Surgery & Anesthesia: The Overlooked Keys to Universal Health Coverage

By Dominique Vervoort, Chair of InciSioN — International Student Surgical Network

Five billion people lack access to surgical and anesthesia care when needed. As a result, over 17 million preventable deaths occur each year, and 28–32% of the global burden of disease can be attributed to surgically treatable conditions. Every year, 313 million procedures take place around the world, yet 74% of all major surgeries occur in the wealthiest third of the world. In contrast, only 6% is reserved for the poorest third, where 81 million people are pushed (further) into poverty for accessing surgical care every year.[1]

The WHO’s constitution acknowledges that the enjoyment of the highest attainable standard of health is a fundamental human right. Nevertheless, 400 million people worldwide lack access to the most basic life-saving care.[2] 150 million people suffer from catastrophic expenditure due to healthcare costs, whereas 100 million people are pushed below the poverty line as a result. Similarly, 5.6 billion people living in low- and middle-income countries (LMICs) rely on out-of-pocket spending (OOPS) to cover at least half of their healthcare costs, making up to one-third of households in Africa and Southeast Asia borrow money or sell assets to pay for their medical bills.[3]

“UHC is the single most powerful concept that public health has to offer.”
 — Dr. Margaret Chan, previous Director-General of the World Health Organization

Universal health coverage (UHC) implies that all individuals and communities have access to quality healthcare services without financial hardship when needed. Social equity takes center stage in achieving and sustaining UHC, and as such, the needs of the poor and marginalized need to be prioritized at all stages through pooling of resources and redistributive mechanisms ensuring financial protection and subsidies for the poor.

Although higher spending does not always improve health, the right investments at the right time can. In the past decades, over 100 LMICs, home to ¾ of the world population, have taken steps towards UHC, designing their own unique pathways towards health for all. On average, total health expenditure (THE) increased by 80% in LMICs between 1995 and 2010.[4] Nevertheless, OOPS remains high (32.1% of THE) compared to government spending (12%), which remains low in the Middle East (8.7%) and South Asia (8.3%). Sub-Saharan Africa spent 11.1% on health, still falling short of the Abuja Declaration target of at least 15% of total government expenditure. These numbers suggest that many — if not all — countries have the ability to increase government health expenditure, allowing for improved access for poorer populations, and supporting the progress towards UHC.

Despite previous (and sustained, yet unjustified) concerns, UHC is technically possible and affordable for all countries. The Lancet Commission on Investing in Health estimated that every dollar invested in health returns ten times the benefits in terms of economic growth.[5] It is estimated that investments in health $371 billion ($58 per person) per year are needed by 2030 to achieve the health-related Sustainable Development Goals (SDGs) through UHC.[6] In LMICs, domestic resources can cover 85% of the needed investments to work towards UHC. Notwithstanding the remaining financing gap ($17–35 billion per year for LICs, and $3–4 billion per year for conflict affected countries), most countries are able to achieve some extent of universality by themselves. External sources ought to fund the rest, whilst countries work to raise domestic funds and close the gap gradually over time.

#SurgeryUHC

In countries having UHC packages, obstetric care is most commonly included.[4] However, despite the financial risk protection, high volume of cases, limited skilled health workers and distorted cultural perceptions limit the utilization thereof. Nevertheless, inclusion of obstetric care has improved the safety and quality of obstetric care and the number of births in skilled facilities, with an overall lower maternal mortality rate in sub-Saharan Africa.[4]

Surgery and anesthesia are essential components of UHC, especially in the context of a growing global prevalence of (often surgically treatable) non-communicable diseases (NCDs) and persistently high rates of OOPS in LMICs.[7] High percentages of OOPS in, especially, LMICs discourage people from seeking surgical care, leaving them with the choice between health and other basic necessities (e.g., food and rent), whereas those that do face high levels of catastrophic expenditure.

“Achieving UHC will be my top priority, because I believe it is the best overall investment we can make.”
 — Dr. Tedros, Director-General of the World Health Organization

UHC is needed for people’s health and well-being, and a crucial pillar towards sustainable development, creating the need to address the wider dimensions of health, rather than merely diseases. The cost of neglect, both in dollars and lives, underlying access to surgery is too high not to pay attention to. Surgery should not be a luxury only for those able to pay, but an accessible option for everyone, everywhere, when needed.

References:

1. 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. 2015;386(9993):569-624.

2. World Health Organization. Together on the road to universal health coverage: a call to action. Geneva; 2017.

3. Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. Moving towards universal health coverage: Health insurance reforms in nine developing countries in Africa and Asia. Lancet [Internet]. 2012;380(9845):933-43. Available from: http://dx.doi.org/10.1016/S0140-6736(12)61147-7

4. World Health Organization (WHO). Tracking Universal Health Coverage: First Global Monitoring Report. World Heal Organ. 2015;79.

5. Jamison DT, Summers LH, Alleyne G, Arrow KJ, Berkley S, Binagwaho A, et al. Global health 2035: a world converging within a generation. Salud Publica Mex [Internet]. 2015;57(5):441-3. Available from: http://dx.doi.org/10.1016/S0140-6736(13)62105-4

6. World Health Organization. WHO estimates cost of reaching global health targets by 2030 [Internet]. 2017. Available from: http://www.who.int/mediacentre/news/releases/2017/cost-health-targets/en/

7. Okoroh JS, Chia V, Oliver EA, Dharmawardene M, Riviello R. Strengthening Health Systems of Developing Countries: Inclusion of Surgery in Universal Health Coverage. World J Surg. 2015;39(8):1867-74.

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