The deficit in global surgical care: a crisis
It is estimated that over 5 billion people go without adequate access to safe and affordable surgical care and anesthesia every year, contributing on average to more than 16 million deaths annually [1, 2]. However, loss of life is by no means the only consequence of this global health crisis. Millions more face crippling disabilities due to lack of surgical care, and losses in economic productivity are also substantial [3].
As with many other global health crises, low-and middle-income countries (LMICs) bear the brunt of this burden. In these settings, access to even the most basic surgical care is unavailable for 90% of people [2]. In situations where surgical care is available, patients are often made to pay out of pocket for expensive surgeries — the cost of which can be an overwhelming economic set-back on patients and their families. It is estimated that a quarter of people who undergo a surgical procedure will be burdened with catastrophic expenditure as a result of seeking care [2]. That proportion works out to 81 million individuals paying out of pocket for surgical care or the non-medical costs of accessing surgical care in an amount that exceeds 40% of their income [4].
Although its tremendous impact on the health and well-being of individuals is abundantly clear, access to affordable and quality surgical care is rarely discussed on the global agenda. In 2015, United Nations Member States adopted 17 Sustainable Development Goals, one of which was specifically aimed at ensuring healthy lives and promoting well-being for all at all ages [5]. As part of this goal, some examples of specific target areas include reducing maternal and childhood mortality, ending the epidemics of neglected tropical diseases, combatting communicable diseases, and strengthening the prevention of substance abuse [5]. Yet, among these many targets, increasing access to affordable surgical care is not mentioned once. In fact, a specific target that focusses on achieving Universal Health Coverage has drawn widespread attention as the magnitude and impacts of the global surgical deficit come to light. Many voices in the field have expressed doubts about how Member States will be able to achieve any such goal without explicit reference to improving capacity for global surgical care [2, 6, 7].
Despite this disconnect between surgery and universal health coverage on the global agenda, the overwhelming impact of the global surgical deficit is undeniable. Yet, improving access to affordable surgical care is not rocket-science. While scale-up does pose a major challenge, factors inhibiting access to surgical care such as hospital infrastructure, competition for medical dollars, and the so-called “brain drain” of physicians from low-resource contexts to high-income countries are highly targetable areas that have for too long been ignored [8, 9]. Moreover, addressing these barriers to affordable and safe surgical care are extremely cost effective, even ranking among the top most cost-effective health interventions by the World Bank in 2015 [10].
Partners in Health has long recognized the need for improving access to high quality surgical care, regardless of one’s economic status, and is working hard to reduce the significant gap between HICs and LMICs. One of their most exciting efforts has been the creation of a surgical teaching program at the University Hospital in Mireblais, Haiti, for local medical residents. The program is the first of its kind in rural Haiti and is working to address the ‘double’ brain drain of doctors to the nation’s capital, Port-au-Prince, as well as beyond the nation’s borders.
Dr. Paul Pierre, a senior advisor for PIH, said that the residency program “represents the most serious attempt, to my knowledge and during my lifetime, to systematically create a critical mass of Haitian physician specialists that will have the opportunity to be fully useful to all Haitians.” Such a program is a critical first step in creating the next generation of surgeons that can begin to bridge the divide in surgical care worldwide.
A key tenet to all of the work PIH does is ensuring access to affordable care, and surgery is no exception. PIH provides free surgical care to all patients — reducing one of the most significant barriers to patient treatment — and has the capacity to provide surgical care in orthopedics, otolaryngology, pediatrics, plastics, urology, obstetrics and gynecology, and general surgery. In cases that extend beyond these areas, especially those requiring complex surgeries, PIH has scaled up efforts to provide care through collaboration with international teams, allowing them to treat patients in even the direst situations.
Thankfully, PIH is not alone in tackling this major global health issue. In 2013, the Lancet’s Commission on Global Surgery was formed, which recognizes the neglected role of surgery in public health and aims to improve access to surgical care through four pillars: 1) health care delivery and management; 2) workforce, training and education; 3) information management; and 4) finance and economics. PIH participates in the commission, and is working alongside governmental and non-governmental organizations, academic institutions, and professional societies in 14 different countries to make these aims a reality. While achieving universal access to safe and affordable surgical care is still far away, the work of PIH and the Commission on Global Surgery are taking important strides in addressing this significant global health issue.
1. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health. 2015;3:S8–9.
2. 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. The Lancet. 2015;386:569–624.
3. Bickler SN, Weiser TG, Kassebaum N, Higashi H, Chang DC, Barendregt JJ, et al. Global Burden of Surgical Conditions. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors. Essential Surgery: Disease Control Priorities, Third Edition (Volume 1). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2015. http://www.ncbi.nlm.nih.gov/books/NBK333518/. Accessed 7 Dec 2018.
4. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. The Lancet. 2003;362:111–7.
5. United Nations. Sustainable Development Goals. 2015. http://www.undp.org/content/dam/undp/library/corporate/brochure/SDGs_Booklet_Web_En.pdf. Accessed 9 Dec 2018.
6. Ahmed F, Michelen S, Massoud R, Kaafarani H. Are the SDGs leaving safer surgical systems behind? Int J Surg. 2016;36:74–5.
7. Henry JA, Abdullah F. Global Surgical Care in the UN Post-2015 Sustainable Development Agenda. World J Surg. 2016;40:1–5.
8. Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry AF, Enright AC, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. The Lancet. 2010;376:1055–61.
9. Mullan F. The Metrics of the Physician Brain Drain. N Engl J Med. 2005;:9.
10. Debas, Haile T.; Donkor, Peter; Gawande, Atul; Jamison, Dean T.; Kruk, Margaret E.; Mock, Charles N. Essential Surgery. Washington, DC: World Bank; 2015.
