In recent years the case for investment in global surgery and surgical infrastructure in low- and middle-income countries (LMICs) has been made repeatedly and convincingly. The Lancet Commission on Global Surgery signaled the important role global surgery has to play in global health, and highlighted the fact that, even though surgically treatable conditions make up a significant portion of the global burden of disease, more than half of the world’s population still lacks access to safe, affordable surgical and anesthesia care. For context, that is three times the global disease burden of HIV/AIDS, malaria and tuberculosis combined.
That is why it is welcome news that the State and Foreign Operations appropriations bill for FY22, currently under consideration in the U.S. Congress, includes language which specifically calls for the U.S. Agency for International Development (USAID) to “support efforts to strengthen surgical health capacity” to address neglected surgical conditions in LMICs. These conditions include cleft lip and cleft palate, club foot, cataracts, hernias, fistulas, untreated traumatic injuries, and many others. Increasingly, improving access to surgical care is understood to be an indispensable part of health systems strengthening, as well as a critical step in achieving the Sustainable Development Goals agreed by all UN member states. However, the question remains; what is the best way to improve access to surgical care?
Historically, a common approach has been to conduct short-term surgical missions, where teams from high-income countries travel to LMICs to provide surgical care, typically performing a large number of surgeries in a short period of time. While these missions are usually carried out with the best intentions, and do provide direct care to many patients in under-served areas of the world, they have faced some criticism on a number of fronts. Visiting surgeons perform a high number of surgeries, but there are many factors that go into achieving a successful clinical outcome. It is easy to get excited about doing 100 surgeries in a week, but there are still concerns. For example, what about post-operative follow-up? Surgeons perform operations relatively quickly, but healing takes time – when a surgeon leaves after a week of surgery, how confident is she that her patients will have access to nurses trained for wound-care? Will the nurses have the materials and resources they need? What about post-operative complications? What if the patient requires another procedure, but all the visiting surgeons are gone?
In spite of these concerns, there is evidence that such short-term missions can achieve good clinical outcomes with low morbidity, mortality and rates of surgical complications, especially with careful patient selection and by avoiding more complex cases. Still, the “fly-in” approach is best seen as a part of one-time disaster response, necessarily limited in scope and scale. It is not the best option for long-term health systems strengthening or improving access to surgical care in a sustainable way. Many participants in short-term surgical missions have themselves noted that a greater emphasis on training and capacity-building is needed in order to ensure better integration with local health care systems. Staff members at local hospitals have also recognized that hosting visiting surgical staff can be very beneficial, but not uncomplicated.
Another, more sustainable approach has been to invest in local specialty surgical centers, or centers of excellence, that typically treat patients with more complex conditions and provide training to local surgical teams, including pediatricians, nurses, anesthesiologists, and therapists. These centers have a permanent presence, are staffed primarily by local health care clinicians, and have the clinical, facility, and equipment infrastructures to handle surgical complications and provide comprehensive follow-up care. This is important, as many surgically treatable conditions require multiple interventions and have specialized preoperative and postoperative needs, such as nutrition and speech therapy for cleft lip/palate procedures or physical therapy and assistive devices for orthopedic procedures. Many patients also need counseling, psychosocial support, economic aid and social reintegration that these specialized centers are better equipped to provide and which are vital to a successful clinical outcome. Additionally, research suggests that, in many ways, these centers are more cost effective and more sustainable than short-term surgical missions, and produce better clinical outcomes for complex cases. They also contribute to the local economy in a way that short-term missions do not (many of which spend a large portion of their budget on travel and lodging expenses for the visiting teams). The specialized surgical centers are also typically well-integrated into the local health care landscape and provide critically needed specialized training, which is often not available elsewhere in the country. As the discussion in global surgery has moved away from a narrow focus on the direct provision of care and towards a broader, more strategic focus on scaling up and building sustainable surgical infrastructure, this approach has gained traction.
It is also worth noting that the specialized surgical centers are “pandemic-proof” in a way that the short-term missions have proven not to be. While many short-term missions were cancelled due to travel restrictions during the COVID-19 pandemic, local centers around the world have been able to continue providing care to their patients. This is not to say that short-term surgical missions do not have an important role to play in training, sharing resources, and providing some direct care. Indeed, with so many patients around the world lacking access to surgical care, these missions are a critical stop-gap. Still, the pandemic has highlighted the urgent need to improve access to surgical care in a sustainable way, with an emphasis on training and capacity-building for local surgical providers.
The move towards a more strategic, systems-wide approach to improving surgical systems and access to surgical care is clearly seen in the push to encourage LMICs to develop National Surgical, Obstetric and Anesthesia Plans (NSOAPs). NSOAPs are specifically mentioned in the State and Foreign Operations appropriations bill language, and they directly support the achievement of all three Outcome Goals of USAID’s new Vision for Health Systems Strengthening 2030 – Equity, Quality and Resource Utilization. That is why it is crucial for a specific dollar amount to be appropriated for the strengthening of surgical systems through the State Foreign and Operations bill. This would allow USAID to support the provision of much needed care to patients, but also the long-term up-scaling of local surgical capacity, which will help patients today but also have a real impact on the health infrastructure and sustainable development of LMICs in the future.
Joshua Korn is the Director of the Grants Acquisition and Management Office for CURE International. Previously he served as the Executive Director of the CURE International hospital in Niger, West Africa. Natalie Meyers is the Director of Global Advocacy & Africa Programs at ReSurge International. She has extensive international experience, including holding a previous post as a Presidential Management Fellow at USAID serving in both D.C. and at the U.S. Embassy in Tanzania.