What is ‘global surgery’? Defining the multidisciplinary interface between surgery, anaesthesia and public health

Introduction

Surgery has famously been described as the ‘neglected stepchild of global health’ and one of the ‘Cinderellas of the global health agenda’.1 2 Anaesthesia has fared even worse, described as the ‘invisible friend’ of the neglected stepchild.3 As far back as 1980, the then WHO Director-General, Dr Halfdan Mahler, highlighted that ‘the vast majority of the world’s population has no access whatsoever to skilled surgical care and little is being done to find a solution’.4 Surgical care is typically considered as too complex, too expensive or having too limited a role to play in treating the global burden of disease.5

However, growing data now highlight the underappreciated volume of global surgical disease, profound variations in the delivery of surgery globally and cost effectiveness of surgical treatments. Taken together, these have resulted in increasing recognition of the need for affordable access to timely, safe and high quality surgery and anaesthesia services as essential components of a functional health system.6 New priorities within healthcare policy are now recognising this, challenging these assumptions regarding the relevance and affordability of surgery and anaesthesia in under-resourced health systems.7

The evolving interface between surgery, anaesthesia, public health and global health has been the result of numerous academic and policy stimuli, most notably the Lancet Commission on Global Surgery,8 as well as the increasing global burden of non-communicable diseases, many of which necessitate surgical management.9 Increased awareness of the major global disparities surrounding the disease burden amenable to surgery and the provision of safe surgical care has led to a particular focus on low-income and middle-income countries (LMICs), areas with the greatest burden of surgical disease, yet often with the least capacity to manage it.

‘Global surgery’ is the term commonly adopted to describe this rapidly developing multidisciplinary field, concerning the improved and equitable surgical care across international health systems, often with an explicit focus on LMICs. However, this is an emerging terminology with variable definitions, unsurprising, given that the broader concept of ‘global health’ has been variously described as ‘a metaphor, a conceptual framing, a set of legal norms, and as a distinct field of practice’.10

We define global surgery and anaesthesia as the enterprise of providing improved and equitable surgical care to the world’s population, with its core tenets as the issues of need, access and quality (figure 1). This definition intentionally frames surgery and anaesthesia as a composite entity, in recognition of the interdependence of these two specialities, but without excluding other aspects of perioperative care and wider specialisms supporting this. Despite a clear recognition of the multidisciplinary nature of global surgery in its early definitions, the single-specialty global surgery moniker fails to represent the breadth of the professional community engaged in this work. We also see value in framing the issues around need, access and quality, rather than the means (study, research, practice and advocacy) by which they are often addressed.

This review updates and quantifies the current evidence underlying the core principles supporting this definition of global surgery, demonstrating that the emerging body of work is distinguished by a breadth of approaches with a commonality of core issues. Furthermore, we aim to show that global surgery and anaesthesia are not led by any given clinical specialty, but instead have the patient requiring surgery as their focus. It is as much the responsibility of the policy maker and the public health researcher, as it is of the operating clinician.

Need, access and quality

Role of national and international bodies

The principal responsibility for populations suffering from surgically treatable diseases lies with their respective governments. The World Health Assembly in 2015 unanimously passed resolution 68.15, calling for its members to recognise this care as a critical and integral component of universal health coverage.80 Subsequent work towards developing and implementing new National Surgical Obstetric and Anaesthetic Plans (NSOAPs) demonstrates the response to this call.81 These support surgical system strengthening through a three-step process, consisting of a national baseline assessment, facility assessments and national planning, which is fully integrated into a country’s national health strategy.82 Zambia was the first country to complete this,83 and a total of five countries have now launched their NSOAPs, with over 20 countries having committed to initiating similar processes.84 85

International professional bodies, such as the College of Surgeons of East, Central and Southern Africa and the College of Anaesthesiologists for East Central and Southern Africa, are also working to champion increased standards, enhanced training and improved professional regulation of specialist medical practitioners. This is supported by a constellation of political, academic and charitable organisations operating at the policy level, including the WHO Global Initiative for Emergency and Essential Surgical Care.

Central to these national and international approaches is the recognition that surgical care represents an ‘indivisible, indispensable part of health care and of progress towards universal health coverage’.86 The care of the patient with a surgically treatable condition requires more than an isolated surgeon in an operating room; the surgical system reaches from prehospital care through to rehabilitation and, even within the hospital environment, relies on the emergency department, anaesthesia, critical care, radiology and pathology services. This multifaceted relationship both underpins the value of surgery in healthcare system strengthening and explains the complexity in driving improvement.

