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Global surgery and anaesthesia
Defining Global Surgery
The concept of global surgery has gained prominence in public health discourse over the past decade. Although traditional issues in global health continue to attract attention, global surgery as a discipline is now an integral part of the dialogue. Global surgery has been defined as ‘an area of study, research, practice and advocacy that seeks to improve health outcomes and achieve health equity for all people who require surgical care, with a special emphasis on underserved populations and populations in crisis’. This definition incorporates the key concepts of scientific investigation, clinical health service delivery and ongoing activism to promote the concepts of equity and universal health coverage.
The Importance of Surgery and Anaesthesia in Global Health and Universal Health Coverage
Global surgery and anaesthesia care were first introduced to the global health world in 1980 when Halfdan Mahler, a surgeon and the director general of the World Health Organisation (WHO), noted its importance in an address to the World Congress of the International College of Surgeons ( Box 29.1 ). However, it took almost 30 years for progress to be made in this domain. The reasons are numerous, but a primary issue is that surgery and anaesthesia are complex and multidisciplinary specialty services that address a range of diseases and conditions. Most traditional public health interventions focus on a specific health issue (e.g., nutrition), disease diagnosis (e.g., malaria), or underserved population (e.g., pregnant women). Typically, when service delivery is addressed, it focuses on a very circumscribed clinical mechanism that addresses a particular disease burden, such as vaccination and its associated delivery mechanisms or directly observed therapy (DOT) for multidrug-resistant tuberculosis (TB). Surgery and anaesthesia, by definition, exist within a complex health system, typically at a facility level, and require the interaction of multiple specialties (physicians, surgeons, nurses, allied healthcare providers, etc.) and multiple resources (durable and consumable goods, medications), along with the support of management capacities and practices that allow the efficient use and interaction of all these resources.
Box 29.1
Key themes of director general halfdan mahler’s original address to the international college of surgeons, mexico city, 1980
Adapted from World Health Organisation. Address by Dr H. Mahler. https://www.who.int/surgery/strategies/Mahler1980speech.pdf?ua=1 .
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Political, social and economic factors influence health.
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There exists profound social injustice and maldistribution of surgical resources.
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Primary healthcare is essential healthcare and must be universally accessible to all individuals and families in an acceptable and affordable way.
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Primary healthcare must include the appropriate treatment of common diseases and injuries, which fundamentally includes surgical care and capacities; without it, people will not have faith in the healthcare system.
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The international surgical community is challenged to identify essential surgical procedures and equipment, similar to what has been done with essential medications to address diseases that are common and burdensome.
Surgical and anaesthesia care are critical components of essential primary care and universal health coverage (UHC). Without such services, many important and highly prized health gains cannot be realised: death and disability from trauma and injury cannot be averted without surgical care, maternal and neonatal mortality cannot be reduced without emergency obstetric care (including caesarean delivery), life-threatening infections cured by interventional services cannot be addressed, congenital malformations cannot be corrected, and cancers can be neither diagnosed nor treated without the diagnostic and therapeutic interventions provided within the surgical ecosystem. UHC comprises three critical component parts: access to care, quality of care and protection from financial risk. For each of these domains, surgical and anaesthetic capacities still struggle to meet the promises set out by the WHO. The Lancet Commission on Global Surgery estimated that 5 billion of the world’s 7.6 billion people do not have access to timely, affordable, safe surgical care ( EBM 29.1 ).
Access to care
Each year over 300 million operations are performed worldwide. This equates to 1 operation for every 24 people living today. Yet access is unevenly distributed. In high-income countries, the rate of surgery is frequently above 10,000/100,000 population, whereas in countries with the lowest health expenditure (<$100 per capita) the rate of surgery is well below 1000/100,000. Yet surgical care is essential for averting disability and death. At least 30% of the total disease burden worldwide is treated in whole or in part by surgery, and essential and emergency surgical and anaesthetic care could avert 6% of deaths. By comparison, full implementation of HIV, TB and malaria prevention and treatment would avert <1% of global mortality, yet cost several times as much per patient. To meet the basic emergency and essential needs of populations in low-income and lower-middle-income countries, at least 140 million more operations are required annually. This need is being recognised and rapidly met by many countries, particularly in the lowest-health-expenditure brackets that have seen the most rapid growth in surgical capacity and volume over the last decade ( Table 29.1 ; EBM 29.2 ).
