Introduction
The world's burden of surgical diseases is large and increasing. Unfortunately, <5 % of all surgical procedures are performed in countries ranked within the lowest one-third in terms of per-capita health expenditures [1]. The unmet need for surgical care results in unacceptable morbidity/mortality rates associated with a host of conditions (trauma, pregnancy-related complications, other emergencies). This is especially true for rural and marginalized populations in low- and middle-income countries (LMICs). Recognizing that variations in the spectrum of surgical diseases are observed among and within countries, “essential” surgery and anesthesia may be viewed as a core group of services that can be delivered within the context of universal access. These high-priority interventions are those for which: (1) there is a large public health burden; (2) the treatment is highly successful; (3) the treatment is cost-effective [2].
To date, essential surgery and anesthesia have received minimal financial and political support as public health strategies because of the perception that the services are costly, are resource-intensive, require highly specialized training, and benefit only a fraction of the population relative to competing health interests. Evidence is amassing to refute these claims.
The World Health Organization (WHO) Global Initiative for Emergency and Essential Surgical Care (GIEESC) was launched in 2005. It is a global forum whose goal is to promote collaboration among a diverse group of stake-holders (individuals, institutions, societies, universities, ministries of health, other nongovernmental organizations) to strengthen the delivery of surgical services at the primary referral level in LMICs (http://www.who.int.surgery) [3–6]. The inaugural meeting was at WHO headquarters in Geneva, Switzerland in November 2005 [7], and subsequent biennial meetings were hosted by ministries of health in Dar es Salaam, Tanzania in September 2007) [8] and Ulaanbaatar, Mongolia in June 2009) [9]. There are currently more than 624 GIEESC members from 93 countries representing all six WHO regions. In all, 45 % of members are from LMICs. The LMICs with ≥10 GIEESC members are India, Nigeria, Ethiopia, Ghana, and Uganda.
The WHO GIEESC members have contributed to a number of activities aimed at strengthening the delivery of essential surgical services in LMICs. One component involved the implementation, local adaptation, and translation of training tools that were developed by the WHO's Emergency and Essential Surgical Care (EESC) project, which was initiated in the Clinical Procedures Unit of the Department of Essential Health Technologies in 2004 [3–6]. These training tools include the WHO Integrated Management of Emergency and Essential Surgical Care (IMSCStoolkit [10] and the Manual of Surgical Care at the District Hospital [11]. These materials have been introduced in 39 countries through collaborations with the respective Ministry of Health (MoH) and WHO country offices. The materials have been translated into Mongolian, Spanish, Chinese, Vietnamese, Korean, Dari, and Farsi.
A WHO situational analysis tool to assess the availability of EESC at the level of individual health facilities was developed in 2007. It was based on infrastructure, human resources, procedures, equipment, and supplies [12]. This questionnaire has now been utilized in more than 35 countries, and the data collected and entered in the WHO EESC Global Database has been published to highlight gross deficiencies in the availability of EESC [13–22]. The WHO EESC Global Database was created to facilitate data entry from different countries. The situational analysis tool has been integrated into the WHO's Service Availability Mapping (SAM) technology [23] with the goal of facilitating monitoring the availability of surgical services at the facilities level. This technology was introduced in Mongolia in 2009. Plans have been made to continue with a surgical module in the WHO's recent adaptation of facilities-based monitoring, Service Availability and Readiness Assessment (SARA). A planning tool was developed to assist policymakers integrate EESC into their national health plans.An online Global MedNet serves as a platform for online discussions and for posting announcements and materials related to GIEESC (http://www.who.int/ surgery/globalinitiative/en/).
Meeting Details
The 4th Meeting of the WHO GIEESC was convened at the University of California, San Diego School of Medicine (UCSD) on November 9, 2011. Close to 200 people from 20 countries were in attendance (Table 1). Overall goals for the meeting were to: (1) report progress and share future plans for LMICs during the next biennium; (2) build synergies with partners to promote the integration of EESC into primary health care, thereby strengthening health systems; (3) convene 10 committees to define priorities for carrying the GIEESC agenda forward (Table 2).
Table 1.