However this concept, clearly articulated in the Lancet Commission, may not survive contact with reality. Although system strengthening is commonly namechecked, the use of established systems methodologies and approaches are largely lacking in the global surgery and anaesthesia literature. This may help explain why advocacy for surgical care is often so difficult. Rather than the clean narrative of pathology-specific vertical interventions with easily measurable end points, improving surgical care necessitates a more nuanced understanding of horizontal system strengthening and an appreciation that focussing on overall mortality and morbidity might mask genuine improvements in specific areas that are still insufficient to affect the overall clinical trajectory at a population level. National and international bodies will need to embrace new ways of thinking if they are to grasp the nettle of improving surgical care on a population basis.

Volunteering and charitable support

A wide array of charities and non-governmental organisations are involved in the global effort to improve surgical services. These vary in their approach, including those providing practice guidelines and standards, such as the World Federation of Societies of Anaesthesiologists (www.wfsahq.org), groups providing training and essential equipment, such as the Lifebox Foundation (www.lifebox.org),87 and volunteer clinical staff organisations, such as VSO (www.vsointernational.org).

Agencies often have discrete objectives or a particular area of focus, and some work exclusively in particular countries or even single hospitals. Those that have developed long-term partnerships between institutions are typically the most sustainable in their impact, although these require a high level of support to remain effective. International programmes are able to work through these partnerships to provide specific and targeted training and equipment.88

The funding support for surgical care in LMICs is poorly understood.89 Between 2008 and 2013, around $27 billion was provided by charitable organisations towards global health, of which around 12% was towards surgery.90 Most of these charitable contributions are often focused towards elective procedures and are not fully aligned with global surgical care requirements.89 90 Moreover, while temporary missions are the most common platform by which charitable surgical care is delivered,91 the benefit is often limited and is seen as an imperfect solution to countries’ unmet surgical needs.91 92 Quantification of financial support and the development of long-standing bidirectional partnerships should be the mainstay of every charitable support mission.93

The provision of surgical services is significantly hindered by the lack of essential surgical supplies and equipment in low-resource settings. The WHO estimates that 95% of medical equipment in LMICs is imported and that 80% of it is funded by international donors or foreign governments.94 In the longer term, appropriate funding and supply chains for medical equipment need to be established. However, many charitable organisations have been set up to alleviate short-term needs by providing discarded clean and unused medical supplies from HIC hospitals.95–98 If run appropriately, such cost-effective needs-based donation could reduce waste and provide substantial benefits to recipient communities.99 However, while up to 70% of medical equipment in sub-Saharan Africa is donated,100 current estimates suggest that only 10%–30% of this becomes operational.101 102 While best-practice guidelines for donations of medical equipment and supplies exist, there is a need for greater adherence to these and in developing longer-term partnerships to work in closer collaboration with recipients.103

The role of volunteers in improving surgical care is complex, given the need for immediate surgical care but also for a sustainable contribution to improving local surgical provision. Criticism can be made of both approaches, with immediate care absolving local health providers from providing care for their populace, while long-term projects can fail to deliver the much-needed surgical intervention for current patients. In practice, a dual approach is required, although the scant funding available often means that charities are forced to operate in competition with each other.

Interest among HIC trainees wanting increased exposure to global surgery is high104–107; however, several barriers limit the development of any formalised training pathway, such as logistical and time constraints or limited funding opportunities.104 107 Such formalised training could, however, prove feasible within current training models108 and may even benefit home health organisations.109 Ensuring that institutional partnerships are developed is essential to allow for bidirectional international exchanges93; however, sustainability and high ethical standards must be ensured. With growing momentum behind the global surgery movement, a more formalised career pathway in global surgery and anaesthesia could come to fruition.

