The findings, interpretations and conclusions are those of the authors and do not necessarily reflect the views of the European Investment Bank
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Surgery involves more than a single discipline and more than the sheer cutting and stitching up of human flesh and bone. It is an essential part of basic care, but it remains inaccessible and unaffordable for many people around the world.
One third of today’s global diseases require surgical intervention, but this type of service is not always accessible or safe. Past global and national public health policies in the developing world have usually been disease specific, focusing on treating the single problem (such as the tuberculosis, HIV or malaria programmes) and not on strengthening the healthcare system and providing access to surgical care.
Surgery is a pillar of the health system. Every human being may need basic to life-saving surgical care in his or her lifetime and only a strong healthcare system with improved surgical care capacity can support true universal health coverage and lead to sustainable national development.
Surgery involves more than a single discipline and more than the sheer cutting and stitching up of human flesh and bone. It is an essential part of basic care, but it remains inaccessible and unaffordable for many people around the world.
Most healthcare systems are simply not fully developed to reach everyone. And in low- and middle-income countries, the situation is even worse, as surgical care in most cases is primarily only available in urban areas.
The Lancet Commission on Global Surgery reported in 2015 that 28-32 percent of the global burden of disease requires surgical intervention and that many people worldwide (about five billion, or 70 percent of the global population) lack access to safe and affordable surgery. The majority of these people live in rural parts of the developing world.
... many people worldwide (about five billion, or 70 percent of the global population) lack access to safe and affordable surgery
In the Republic of Zambia where I have lived, trained and served for more than 10 years as an orthopaedics and trauma surgeon, the practice of safe surgery is almost non-existent in most rural districts, where more than 60% of Zambia’s population lives. The Zambian situation and my personal experience is not unique but a common occurrence in almost all low- and middle-income countries. Even in urban areas, access to surgical care remains limited and this leads to long waiting lists for surgical operations and prolonged periods of waiting time before someone can receive the disability preventing surgical intervention that they need.
This status quo also fans the rising trend of “medical tourism,” in which the privileged few go abroad for surgery and other health services instead of investing in improved surgical care capacity in their countries - a situation that is not sustainable and undermines the development of the health system in Zambia and many other countries. It is no wonder that my country, Zambia, continues to report a high maternal and neonatal mortality rate (591 per 100,000 live births and 34 per 1,000 live births, respectively) despite huge investments into improving maternal and child health during the 15 years of the Millennium Development Goals.
Many mothers with difficult childbirth still have to travel long distances using inappropriate transport on bad roads to seek assistance and this situation often causes the death of the mother and child.
On many occasions, when I joined my orthopaedics and plastic surgery colleagues on rural outreach for the FLYSPEC programme in Zambia, we were called in for an emergency Caesarean section or to control difficult bleeding after childbirth. We were the only skilled personnel at the rural health facilities, and we stayed for only three days at a time.
Surgical access is even more desperate when considering specialised surgical services. Many rural children born with deformed limbs cannot attend school because of the long distances, so they suffer all of their lives, when such problems could have been fixed at an early age. Prolonged bone infection is another common disease easily treated with surgery. Victims of this illness develop chronic wounds and are often treated inappropriately by health personnel who are not trained in surgery. For a skilled surgeon instead, proper surgery takes only three hours and this illness is permanently resolved.
The delivery of surgical care is never a one-man show. It is a partnership - a team effort by different health care providers with specialized skills. However, limited surgical care training facilities, limited operating rooms and costly surgical equipment make things even more difficult in some countries.
The estimated annual loss of total gross domestic product because of surgical expenses by 2030 will be $12.3 trillion.
Addressing these challenges requires concerted efforts and leadership both at the high level and at local level. I have been involved in both levels – developing global and national surgical health policies and programmes while providing training for local workers. The partnership presented by the surgical care team offers an entry point for addressing other public health challenges, such as increasing awareness of anti-microbial resistance, sexual reproductive health and rights and the role of the health sector in addressing violence against women and girls.
The surgical care team presents an innovative avenue for augmenting the Global Partnership for Sustainable Development, a multi-stakeholder partnership sharing knowledge, technology and financial resources to support the Sustainable Development Goals, especially in developing countries.
There is also an economic argument to investing in surgical care in the developing world. In a 2015 report, the Lancet Commission on Global Surgery estimated that 33 million people worldwide face catastrophic expenses paying for surgery and anaesthesia annually and that the estimated annual loss of total gross domestic product because of surgical expenses by the year 2030 will be $12.3 trillion. This equates to a reduction of annual GDP growth of approximately 2% in many low- and middle-income countries.
The Lancet said that investing in surgery is affordable, saves lives and promotes economic growth. It is estimated that greater access to surgical care in developing countries could avert 1.5 million deaths a year. Five million people died of injuries in 2012, and 270,000 women died of pregnancy complications. Many of these deaths could have been prevented. Realizing the importance and great need for improved surgical care within the primary health care system, the 194 Member States of the World Health Organisation under the leadership of the Republic of Zambia expressed their political commitment for improved surgical care.
To translate political commitments into tangible public health programmes that help all, World Health Organization has started developing National Surgical Obstetric and Anaesthesia Plans. Four countries in Sub-Saharan Africa have completed the development of their National Surgical Obstetrics and Anaesthesia Plan (Zambia, Ethiopia, Tanzania and Senegal) and many more (including Rwanda, Zimbabwe, Mozambique, Madagascar) are on the road to achieving this. These plans should, besides addressing the huge burden of neglected surgical disease, also help these countries address other public health challenges and commitments, including the Sustainable Development Goals.