Attendees at the 4th meeting of the WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC)
| Countries in attendance | Country reports |
|
|---|---|---|
| Country | Activities | |
| Ghana | AFRO | |
| Nigeria | The Gambia | WHO tools incorporated into medical school curriculum |
| Solomon Islands | ||
| Philippines | Work toward incorporating EESC into national health plan | |
| Rwanda | ||
| Malawi | ||
| United Kingdom | ||
| United States | Gap analysis for EESC performed | |
| Canada | ||
| Ireland | ||
| Mozambique | ||
| Liberia | ||
| Switzerland | ||
| Mongolia | ||
| Ethiopia | ||
| Senegal | ||
| Zambia | ||
| Pakistan | ||
| Somalia | ||
| The Gambia | ||
| Zambia | Best-practice protocols implemented at primary referral facilities | |
| EESC elements incorporated into medical school curriculum | ||
| Incorporated EESC tools training into the new 2-year surgical training curriculum for general doctors | ||
| Ghana | Situational analysis (33 hospitals) | |
| EESC integrated into first referral hospitals | ||
| Mozambique | IMEESC used to train surgical technicians | |
| Tanzania | WHO/EESC collaborating center | |
| EESC in national health plan | ||
| Established surgical task force | ||
| Situational analysis completed | ||
| Training workshops with MoH at district hospitals | ||
| Kenya | IMEESC and SCDH distributed to district hospitals | |
| Situational analysis completed | ||
| Malawi | EESC has been incorporated into training for medical and surgical officers | |
| IMEESC toolkit available at all district hospitals | ||
| Situational analysis in progress | ||
| Masters training program being developed | ||
| Sierra Leone | Additional training in EESC planned | |
| Liberia | EESC integrated into training manuals for task shifting | |
| MoH has expressed support for EESC training programs | ||
| Sao Tome and Principe | Situational analysis in progress | |
| Nigeria | Situational analysis to be completed | |
| Uganda | EESC materials inserted into medical school curriculum | |
| Situational analysis in progress at district facilities | ||
| Mali | WHO tools, IMEESC, SCDH translated into French | |
| Cote d'Ivoire | Development of French version of EESC training materials | |
| EMRO | ||
| Afghanistan | Situational analysis performed and published | |
| WHO training materials being translated into Dari and Pashto | ||
| Training workshops held using WHO teaching materials | ||
| Pakistan | Situational analysis performed in 18 district hospitals | |
| EESC workshops planned | ||
| Pilot project involving King Edward Medical University and Foundation for Health Care Improvement to “uplift EESC” at six district hospitals | ||
| Somalia | Situational analysis in progress | |
| Development of primary surgical care package based on WHO teaching materials | ||
| Egypt | WHO–MoH workshop on EESC completed | |
| Oman | WHO–MoH facilitators meeting held | |
| Iran | Teaching materials being translated into Farsi | |
| EURO | ||
| Kyrgyzstan | Best practice protocols and equipment list being utilized | |
| Tajikistan | WHO–MoH workshop held using IMEESC toolkit | |
| Part of IMEESC toolkit translated into Russian | ||
| SCDH being translated into Russian | ||
| SEAR | ||
| Nepal | EESC introductory workshop held | |
| India | EESC workshops in Uttarakhand and Meghalaya | |
| Situational analysis in progress | ||
| Democratic Republic of North Korea | Teaching materials translated into Korean | |
| EESC training the trainers workshop held | ||
| Bangladesh | Situational analysis in progress | |
| Bhutan | ||
| Myanmar | Situational analysis completed, publication in process | |
| Maldives | EESC training workshop held with WHO–MoH | |
| Sri Lanka | Situational analysis completed and published | |
| Indonesia | National EESC training the trainers workshop held | |
| WPRO | ||
| Mongolia | EESC being scaled up; training completed for 187 doctors, 657 surgeons/anesthesiologists, 29 midwives, and 50 nurses | |
| Situational analysis completed and published | ||
| Number of surgical procedures has increased | ||
| Mortality and complications have been reduced following implementation of EESC training | ||
| Papua New Guinea | EESC workshop held | |
| EESC integrated into national health standards | ||
| IMEESC toolkit used to upgrade training manual for rural health workers | ||
| Solomon Islands | Plan to integrate EESC | |
| Vietnam | SCDH translated into Vietnamese | |
| China | EESC workshop held with WHO–MoH | |
| Translation of WHO teaching materials in progress | ||
| Philippines | National EESC “training the trainers” workshop held | |
| WHO teaching materials disseminated to all district hospitals | ||
| PAHO | ||
| Ecuador | Training tools translated into Spanish | |
| Guyana | EESC teaching materials utilized for basic surgical training | |
PAHO Pan-American Health Organization, WHO World Health Organization, EESC, Emergency and Essential Surgical Care, IMEESC Integrated Management for Emergency and Essential Surgical Care, SCDH Surgical Care at the District Hospital, MoH Ministry of Health
Table 2.
