Full document - International Hospital Federation

Innovation and clinical specialities: surgery
Population based surgery in low
and middle income countries
ARTICLE BY DAVID A SPIEGEL MD, AND RICHARD GOSSELIN MD, MPH
Division of Orthopaedic Surgery, Childrens Hospital of Philadelphia, University of Pennsylvania School of Medicine,
& University of California at Berkeley School of Public Health
ADAM KUSHNER MD, MPH
Department of Surgery, Columbia University
AND STEPHEN BICKLER MD
Division of Pediatric Surgery, University of California at San Diego
The burden of surgical diseases is large and is increasing, and there are enormous gaps in access to surgery
between high and low income countries. Surgical services may be cost effective at the district level in LMICs,
and providing access to essential surgery should be viewed as “primary prevention” of death and disability.
The integration of essential surgical services into health systems, within the context of primary healthcare
reforms, will surely improve population health.
The world’s burden of surgical diseases is increasing, and
considerable morbidity and mortality may be averted by
providing access to safe and timely surgical care for injuries,
acute abdominal conditions, complications of pregnancy, and
many other diagnoses. 1-12 Injuries, especially due to road traffic
crashes, have been recognized as emerging global public health
concern. 1,2,7-9,11-17 For each death, many more individuals are left
with a permanent disability. Although more than 230 million
surgical procedures are estimated to be performed in the world
each year, there are enormous gaps in access to surgical services
both between and within countries 18 . Only 3.5% of major surgical
procedures are performed in countries ranked in the lowest third
in per capita health expenditure 18 . Surgery has been neglected as
a population-based health strategy in low and middle income
countries (LMICs), despite evidence to suggest that surgical
conditions account for approximately 11% of the world’s disease
burden 1 and basic surgical services may be cost effective even at
the district level in LMICs 19-22 .
The question is not whether universal access to “essential”
surgical (including orthopaedics and anaesthesia) services would
improve population-based health care in LMIC’s, but rather how
this may be achieved. There has been a resurgence of interest in
primary health care 23 as a means to strengthen health systems,
and integration of essential surgery and anaesthesia within the
context of primary healthcare reforms will undoubtedly improve
population health. While recognizing that modern surgical services
are usually available at a limited number of tertiary facilities in
LMICs, there is a great need to provide access for the majority of
the population, who reside in rural communities and are serviced
by a district hospital or equivalent. This process will require a
multidisciplinary, multisectoral effort, under the leadership of
governments and their ministries of health.
Barriers to the delivery of surgical and anaesthetic services
Barriers to the delivery of safe and timely surgery and anaesthesia
include deficiencies in capacity (infrastructure, physical resources,
human resources) and quality (training and experience of
caregivers). While recognizing the positive contributions from nongovernmental
organizations and others in delivering surgical
services, these vertical initiatives have often contributed to
fragmentation within the health system, and may also foster
complacency among health planners leading to inadequate
resource allocation. In addition, the misperception that surgery is
a high cost treatment benefitting only a limited segment of the
population must be reversed if adequate resources are to be made
available to support a functional district level surgical service.
While considerable attention has been directed to addressing
the global human resource crisis, there has been little mention of
deficiencies in capacity of the health system to deliver surgical
services, especially at the district level in LMICs 24,25 . Providing the
capacity for facilities based services, including anaesthesia and
surgery, is obviously more complex than many other health
services such as immunizations, family planning, etc. Using the
WHO’s surgical situational analysis questionnaire, significant
deficiencies in capacity in Sierra Leone were identified, including
shortages of water, electricity, supplies, and trained health
workers 24 . Patients often had to purchase medical supplies prior to
receiving treatment 24 . Kushner et al studied 132 district health
facilities in 8 LMICs, and also identified significant shortfalls in
infrastructure, physical resources, and in the procedures
performed 25 . While incision and drainage of abscesses was
performed at 73%, only 44% could perform a caeserian section.
Only 33% of facilities treated open fractures, and 43% managed
cases of osteomyelitis. Only 13% would treat a clubfoot.
The capacity to deliver orthopaedic surgery is even more
challenging, given the plethora of technological advancements
from high income countries, which are resource intensive and
costly. While attempting to transfer these technologies is
unrealistic at the population level, we suggest that the majority of
essential orthopaedic surgical procedures may be carried out at
the district hospital, relying upon time honored methods of
treatment and only the most basic equipment/implants, for
112 Hospital and Healthcare Innovation Book 2009/2010