Improved surgical care would strengthen the health system at the primary level and is one of the practical means of ensuring universal health coverage in a nation, but safe surgical care cannot be provided without complementary improvements in laboratory and imaging services, blood transfusions and referral services. Improving surgical care capacity will also need improvements in health financing, increased availability of essential medicines, a better health information management system that includes surgery, and better health systems governance. After the Ebola disease outbreak in West Africa in 2014, “weak health systems” were identified as the key factor in the wide spreading and difficult control of the virus.
Many developing countries have invested in other maternal and child health interventions, but not in improving local surgical care. Because of this, they have struggled to bring maternal and infant mortality rates down.
Better management of disabilities through surgery would, for example, improve physical activity and the economic output of many people incapacitated by hernias or poorly aligned fractures. It would improve school attendance of affected children who have to cover long distances to get to class, giving the young a better start in life. Management of birth defects such as cleft-lip and cleft palate, which is treatable only by surgery, would guarantee better nutrition for children in the developing world. Reduced physical disability would contribute to reducing discrimination of those afflicted, including women who suffer prolonged childbirth. Surgery would restore eyesight to the elderly through the surgical removal of cataracts, giving them hope and independence. Improved surgical care would offer social and economic empowerment to individuals, families and communities.
Bleeding is the known leading cause of death for mothers and children during difficult births. It is also the leading cause of death in industrial and road traffic accidents and in injuries from war or natural disasters. Surgery remains the only means and the primary intervention to save lives in situations of life-threatening bleeding. However, many developing countries have invested heavily in other maternal and child health interventions, but not in improving local surgical care. Because of this, they have struggled to bring maternal mortality and infant mortality rates down.
The Republic of Zambia, through the Ministry of Health, identified this gap and public health challenge that was causing many deaths and resolved to improve local surgical care capacity as a key intervention back in 2010. It was for this reason that the ministry then established the directorate of Mobile and Emergency Health Services and I was given the responsibility to set up the emergency health response for Zambia as deputy director. This senior health management role and my experience as a surgeon proved useful when I had to lead negotiations that led to the adoption of a World Health Organisation resolution calling for strengthened surgical care.
Countries in the developing world are grappling with the challenge of teaching the right kinds of skills that are locally needed to their youthful populations. The United Nations High-Level Commission on Health, Employment and Economic Growth, set up in 2016, presented these three messages on how countries can foster better health care and economic growth:
...investing in improved surgical care capacity presents countries with the opportunity to create good-paying, long-term and respectable jobs that empower women and youth, who make up the larger part of the surgical team. Furthermore, job creation in surgical care presents countries with a means of increasing the tax base and raising revenues.
Thus, investing in improved surgical care capacity presents countries with the opportunity to create good-paying, long-term and respectable jobs that empower women and youth, who make up the larger part of the surgical team. Furthermore, job creation in surgical care presents countries with a means of increasing the tax base and raising revenues. Improving access to surgical care puts countries on a firm path to achieving most of the Sustainable Development Goals and targets.
Surgery makes people healthy and it is said that “health is wealth,” because only healthy people can sustain improved productivity, which in turn improves economic performance and leads to sustainable development of a nation.
European and North American organisations have acknowledged the importance of improving local surgical care capacity in the developing world and in their own underserved communities. The European Union, for instance, has provided grant funding for the COST-Africa research that gave the scientific evidence to prove that there was no loss in safety, quality and skills in the “Task Sharing” of surgical care services to non-physician health workers. This grant has now been increased and transformed into the “SURG-Africa” programme, which aims to increase surgical skills training in Zambia, Malawi and Tanzania to improve surgical services.
Another initiative, “The Challenge Prize” at NESTA, has recently set up the “Surgical Equity Prize” as part of a broader campaign to raise awareness, leverage knowledge and expertise, and harness technical and financial resources to improve surgical services worldwide with the justification that a lack of action in improving surgery and anaesthesia could imperil our collective effort to realise several Sustainable Development Goals.
Zambia is setting up the first World Health Organisation Regional Collaboration Centre on surgical care information for the Southern African Development Community.
Current challenges to equitable surgical care include the lack of global coordination and a lack of financial and human resources within health organizations. Countries should work with the World Health Organization and other partners in establishing robust and standardized platforms for the collection and sharing of surgical care data to demonstrate how much this would encourage investments in local surgical care capacity. Zambia is setting up the first World Health Organisation Regional Collaboration Centre on surgical care information for the Southern African Development Community.
But innovative financing for improved surgical care capacity should also be pursued domestically and internationally. To encourage financial and technical support, countries should develop integrated National Surgical Obstetric and Anaesthesia Plans that have a government budget and do not need external financing. In Zambia, the approval by Parliament in 2018 of the National Social Health Insurance Bill could prove to be a monumental milestone for raising much-needed finances for health. This extra money could further support the strengthening of emergency and essential surgical care and anaesthesia as a component of universal health coverage for all Zambian. Funding agencies and development partners, among them the World Bank, the European Investment Bank and the Challenge Prize at NESTA, have explored and included in their plans projects that support the improvement of surgical care capacity for better health outcomes and sustainable national development.
The former director general of the World Health Organisation, Halfdan Mahler, said in 1980 that, “Social injustice is socially unjust in any field of endeavour, and the world will not tolerate it much longer. So the distribution of surgical resources in countries and throughout the world must come under scrutiny in the same way as any other intellectual, scientific, technical, social or economic commodity. The era of only the best for the few and nothing for the many is drawing to a close”.
These words seem more true today than ever before and deserve the support of each and every one of us.
Good health is a precondition for economic prosperity. Empowering weak health systems and giving access to surgical care in the developing countries will rise life expectancies and reduce discrimination caused by untreated disabilities, with implications for socioeconomic systems.
The EU bank supports projects which aim to ensure universal access to effective, safe and affordable healthcare services.
The findings, interpretations and conclusions are those of the authors and do not necessarily reflect the views of the European Investment Bank.
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