Ten committees appointed to define priorities to carry the GIEESC agenda forward
| Committee | Objectives | Action items |
|---|---|---|
| Organizational planning | Define GIEESC organizational structure, governance, monitoring | Develop terms of reference |
| Present and review draft terms of reference to established committees within 6 months | ||
| Each chairperson reports to the organizational planning committee | ||
| Report to WHO EESC annually | ||
| Coordinate GIEESC committees’ activities and report to the biennial WHO GIEESC meeting (2013) | ||
| Finance and resource mobilization | Ensure ongoing financial viability of GIEESC | Fund-raising to meet the $300,000 USD annual goal necessary to support the WHO GIEESC Secretariat |
| Identify and develop other sources of revenue to support GIEESC activities globally | ||
| Organize physician dues and contributions, with the committee to set voluntary contribution levels; develop a mechanism for collecting contributions | ||
| Engage academic institutions to leverage GIEESC serving as a clearing house for research and volunteer activities such as Health Volunteers Overseas | ||
| Leverage with other campaigns and identification of synergies (e.g., Decade of Road Safety) | ||
| Engage foundations and institutions with a consistent outreach and marketing effort with a potential consortium of manufacturers | ||
| Work with other committees for strategic planning and required budgets for program building | ||
| Education and training | Promote educational and training activities of GIEESC | Update WHO IMEESC toolkit and WHO manual SCDH in compliance with WHO guideline review |
| Adaptation of WHO tools to meet local needs (e.g., translations, develop primary surgical care packages) | ||
| Standard training curriculum and training course based on the WHO IMEESC toolkit to be developed and adapted to meet LMICs’ needs | ||
| Burden of surgical diseases | Generate evidence from GIEESC community to quantify the burden of surgical diseases | Facilitate existing burden of surgical disease assessment with EESC global database and research activities of GIEESC members (efficacy/effectiveness, potential complications of treatment, cost-effective analyses) |
| Develop synergy with disease control priorities for developing countries network | ||
| Surgical mission and partnerships | Coordinate global surgical activities and partnerships of WHO GIEESC members | Update online directory/database in WHO GIEESC MedNet |
| Support requests from WHO country offices, MoH, and health facilities in LMICs | ||
| Develop database of WHO GIEESC members’ activities to identify synergies and maximize utilization of organizational resources (catalog GIEESC member activities, track needs of LMICs, prepare calendar of active and future projects) | ||
| EESC as part of health systems strengthening | Promote integration of EESC services into primary health care and health systems | Develop set of indicators for surgical care within the WHO health systems framework |
| Increase collaborative activities with relevant WHO departments | ||
| Survey LMICs’ health plans on the integration of surgical care into primary health systems | ||
| Anesthesia and health systems strengthening | Promote and generate evidence for anesthesia services as part of the primary health care package | Advocate for anesthesia as an essential component of EESC |
| Promote locally driven assistance in anesthesia education | ||
| Develop minimum WHO anesthesia guidelines | ||
| Incorporate minimum requirements for physical resources utlizing IMEESC toolkit | ||
| Update anesthetics in the WHO essential medicines list | ||
| Incorporate WHO standards including into education and training activities | ||
| Pilot local anesthesia education initiatives in five LMICs | ||
| Support appropriate training for providers | ||
| Research and publications | Identify research priorities Promote generation of scientific evidence and publications | Establish a coordinating body |
| Develop guidelines for accessing WHO EESC global database | ||
| Develop a section of the website to list current and future research projects | ||
| Prioritize areas of research | ||
| Update situational analysis tool | ||
| Technology and technology transfer | Support technology and technology transfer needs in LMICs | Monitor technology development through MedNet |
| Develop a strategy for continued assessment and enhancement of GIEESC web presence | ||
| Support technology transfer activities to enhance global surgical education, training, and research | ||
| Advocate for educational outreach regarding existence of new technologies | ||
| Create database/searchable website on technology linked with MedNet and the main GIEESC website | ||
| Advocate for low-cost pricing for technologies | ||
| Appropriate training of any introduced new technologies | ||
| Summarize studies and trials on the ground on transfer of new technologies | ||
| Support technology transfer for training/education initiatives | ||
| Develop an online clearing house of available online curricula (content), courses for anesthesia and surgical care (district level) | ||
| Develop curriculum/course provided free or at low cost for LMICs (e.g., of existing WHO IMEESC toolkit) | ||
| Promote translation of tools into local languages | ||
| Develop partnerships with training institutions and hospitals for transfer of technologies (e.g., telemedicine) | ||
| Advocacy | Advocate for the importance of delivery of emergency and essential surgical care (EESC) locally, nationally, and internationally | Define objectives (EESC, disaster management) |
| Raise public awareness of preventative and curative aspects of surgical care | ||
| Identify partners to promote EESC (institutions, health authorities, parliaments, societies, NGOs, foundations, and civil society) at the international, national, and local levels | ||
| Identify specific advocacy tools | ||
| Act as a liaison between working groups and the public |
LMICs low and middle income countries, NGOs nongovernmental organizations
Representatives from 15 LMIC's participating in the WHO EESC program presented the challenges, progress, and future plans for implementing EESC in their countries. The information gathered on an additional 14 countries is summarized in Table 1. The challenges faced by this cohort were uniform and focused on the availability of services (infrastructure, physical and human resources). Difficult terrain and problems with transportation were cited as a challenge in several countries (e.g., Nepal, Pakistan, Somalia, Tanzania, Mongolia). Lack of trained caregivers was universally observed, as was the difficulty of retaining them after they were trained often because of insufficient remuneration and/or ill-equipped health facilities.
