GLOBAL SURGERY
1. Context
This focuses on equitable access to emergency and essential surgery. It encompasses a range of challenges including inaccessibility, disease burden, and economic burden
2.What is global surgery?
Global surgery aims to ensure fair access to critical and emergency surgical services. While its primary emphasis is on low- and middle-income countries (LMICs), it also addresses disparities in access within high-income countries (HICs), focusing on underserved populations. These essential and emergency surgical interventions encompass a range of procedures, including surgery, obstetrics, trauma, and anesthesia (SOTA). Despite minor variations, there is general agreement among various international organizations on approximately thirty procedures classified as emergency and essential surgery
Global surgery refers to the delivery of surgical care on a global scale, with a focus on addressing the surgical needs of underserved populations in low- and middle-income countries (LMICs). This field encompasses a broad range of surgical services, including preventive measures, emergency and essential surgical care, and rehabilitative services.
Key aspects of global surgery include:
- Many people around the world lack access to essential surgical services. Global surgery aims to improve accessibility to safe, timely, and affordable surgical care for all, especially in regions where such services are limited
- Surgical conditions contribute significantly to the global burden of disease. Global surgery initiatives aim to address conditions such as injuries, obstetric complications, infectious diseases requiring surgery, and non-communicable diseases through surgical interventions
- Efforts in global surgery often involve training local healthcare providers, strengthening healthcare systems, and building the capacity of local surgical teams. This helps ensure sustainable improvements in surgical care within communities
- Global surgery advocates for equity in healthcare, recognizing that access to surgical services is a fundamental component of comprehensive healthcare. It emphasizes the importance of social justice in addressing health disparities
- The field of global surgery also involves research to better understand the surgical needs of different populations, as well as advocacy to raise awareness and mobilize resources for improving surgical care globally
3. History of " Global Surgery"
- The year 2015 marked a pivotal moment, often referred to as the "Annus Mirabilis" or miracle year, for the global surgery field. It served as a turning point in recognizing the significance of surgical care on a global scale.
- A crucial catalyst for this shift was the Disease Control Priorities Network (DCPN) report on essential surgery, sponsored by the World Bank. This report emphasized the cost-effectiveness of emergency and essential surgical care, the benefits of scaling up surgical systems, and the substantial surgically preventable disease burden.
- Another key development in 2015 was the establishment of The Lancet Commission on Global Surgery (LCoGS). This commission brought together experts and stakeholders to assess the global status of surgical care access, define indicators for monitoring surgical care readiness, systemic capacity, and impact.
- It also contributed to the formulation of implementable strategies such as the national surgical, obstetrics, and anesthesia plan (NSOAP). A critical outcome of these efforts was the passage of the World Health Organization Declaration on Safe Surgery (WHO Resolution 68.15). This declaration underscored the necessity of a commitment to emergency and essential surgical systems for achieving universal health coverage
4. Concerns
- The challenges in global surgery are substantial, covering issues such as lack of accessibility, disease burden, and economic implications.
- According to the LCoGS, more than 70% of the global population, totaling five billion people, lack timely access to safe and affordable surgical care. Notably, 99% and 96% of individuals in low- and lower-middle-income countries (LLMICs), respectively, face access gaps, a stark contrast to the 24% in high-income countries (HICs), indicating a significant global disparity.
- Among these, over 1.6 billion people without access reside in South Asia, representing more than 98% of the region's population lacking access to safe and affordable SOTA care.
- The lack of access is closely linked to the disease burden. In 2010, surgically treatable conditions accounted for approximately 17 million deaths, surpassing the combined mortality burden of HIV/AIDS, tuberculosis, and malaria.
- The Global Surg Collaborative highlighted peri-operative mortality as the third most common cause of death, underscoring the impact of delayed care, unsafe surgeries, and limited surgical system capacity.
- The DCPN's comprehensive assessment revealed that scaling up surgical services at district hospitals in low- and middle-income countries (LMICs) could avert over 77 million surgically preventable Disability-Adjusted Life-Years (DALYs), constituting 3.5% of the total disease burden in these countries. South Asia had a higher DALY rate than the LMIC average, contributing significantly to surgically preventable burdens in neonatal and maternal diseases, congenital anomalies, digestive conditions, and injuries.
- The disease burden also carries an economic weight. The projected cumulative loss to GDP due to the lack of scaling up surgical care is estimated to be $20.7 trillion (in purchasing power parity terms) across 128 countries by 2030. Annually, the societal welfare loss is approximately $14.5 trillion for 175 countries, with South Asia accounting for around 7% of the global lost welfare
5.Addressing the Issue
- Despite the significant disease and economic burdens associated with it, surgery tends to be overlooked in international policies and health planning.
- The Lancet Commission on Global Surgery (LCoGS) observed that surgery accounted for less than 1% of all indicators mentioned in reports from influential organizations like the World Bank, World Health Organization (WHO), UNICEF, and others.
- This neglect extends to national policymaking, as evidenced by an analysis of National Health Strategic Plans from 43 African countries, where 19% did not mention surgery or surgical conditions at all, and 63% mentioned surgery only five times or less.
- A similar trend was noted in over 70 years of policymaking in India, with the most recent National Health Policy (2017) containing only two partial mentions of the term "surg." Even in the context of cancer control plans, India's new guidelines on non-communicable diseases (2023), which heavily focus on cancer, lack substantial references to surgery according to The Lancet Commission on Global Cancer Surgery.
- Although national health account data on funding for surgery is limited, data from sources like Developmental Assistance for Health (DAH) indicates a neglect in funding for surgery and related areas. DAH contributions to trauma care are less than $1 per Disability-Adjusted Life-Year (DALY) compared to $41 per DALY for HIV or $25 for tuberculosis.
- While U.S. charitable organizations and foundations have allocated millions to surgical care in low- and middle-income countries (LMICs), these funds are often directed towards specific diseases such as cleft palate, obstetric fistula, and ophthalmic issues, with minimal support for strengthening overall surgical systems in individual countries.
- For instance, of the $105 million spent by 470 U.S. foundations from 2003 to 2013, only $7.1 million and $1.7 million were allocated to the training of local surgical providers and infrastructure, respectively.
- Neglect is also evident in research, as shown by a bibliometric analysis revealing that in 2022, there were only 315 'global surgery' titles (1.5%) in the PubMed database compared to 21,453 'global health' titles.
- Research and funding are interconnected, with the National Institutes of Health (NIH), the largest healthcare research funder in the U.S., funding a significant number of large research projects, but only a fraction related to surgery, and even fewer focused on global surgery. The neglect observed in policy, financing, and research is interconnected, with each aspect influencing and reinforcing the others
6. Way forward
While the challenges in global surgery may seem formidable, they are surmountable. Research from the Lancet Commission on Global Surgery (LCoGS) and the Disease Control Priorities Network (DCPN) has demonstrated that emergency and essential surgical care not only proves to be cost-effective but also offers significant cost benefits. Over 30 low- and lower-middle-income countries (LLMICs) now possess subnational data on their surgical care indicators, with India being the most extensive contributor to this dataset. Several African nations have developed and put into practice National Surgical, Obstetric, and Anesthesia Plans (NSOAPs), showcasing robust political and policy commitment since 2015. In South Asia, Pakistan has established a National Surgical Care Vision, Nepal has initiated an NSOAP, and the Pradhan Mantri Jan Arogya Yojana has facilitated millions of surgeries at minimal or no cost for the bottom 40% of the Indian population. Addressing global surgery challenges requires a focus on research and innovation, policy emphasis, and sustained financial support
Source: The Hindu
