Help Wanted

Global agencies must play crucial role in effort to stop millions of deaths due to lack of surgical care

Surgery taking place in a busy operating room.
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Lack of reliable, affordable access to surgery kills more people around the world each year than HIV, tuberculosis and malaria combined.

In addition to the unquantifiable human suffering, this lack of surgical care is expected to cost the global economy some $12 trillion by 2030 in lost productivity.

Yet, this dark picture, described in the 2015 Lancet Commission on Global Surgery, has a surprising bright side, according global health experts.

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Developing the capacity necessary to fill the world’s unmet surgical needs in low- and middle-income countries would cost $350 billion—a relatively meager investment by global economy standards—and would have the potential to yield an impressively high return of more than $11 trillion, according to the Lancet Commission.

The tricky part is figuring out how to get the resources needed now to make a brighter future possible. It’s been especially challenging, global surgery advocates say, because until recently, few funders have considered surgical capacity to be an important part of global health delivery or international development.

This fall, a series of commentaries published in the journal Surgery highlights the roles that four major global health agencies and funders could play in closing the surgery gap. In the quartet of papers, a team of scientists led by researchers from the Harvard Medical School Program in Global Surgery and Social Change call for increased support to help research, develop and deploy solutions to address the surgical shortfall. The authors on the report include surgeons, global health experts and representatives from several funding agencies.

The launch of the Lancet Commission, which made crucial progress in mapping the path toward global surgery equity, has resulted in a growing acknowledgement of the importance of surgery as an integral part of global health.

The four-paper series reviews the central role played by each of the major health agencies —the World Bank Group, the World Health Organization, the U.S. Agency for International Development and the Bill and Melinda Gates Foundation—in strengthening health systems. The papers go on to highlight the specific roles each organization could play in developing infrastructure and access to surgery, obstetrics and anesthesia—the foundational medical-surgical specialties crucial to efforts that ensure reliable access to safe surgical care, according to the authors.

“We know that providing safe, affordable, timely surgery will save millions of lives and trillions of dollars in lost productivity,” said John Meara, the Steven C. and Carmella R. Kletjian Professor of Global Health and Social Medicine in the field of Global Surgery at HMS and senior author of the four papers. “Whether you want to improve maternal and child health or find cost-effective investments that can jump-start economic development, surgery has to be part of the answer.”

Surgery is an integral part of effective health systems, and surgical capacity is an excellent indicator of the vitality of a health care system, the authors note. For example, if a hospital has the staff, space and supplies needed to provide surgery, it is much more likely to meet other community health needs.

“Our reports are intended to serve as a blueprint for policy development and advocacy and to educate surgeons, obstetricians and anesthesiologists,” Meara said. “But we also want them to be a clarion call to the agencies about the critical roles they should play in integrating surgical care into health system strengthening and sustainable development if they want to achieve meaningful, long-lasting outcomes.”

In recent decades, most global health funders have focused on attempting to prevent, treat or eradicate specific diseases, rather than on strengthening integrated health systems that can meet a variety of medical needs. Surgery is only a small part of treatment for many of the major diseases and as a result has often been neglected in these efforts, the researchers said.

The World Bank, under the leadership of Jim Yong Kim, former head of the HMS Department of Global Health and Social Medicine, has championed the cause of global surgery in recent years. Kim has called surgery the “neglected stepchild” of global public health, and says that surgery is an “indivisible, indispensable part of health care.” The World Bank took the lead in adopting the measures of surgical capacity as an important indicator of development, and supported the creation of a list of 44 essential surgical procedures that are cost effective and feasible and address large burdens of disease in developing nations. The organization is also facilitating data collection on the efficacy of these procedures in order to have evidence to advocate for including them in all health systems.

The authors note that the World Bank’s key contribution to global surgery will likely come in the form of providing and facilitating financing for developing surgical capacity, perhaps something along the lines of the innovative Pandemic Emergency Financing Facility, which uses World Bank-backed bonds as a hedge against catastrophic outbreaks of infectious disease. The World Bank’s Global Financing Facility may be just the vehicle needed for global surgery.

The World Bank Group is also helping the WHO reorganize its international health programs. The authors argue that this reorganization provides an excellent opportunity to move away from isolated, disease-specific initiatives and toward a more integrated approach that favors health systems’ strengthening with surgery, obstetrics and anesthesiology built into the foundation.

USAID, which is facing drastic cuts to funding for international aid, can still play an important role in supporting global surgery by leveraging existing in-country relationships around the world and by taking advantage of the its position as a leader in international development and global health funding. These actions could signal the importance of global surgery by, for example, emphasizing the importance of existing surgical training programs.

The Gates Foundation, the largest private player in the field of global health funding, has an opportunity to assume a leadership role in global surgery, which aligns closely with the foundation’s belief that all lives have equal value and share the right to health and economic success and with its data-driven approach to global health funding. The foundation’s strategy of funding both “upstream” areas of underfunded promising research and “downstream” areas of care delivery would provide key support for building global surgery. For example, upstream funding could facilitate data collection on key indicators of surgical care development, while downstream funding provides resources for the implementation and integration of the 44 essential surgical procedures identified by the World Bank.

To make universal access to essential surgery a reality, the authors said, surgeons must champion the cause by leading national surgical planning projects, collecting evidence of the efficacy and feasibility of surgery, testing models for deploying surgical capacity in a variety of low-resource settings and pushing for including metrics of surgical capacity in indices of health and national development. They must also encourage the big global health and international development agencies to assume leadership roles in funding and prioritizing surgery in strategic planning and policy to achieve the UN Sustainable Development Goals.

“Ultimately, these efforts will not be successful without the active participation of these four agencies,” Meara said.

The first authors of the four pieces in the special Surgery series were Paul Farmer Global Surgery Fellows in the HMS Department of Global Health and Social Medicine.

David Ljungman, a consulting colorectal surgeon and surgical oncologist at Sahlgrenska University Hospital, Gothenburg, Sweden, was first author of World Health Organization: Leading surgical care toward sustainable development in the era of globalization. Co-authors include Emmanuel Makasa of the Ministry of Foreign Affairs in Lusaka, Zambia, and the School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa, and Robert Marten of the London School of Hygiene and Tropical Medicine, London, England.

Alexander Peters, general surgery resident in the Department of Surgery, Weill Cornell Medical Center, was first author of The World Bank Group: Innovative financing for health and opportunities for global surgery. Co-author Emi Suzuki is a demographer in the Development Data Group at the World Bank.

Rachel Koch, a resident physician in the surgery department at Vanderbilt University Medical Center, was first author of The Bill & Melinda Gates Foundation: An opportunity to lead innovation in global surgery. Co-author Monica Kerrigan, vice president for innovation at Jhpiego is the former deputy director of family planning at the Gates Foundation.

Kristin Sonderman, clinical fellow in surgery, Brigham and Women’s Hospital, was first author of USAID: Current support for global surgery and implications of reform. Co-authors include Tiaji Salaam-Blyther of the Congressional Research Service, Washington, D.C., and Lauri Romanzi, a gynecologic surgeon and global women’s health activist in New York.

John Meara receives funding from the GE Foundation.