Surgery remains ‘the neglected stepchild of global health’

The Royal College of Surgeons in Ireland is working to meet surgical training needs in Africa

Across the world this year, many more people will die from lack of access to safe surgery and anaesthesia than from malaria, HIV/Aids and tuberculosis combined. Common conditions such as appendicitis, hernia and complicated childbirth frequently result in death and untreated bone fractures often lead to life-long disability and consequent financial ruin for whole families.

While there have been remarkable gains in global health over the past 25 years, these have focused on infectious diseases and nutrition and have not addressed access to essential surgical care.

In the words of Jim Yong Kim, president of the World Bank, and Dr Paul Farmer, Harvard professor and founder of Partners in Health, surgery has been "the neglected stepchild of global health".

Dr David Wilkinson of the World Federation of Societies of Anaesthesiologists has identified the components of the service deficit as including: a skilled workforce; basic equipment and infrastructure; essential documentation and monitoring and evaluation.

For the past eight years, the Royal College of Surgeons in Ireland (RCSI), with great support from the Irish people in the form of funding from Irish Aid, has been engaged in substantial collaboration with the College of Surgeons of East, Central and Southern Africa (COSECSA) to address the surgical manpower gap and, hence, the deficit in essential surgical care.

COSECSA, a “college without walls” and with scant resources, trains surgeons across the eastern half of sub-Saharan Africa and spans 10 countries with a total population of 320 million people. This vast population has fewer than 1,700 surgeons – that’s one surgeon for every 200,000. Compare this with high income countries, such as Ireland, where we have a ratio of 1 for fewer than 10,000 people.

The RCSI collaboration has had considerable success in significantly increasing the capacity of COSECSA to train surgeons within the region and often at provincial level, so as to minimise internal brain drain. However, this has occurred in a context where there has been little meaningful engagement by local country governments or health ministries in addressing the overall problem. Until now, common misconceptions about surgery being expensive and unaffordable have prevailed. But two events in recent weeks hold out the prospect of changing all that.

Firstly, the Lancet commission's recently published landmark study, Global Surgery 2030, provides real data and suggests solutions for achieving access to "safe, affordable surgical and anaesthesia care when needed". The commission outlines just how stark the situation really is.

Access to care

Of the more than 300 million surgical procedures worldwide in 2012, only 6 per cent were performed in countries that comprise 37 per cent of the world population. Five billion (or two-thirds) of the world’s population lack access to care, despite the fact investment in surgical and anaesthesia services is affordable, saves lives and promotes economic growth. Indeed, financial modelling identifies a benefit-cost ratio of greater than 10:1.

Provision of essential surgery will prevent 1.5 million deaths each year, or 6.5 per cent of all avertable deaths. A quarter of all people who have a surgical procedure will face financial catastrophe as a result of seeking care.

These are shocking statistics but, for the first time, they provide global surgery with a strong evidence base and define a problem that demands action. Action is needed from the wider global community but, more critically, governments of low and middle-income countries must recognise surgery as an essential and affordable part of a national health service and take the strategic decisions to enable funding of surgical initiatives, including support for training the required workforce.

And so to the second seminal event of recent weeks. On May 22nd, at the World Health Assembly in Geneva, ministers for health from around the globe approved the World Health Organisation (WHO) resolution, entitled "Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage".

Universal health coverage, already endorsed by the WHO, envisages that all citizens of the world can obtain essential health services without suffering financial hardship when paying for them. This new resolution states that essential surgical care is an inseparable component of this.

There is a large international community of surgical and anaesthetic organisations, individuals, institutions and colleges, including RCSI, which has been working towards this initiative and which now applaud and celebrate its adoption.

Game changer

This game-changing resolution represents a real opportunity for progress. It urges member states, for the first time ever, to “identify and prioritise a core set of emergency and essential surgery and anaesthesia services at the primary health care and first referral hospital level” and furthermore to “develop methods and financing systems for making quality, safe, effective and affordable emergency and essential surgical care and anaesthesia services accessible to all who need it”.

Success in these and other requirements will be measured and reported to the World Health Assembly in 2017.

In the meantime, it allows organisations such as COSECSA to make the case that long-term capacity development and surgical training programmes are fundamental to addressing the ambitious objectives set out under the resolution. With new authority, they can seek and obtain funding from their own ministries and approach external donors and funders, who can now see the enormous life-saving potential of such investment.

It is appalling that most people have no access to basic surgery. It will not be institutions or individuals in the high income countries that will resolve this situation, but rather it is lower and middle-income country governments who must provide the infrastructure and local institutions to train the future surgical providers.

Our role is to support governments and education and training bodies to meet this challenge. This is the key to the principles of sustainable development and partnership that underpin Ireland’s aid policy, as delivered by Irish Aid, and also guides the endeavours of RCSI in sub-Saharan Africa.

Declan J Magee is president of the Royal College of Surgeons in Ireland