Implementation and scaling up of EESC activities has varied among countries. The teaching materials have been integrated into various curricula for medical students, doctors, nurses, and other health professionals. The latter include rural clinical health officers, surgical technicians, and doctors, health officers (Ethiopia), clinical officers (Malawi), medical school students (Uganda), medical graduates (Liberia), and surgical technicians (Mozambique). The 2 year degree program for doctors in surgery developed by the College of Surgeons in East, Central, and Southern Africa included the EESC teaching materials as well. The WHO Integrated Management for Emergency and Essential Surgical Care (IMEESC) programs and surgical care at the district hospital (SCDH) have also been utilized in primary health facilities in EESC countries. With regard to future plans, most of the countries focused on defining deficiencies in availability with the WHO's situational analysis tool, providing greater opportunities for EESC training by integrating these materials into existing curricula for different types of health providers, and conducting more training workshops.
After the presentations my the various countries, committees were assembled (Table 2) and were asked to reach consensus on priorities to define a road map for GIEESC over the next biennium. The activities of these committees include research (disease burden, service availability, outcomes of training initiatives, designing surgical metrics, refining data collection tools), developing and refining IMEESC tools, supporting training activities, developing low-cost technologies, finding avenues by which EESC may be integrated into primary health care, advocacy, promoting integration of EESC into national health plans, supporting development of a World Health Assembly resolution, and fund raising. Committee members will be elected every 2 years, with one member representing each of the six WHO regions. The committee chairperson will report back to the organizing committee and present a summary of the committee's activities at the biennial WHO GIEESC meeting.
Discussion: The Way Forward
Collective action will be required to improve the delivery of surgical services at the district level in LMICs. Hence, the WHO GIEESC is growing in momentum. Committees have formed, and their actions will serve to move the agenda forward. The overall emphasis is to identify the appropriate mechanisms to promote availability of a core group of services to reduce the burden of death and disability due to surgical conditions, provide and adapt training programs in keeping with WHO surgical standards on the principles and techniques of essential surgery and anesthesia, support research to characterize the burden of surgical diseases and evaluate the impact of initiatives to reduce this burden, and promote advocacy and awareness of the importance of our quest. These points can collectively be addressed within the context of primary health care and strengthening health systems.
When considering ways to integrate surgical care at the primary referral level, we must first characterize the diverse barriers to the access, availability, and utilization of surgical services [24, 25]. Solutions require an integrated effort from individuals, organizations, and institutions in many sectors of each society. We might organize them based on an adaptation of the WHO's conceptual model of a health system, which focuses on the interaction between people (consumers, demand side) and the system (supply side). The supply side has been subdivided into six building blocks: (1) governance (stewardship, policies, regulation); (2) service delivery (effective, safe interventions); (3) human resources (number, distribution, skill mix); (4) information (production, analysis, dissemination); (5) medicines and technologies (quality, safety, cost-effectiveness); (6) financing (protection from personal catastrophic health expenditures) [26].