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Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624.
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Dare AJ, Grimes CE, Gillies R, et al. Global surgery: defining an emerging global health field. Lancet. 2014;384(9961):2245–7.
EBM 29.1
Surgery in healthcare
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Worldwide, 5 billion people do not have access to safe, affordable surgical and anaesthesia care when needed.
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To save lives and prevent disability, 140 million additional surgical procedures are needed in low-income and lower-middle-income countries each year.
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Worldwide, 33 million individuals face catastrophic health expenditures as a result of payment for surgery and anaesthesia care each year.
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Investing in surgical services in low-income and lower-middle-income is affordable, saves lives and promotes economic growth.
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Surgery is an ‘indivisible, indispensable part of healthcare’.
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Weiser TG, Haynes AB, Molina G, et al. Size and distribution of the global volume of surgery in 2012. Bulletin of the World Health Organization. 2016;94(3):201–9F.
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Debas HT, Donkor P, Gawande A, et al. Essential surgery. Disease control priorities, 3rd ed. Washington, DC: The World Bank; 2015.
EBM 29.2
Disparity in surgical service provision
Surgical volume is large and growing, with caesarean delivery comprising nearly a third of operations in most resource-poor settings. Nonetheless, there remains disparity in the provision of surgical services globally.
Table 29.1
Comparative rate of surgery per health expenditure grouping, 2004 and 2012
| Total Health Expenditure Group | Mean Annual Surgical Rate by Year (per 100,000 Population) | % Change in Surgical Rate | % of Global Volume of Surgery (2012) | % of Global Population (2012) | |
|---|---|---|---|---|---|
| 2004 | 2012 | ||||
| Very low | 394 | 666 | 69.0% | 6.3% | 36.8% |
| Low | 1851 | 3973 | 114.6% | 23.1% | 34.2% |
| Middle | 3944 | 4822 | 22.3% | 10.9% | 11.4% |
| High | 11,629 | 11,168 | −4.0% | 59.8% | 17.7% |
| Global | 3941 | 4469 | 13.40% | — | — |
Quality of care
Increasing surgical access without a corresponding improvement in the quality of care delivered would still result in a massive failure of the health system. The volume of operations worldwide is double the number of births; although safe birth initiatives are considered of utmost priority, surgical safety initiatives are rare, and the provision of care is extremely variable. Morbidity and mortality after surgery tend to be much higher in lower-resourced environments. Complication rates in these settings, such as postoperative infections, are double those in wealthier regions, even after adjusting for the case mix. Even within countries, the variability in surgical outcomes has been the subject of numerous impactful studies. In many settings, the differences between higher and lower mortality rates are closely associated with the organisational capacities of the hospital and health system—the concept of ‘failure to rescue’ is a critical consideration in highly resourced environments where resources are available but skill sets, organisational arrangements, management practices, care routines and complex service provision affect the ability of clinicians to recognise and treat deteriorating patients. It seems likely that these capacities are even more pronounced in low-income countries. This has led to renewed interest in the ‘capacity to rescue’ and the tools, techniques and care programmes that support the early identification and salvage of patients at risk for mortality as a result of complications.
Financial risk protection
The cost of scaling up surgical and anaesthetic services is not insignificant. The Lancet Commission on Global Surgery estimated that countries not currently meeting the basic surgical needs of their populations must invest a cumulative $300 to $500 billion to improve service capacity. However, the costs of not making these investments are even more profound—over the next 15 years, countries that do not provide essential surgical and anaesthetic care for their populations will lose over $12 trillion in gross domestic product (GDP) productivity; financing to scale capacities would provide a 40× return on investment.
The dramatic improvements in health delivery, economic development and life expectancy have led to an increase in the demand for services. Despite the challenges of providing complex surgical and anaesthetic care, people still seek and undergo operations to treat disease in every country, both rich and poor. The cost for such care can be impoverishing for individuals and families, especially when insurance schemes or other provisions for financial coverage are absent. At least 80 million people each year are impoverished in having to pay for needed care. Insurance coverage and financial protection mechanisms have improved remarkably over the past decade, but there remain conspicuous differences in effective coverage between richer and poorer countries, particularly with regard to noncommunicable diseases.
29.1
Summary
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