This article originally appeared on NextBillion.
By Ashley Eberhart and Faaria Volinski
Each year, 1.5 million lives are lost in low- and middle-income countries because patients do not have access to essential surgical procedures. For those actually able to access surgical care, 48 million are impoverished yearly by the direct costs.
Photo courtesy of the GE Foundation
Last year at the first meeting of the Lancet Commission on Global Surgery, World Bank President Dr. Jim Yong Kim stressed that “surgery is an indivisible, indispensable part of health care.” However, safe surgery remains a great need. Health facilities lack infrastructure, equipment, people, processes, and measurement and feedback systems, and the economic consequences are startling: If existing access to surgery remains unchanged, low- and middle-income countries will lose $12.3 trillion by 2030. Lack of access, both physical and financial, to safe surgery is a burden for individuals, communities and countries alike.
Building Leadership for Safe Surgery
Recently, GE Foundation launched Safe Surgery 2020, a $25 million initiative that aims to accelerate access to safe surgery and anesthesia worldwide over the next five years. “By addressing the surgical ecosystem, we aim to impact the greater health care delivery system,” said GE Foundation President Deborah Elam at the launch event. GE Foundation is not alone in pushing for safe surgery to take a higher priority on the global agenda; John Meara and Mark Shrime of Harvard Medical School recently wrote in a New York Times op-ed, “Improve a surgical system, and you improve the very things that are necessary for the delivery of health care in general.”
Based on three main pillars – leadership development, innovation and elevating ideas – Safe Surgery 2020 is rooted in the idea that safe surgery champions in operating rooms, hospitals and at national levels have the potential to drive cost-effective, systemic change. For example, training a doctor to empower other members of the care team to report and act upon clinical observations, or encouraging a hospital director to increase transparency in measurement and feedback mechanisms, can greatly improve surgical outcomes.
In practice, the initiative will provide a variety of support mechanisms, which may include face-to-face leadership training, on-the-job mentorship, and a diagnostic tool to help leaders assess the baseline quality and safety of their facilities and identify areas for improvement. In addition, a facility toolkit will be made available to provide targeted support to leaders based on their needs.
According to Dr. Harshad Sanghvi of Jhpiego, “Leadership is critical to overcoming a demotivated health care system. And it’s not just surgeons or anesthesiologists who will make the change – 70 percent of surgical need can be met by non-surgeons.”
Harnessing the Capabilities of Non-Surgeon Health Workers
The idea that leadership in a clinic is not limited to surgeons points to task sharing to the great number of other health workers, including nurses, technicians, community health workers and others. Take glaucoma: Close to 600,000 Ethiopians require surgery to prevent blindness from advanced glaucoma, and a trained nurse is fully capable of administering the needed surgeries in rural areas when surgeons are unavailable.
Ethiopia will in fact be the first to work with GE to implement the Safe Surgery 2020 initiative. According to Dr. Kesetebirhan Admasu, Ethiopia’s minister of health, the country has an ambitious goal to make safe surgery accessible within two hours’ walking distance from every Ethiopian home. This will require getting 500 new hospitals up and running in the next five years. Rural residents will pay a premium of $10 per year for access to health care services, while those below the poverty line will be covered financially by their local government. Task sharing will be a crucial component to making this happen.
Though task sharing has proven to be very successful, concerns remain. What is the career path for a nurse trained to perform C-sections in the absence of doctor or surgeon qualifications? As legal systems change, how can support-level health workers be protected, especially if they are administering surgeries on their own? Governance will need to keep up as task sharing increases, and improvements in higher levels of care need to remain top-of-mind. As Sanghvi stressed, “We do have to keep training everyone. The demand for surgeons is growing, especially as people have more and more disposable income and are demanding quality services.” The definition of a surgeon must change. It is imperative that non-physicians can also serve as surgeons.
Making Safe Surgery Context-Appropriate
Another challenge is ensuring that approaches to safe surgery are custom-built for the environment at hand. Infrastructure and equipment needs vary widely by country, state and even facility, which is often highly dependent on existing government involvement. One facility might have trouble finding biomedical technicians to repair equipment, while another nearby might find the same equipment unusable without consistent access to electricity. One hospital might have multiple surgeons, but no anesthetist with the qualifications to manage complex cases, while another might have no surgeons at all.
Partnership is key to fostering leadership and enabling surgeons, anesthesiologists and nurses to deliver safe surgery with the manpower, equipment and infrastructure they have available. This includes both hospital-to-hospital partnerships to share learnings and experiences, as well as partnerships with government and the private sector to ensure legal regulations and fund support leaders to build safe surgery ecosystems.
Safe Surgery 2020 is a promising start to foster the leadership development required to improve the success rate of surgeries in low- and middle-income countries. “Transforming surgical safety will require a multi-sectoral effort,” said Elam. “We are proud to launch this initiative, but we realize that we simply can’t do it alone. Safe Surgery 2020 must be part of a broader, global effort to put surgery on the agenda.”