Mukherjee JS. Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti. J Public Health Policy. 2004;25(2):137-158.
- Farmer P. From “marvelous momentum” to health care for all. Foreign Affairs. 2007 Mar;86(2):155-161.