Barriers at the individual level (demand side) relate to the lack of utilization of existing services because of the population's reliance on traditional healers or other non-medical practitioners, level of education, religious and/or cultural beliefs, financial considerations (direct and indirect costs of seeking treatment), and even fear of anesthesia or surgery. Barriers at the system level (availability of services) can be categorized according to the six building blocks mentioned above. Issues related to governance include policies and regulations, resource allocation, inclusion of basic surgical care in national health plans, and the lack of a resolution at the World Health Assembly supporting essential surgical care as a key component for improved global health. Barriers with regard to service delivery include deficiencies in infrastructure, physical resources/supplies, human resources (absolute numbers of providers, urban versus rural distribution, skill set), and inadequate mechanisms for transportation and referral.
Geographic variables are also important in many settings, as patients may need to travel for long distances, often over difficult terrain, to reach a health facility. Financing remains a challenge for health systems in general, and current levels of financial investments are insufficient to subsidize even basic health services let alone facilities-based services such as surgical and anesthestic care. Information may be viewed as a key link in a health system. Significant deficiencies relate to a lack of data (few surgical metrics [27, 28], inadequate data regarding the burden of surgical diseases or service availability), and a lack of monitoring capabilities (service availability, quality and outcomes).
Although the perception of surgery and anesthesia in the global health community is certainly a barrier to EESC, current trends in health care programming may be advantageous to GIEESC and the surgical community. There has been a recent paradigm shift in global health programming, with the pendulum having swung from “vertical” (disease-specific) initiatives to “horizontal” initiatives, which aim to strengthen the health care system [26]. Similarly, there has been a resurgence of interest in “primary health care,” defined as “essential health care” based on practical, scientifically sound, socially acceptable methods and training made universally accessible in the Alma-Ata Declaration (1978) [29]. Surgical care is recognized as facilities-based service within this overall scheme [30].
Advocacy is crucial as the GIEESC moves forward. Also, we must recognize the importance of social and political variables in our efforts to advance surgical care. Political factors play an important role in determining the recognition (and resources) that public health initiatives receive [31–33]. Enormous financial resources have been allocated to selected diseases despite the fact that their contribution to the world's burden of disease is small. Shiffman commented that, “material factors such as morbidity and mortality and the availability of cost-effective interventions may not explain the variance and the levels of attention health issues receive” [32]. He and his colleagues developed a conceptual framework to explain political priority for global health issues based on the (1) power of the actors, (2) power of ideas portraying the issue (frames), (3) political contexts in which the actors operate, and (4) nature of the issue itself [32, 33]. We can anecdotally evaluate progress to date with EESC and GIEESC relative to Shiffman's framework. With regard to the power of the actors, the global surgical community has yet to coalesce into a unified front. Hedges et al. [31] stated that “organizational fragmentation within global surgery efforts impedes large scale action”. Framing the issue remains a challenge, as there has been a lack of concensus in defining “surgery”. From the standpoint of political context, the surgical community has been unable to successfully link surgical care with a “policy window” such as the Millenium Development Goals. Finally, the inability to capture the burden of surgical diseases with existing metrics has hindered our ability to draw attention to the magnitude of the problem and to facilitate comparison between the surgical burden and that of competing health priorities.
We envision the WHO GIEESC as a surgical and anesthetic policy community with the strength and dedication to push the agenda forward. There is a need to establish stronger collaborations and partnerships with civil society, ministries of health, and other entities focusing their efforts on strengthening health systems and implementing the primary health care model. Surgical care can be promoted within the context of health systems strengthening to help achieve the Millennium Development Goals. The recent emphasis on primary health care may offer a “policy window” as EESC is horizontal and resonates with the concept of strengthening both primary health care and health systems. Quantifying the burden or magnitude of surgical diseases requires additional data to demonstrate the cost-effectiveness of EESC, that EESC can improve outcomes, and that EESC should be scaled up. The time is ripe for all those dedicated to reducing the morbidity and mortality associated with surgical diseases to unite and push this agenda forward.
Contributor Information
David A. Spiegel, Division of Orthopaedic Surgery,Childrens Hospital of Philadelphia, University of Pennsylvania School of Medicine, 2nd Floor Wood Building, 34th Street and Civic Center Blvd., Philadelphia, PA 19104, USA
Fizan Abdullah, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287-0005, USA fa@jhmi.edu.
Raymond R. Price, University of Utah, Salt Lake City, UT, USA Intermountain Medical Center, Intermountain Healthcare, 5169 South Cottonwood Street, Suite 410, Salt Lake City, UT 84108, USA; Swanson Family Foundation, Ogden, UT, USA.
Richard A. Gosselin, School of Public Health, University of California, Berkeley, CA, USA froggydoc@gmail.com
Stephen W. Bickler, Department of Surgery, School of Medicine, University of California, San Diego, CA, USA sbickler@ucsd.edu
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