Surgery,obstetrics and anaesthesia: a Cambrian explosion for global health

Introduction

This was originally presented as one of the President's Leadership Lectures for the Royal College of Physicians and Surgeons of Glasgow, entitled “Cambrian Evolution in Global Health: Global Surgery, Obstetrics, Anaesthesia” by Dr. John Meara on June 5, 2018, as part of a series on Leadership and Action in Global Health. Global health, security and economic development are dependent upon the health of people of all nations. SARS and Ebola taught us that weak health systems anywhere jeopardise people everywhere; our world will never achieve pandemic preparedness by preparing for pandemics. Health system strength is the only purveyor of true health security. Our current global health structure has not yet evolved to do what the world needs of it. Despite significant advances in some areas of public health over the past few decades – overwhelmingly led by vertical, single disease efforts – disparities in health have worsened in many areas. The poorest billion on our planet bear a disproportionate share of the world’s disease burden, increasingly so for non-communicable diseases like cancer, trauma and diabetes. Global health governance mechanisms like the World Health Organization (WHO) are structured around vertical silos, limited in scope to one disease or aspect of care. Cross-programme collaboration and fundraising are possible but difficult in this environment, and big-name funders like the Bill & Melinda Gates Foundation have traditionally awarded large grants to disease-specific projects rather than cross-cutting endeavours. Effective communication is rare between care providers, governments, funders and stakeholders, creating a Tower of Babel effect in public health at every level.

This immature global health structure cannot effectively implement international development goals such as the Sustainable Development Goals (SDGs), the United Nations’ 17 overarching goals to address broad economic and social issues. Good health and well-being for all, Goal 3 of the SDGs, includes universal health coverage as a separate target (target 3.8). Such broad issues require not only collaboration across governments and multilateral organisations, but more importantly a resilient and cohesive global health structure. While individually effective programmes can blossom in this structure, maintaining a cohesive trajectory and holistic backbone becomes increasingly difficult. Each organisation and program is addressing one small aspect of health and disease – not global health as a whole – such that we are each blindfolded and identifying a different ‘part’ of the ‘elephant’ that is global health.

The solution requires a rapid evolution of the present health system conceptualisation. We must grow beyond the narrow vertical health fetishes that dominated the last half century – in funding, implementation and research – towards a holistic, horizontal paradigm on a firm foundation of surgery, obstetrics and anaesthesia as an indivisible, indispensable part of healthcare. As the Cambrian period brought skeletal infrastructure to life on our planet with vertebrates, allowing life to take on new capabilities never before witnessed on earth, so will surgery, obstetrics and anaesthesia provide the much needed healthcare delivery infrastructure that will allow this increasingly attractive concept of health system strengthening to take global healthcare along a new path. This daunting task is impossible with a piecemeal, vertical, single disease approach to human health.

Current systems are poorly aligned across domains, with fragmentation evident at the national and global scales in the form of significant disparities in care and funding. Surgery, anaesthesia and obstetrics are at the heart of every health system – and yet surgical diseases receive no substantial global funding, compared to HIV/AIDS, TB and malaria which have US$5 billion in combined global funding. Surgery, anaesthesia and obstetrics represent the most cross-cutting domains in healthcare. They are synergistic, but also require resilient partners in medicine, primary care and emergency and pre-hospital services, as well as allied services including pathology, blood banks, rehabilitation, and nursing, among others. A health system cannot be strong without these domains, nor can surgery, obstetrics and anaesthesia provide safe, timely and affordable care without the context of a strong health system. These three domains form the core foundation upon which the whole of global health is built and serve as the skeletal structure and indicator of robust health systems.

Scaling up surgical, obstetric and anaesthesia (SOA) care must be driven partly at the national level by governments and key stakeholders, such as professional societies, as each health system will require individualised solutions based on local needs. This SOA backbone has gained recognition as a critical component of universal health coverage and global health structure recently, centred around four main documents. In 2015, Volume 1 of Disease Control Priorities 3rd edition was dedicated to essential surgeries and its benefits. This panel called attention to the inequalities in surgical care that are a symptom of the fragmentation of global health structure, a missing holistic approach to health systems. The Lancet Commission on Global Surgery also launched their formal report that same year. Findings from the Commission demonstrated how severely the global health community had underestimated the burden of surgical diseases: five billion people do not have safe, timely and affordable access to surgery and anaesthesia. An estimated 17 million deaths could be prevented annually by strengthened surgical care, and nearly US$12.5 trillion of economic welfare could be lost in low- and middle income countries (LMICs) between 2015 and 2030 due to untreated surgical diseases. SOA system indicators were also advanced as markers to track progress in surgical system strengthening, including workforce, post-operative mortality, surgical volume, economic burden of care for patients and timely access to care. Data must not only reflect the health of a system in real-time but also be practical so as to allow providers and governments to scale and fine-tune their SOA and overall health delivery systems.

The 68th World Health Assembly – the annual global health policy meeting of the World Health Organization’s Member States – followed these two documents in 2015 and resulted in the unanimous approval of Resolution 68.15, which recognised ‘Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage’. This resolution urged Member States and WHO to allocate resources to strengthening efforts in light of the global surgical burden and to report back progress on a biennial schedule mandated by a follow-up Decision Point 70.22. Almost immediately, countries responded to the call by creating national surgical, obstetric and anaesthesia plans (NSOAPs) as part of their overall national health strategic plans working toward universal health coverage.

These NSOAPs are context-specific, tailored solutions for strengthening SOA care systems in nations – especially LMICs that are disproportionately affected by inadequate healthcare. Several countries in Africa have already published their NSOAP, such as Senegal, Ethiopia, Zambia, and Tanzania, and are in the process of implementing their plans. Plans must be refined iteratively with real-time data used for evaluation during implementation to avoid creating or worsening rifts within the national health structures of these countries; ultimately, these new surgical indicators must be transparently published for independent accountability. Baseline national SOA capacity assessments should also be reported in order to better target national and regional gaps in coverage. Strengthening the SOA infrastructure of healthcare systems with a consistent national strategic approach will translate to a more cohesive global health structure through more cross-border opportunities for synergy and shared experiences – the economies of scale and scope using SOA strengthening are profound. Global citizens of all nations and economies must work together towards this goal.

However, surgical care requires funding for the effective implementation of NSOAPs as a holistic systems approach to achieving health equity and social justice. While governments must allocate funding to strengthening their nation’s SOA backbone, additional external funding must be linked to progress in SOA indicators. Such SOA indicators derived from data-driven external funding and through improved population health and economic output are important motivators for ministries of health, and private sector investors in the healthcare delivery. With such political and financial support, global health will finally be able to stand upright.

It is time for a second Cambrian explosion – this time in global health – 541 million years after the initial event that produced a period of incredibly rapid diversification of organisms, an ‘explosion’ in the variety of life. Vertebrates were one of the subphyla that came about during this Cambrian explosion, and remain one of the most diverse and dynamic forms of life. With their cross-cutting nature, surgical, anaesthesia and obstetric care now represent the modern skeletal infrastructure of global health. Given the severity of its burden and budding prominence on the global agenda, SOA care is a platform for driving the rapid expansion of strong healthcare systems. We stand at the brink of the integration of this SOA ‘vertebral structure’ into health system strengthening, allowing global health to stand and support all sectors of healthcare delivery as an equal partner in health. The vertebrate skeleton that is SOA care provides resilience and permanence for health security and pandemic preparedness, non-communicable disease, infectious disease, reproductive, maternal, newborn and child health and more. Simultaneously, this SOA backbone allows nations to stand and form fully functional horizontal health systems that will lead to universal health coverage and realisation of the SDGs.