Future health policy and research in global surgery

The recognition of both surgery and anaesthesia as key areas in the global health debate is comparatively recent, and surgical conditions and treatments remain poorly recognised as a public health priority.110 Public health and infectious diseases have developed an evidence base to underpin future work, and while this remains in relative infancy for both surgery and anaesthesia, research studies in the field are now driving development of future interventional projects.25 26

In order to manage surgical health systems and to monitor their development, it is first necessary to establish meaningful and comparable baseline data on need, access and quality. Six standardised metrics for capturing health system dimensions of capacity, service delivery and outcomes were put forward by the Lancet Commission on Global Surgery: (1) 2-hour access to the three Bellwether procedures (caesarean delivery, emergency laparotomy and management of an open fracture); (2) surgeon, anaesthetist and obstetrician workforce >20 per 100 000; (3) surgical volume of 5000 procedures per 100 000; (4) reporting of perioperative mortality rates; (5) risk rates of catastrophic expenditure and (6) impoverishment when requiring surgery.8

Some of these have now been included among the WHO 100 Core Global Health Indicators, and four have since been published in the World Bank’s World Development Indicators. Unfortunately, none are yet collected routinely and reported to the WHO, with data collection frequently driven by professional associations and researchers rather than governments. A recent evaluation of these six global surgery metrics revealed that only one (workforce) had data from more than half of the WHO member states, and two (protection against catastrophic and impoverishing expenditure) had virtually no data collected.12

At present, the future model of surgical provision is not yet clear; whether funding should go into a few very high-quality centres with better transport links or through multiple centres to integrate surgery into a more familiar tiered model of expanded district hospitals remains undetermined.111 112 The role of new technologies to improve global health also remains uncertain but offers considerable potential, provided it is affordable, acceptable and adoptable.113

Traditionally, clinical academics have been slow to engage with and support the global surgery cause, although the importance of this field is now being recognised.114 In the UK, the National Institute for Health Research funds a number of research groups with an explicit focus on global surgery.115 116 As part of this, a recent international Delphi process has engaged LMIC clinicians, patients and expert methodologists to prioritise future research into areas of unmet clinical need for surgical patients in LMICs; this has led to the identification of three priority topics: access to surgery, outcomes of cancer surgery and perioperative care.117 The recent publication of a dedicated global surgery issue by the British Journal of Surgery reflects the growing academic recognition of this field,62 allowing for a revolutionary dynamic between HIC and LMIC researchers.

Global surgical collaboratives may be one effective means to facilitate and train local health workers to engage with such research and quality improvement endeavours,118 119 as at present, research from LMICs represents only about 4% of surgical literature.120 However, a genuine sense of collaboration can be achieved by encouraging locally driven and locally accessible research and quality improvement.121 This includes engaging local clinicians to lead on topics that may be rare or less relevant to high-income clinicians but are important in low-resource settings.122 Moreover, in addition to surgical disease-specific research, there is also a need to ensure global outcome comparisons by means of certain patient groups, such as children,61 surgical approach, such as laparoscopy,123 or operative intervention, such as anastomosis formation.124

Future directions for developing and implementing global surgery health policy is a topic of ongoing debate. The Lancet Commission on Global Surgery suggested that a broad array of ongoing research themes are required, including policy, quality and safety, training and education, partnership, information management and care delivery innovation and burden.6 For this to be delivered, there is a need for clinicians, the public health policy community and other stakeholders to agree on the specific surgical conditions and treatments warranting investment,125 ensuring an effective public positioning to attract suitable political support.126 Individuals and organisations from across the globe should work collectively and interprofessionally with HIC and LMIC partners working in equal contributions to build the surgical systems of the future.127

Conclusion

Global surgery and anaesthesia can be defined as the multidisciplinary enterprise of seeking to provide improved and equitable surgical care to the world’s population, based around the central pillars of need, access and quality (figure 1). This deliberately broad definition includes disadvantaged areas of otherwise wealthy countries as much as it does LMICs, and covers the spectrum of activities from primary research, through public health interventions and policy making, to direct improvements in clinical care. It does not focus on the events that occur in the operating theatre alone, or attribute ownership of either patients or their pathologies to a single clinical provider, but instead frames surgical care as an integrated pathway within a wider health system that requires multiple elements working in concert to deliver safe, timely and affordable care.

There remains a need to redefine global surgery and anaesthesia not by its tools or constituent specialisms but by its aims. Delineating need, access and quality into discrete entities is a useful device to structure discussion. In practice, however, they are heavily interdependent, and efforts at understanding and improving existing care will necessarily involve an element of each. Importantly, it must be a field that explicitly links all those engaged, from the upper echelons of the WHO to local rural providers delivering their clinical care.