Table 2.

Recommendations for strengthening vulnerabilities exposed by the COVID-19 pandemic stress-test

Domain	Recommendation	Rationale
Infrastructure	First-time screening telemedicine consultations Pre-pandemic stockpiling of blood products Exemptions to lockdown restrictions and COVID-19 testing for blood donors Public blood donation campaign, mobilisation via technology, drone-based deliveries Provide transport for donors [10] Reducing blood donation intervals [10]	Reduced access to first-level facilities Surgical speciality hospitals fulfilling safe surgery criteria repurposed for pandemic-related services Risk of depleted available blood donation pool due to lockdown orders
Workforce	Provide sufficient PPE to ensure safety of surgical workforce Hazard pay and life assurance cover for dependants Use non-monetary remuneration for health-care workers who are chronically underpaid ‘Intangible alternative rewards’, e.g. recognition-of-service awards and promotions [22] Provide mental health services to SAOs and HCWs via tele-remote services Prioritise HCWs for testing	Risk of reduced specialist SAO providers with narrower distribution due to illness and burn-out Reduction in SAO graduates due to stalled training programs Reduced retention of HCWs Reduced density of nurses and ancillary staff
Service delivery	No blanket elective cancellations Risk-based approach to elective cancellations Use size of waiting list and demand elasticity to determine surgical volume Use stepwise approach for cancellations that depends on number of cases in the country and expected backlog Pre-operative testing for all patients to identify those at increased risk of poor post-operative outcome	Reduction in annual surgical volumes Increased peri-operative mortality with concurrent COVID infection Risk of incremental mortality and increased DALYs lost due to cancellation may outweigh risk of specific elective procedures in LMICs Need to ensure continuity of surgical care and training of surgical workforce
Financing	Implement ring-fencing/prepayment mechanisms for funds specific to surgical conditions, e.g. “road accident fund” that cannot be redirected Manufacture low-cost PPE locally Use additive manufacturing techniques Reduce cost of surgical care and PPE using robust supply chain management principles [42] Separation of emergency and routine surgical supply chain to minimise disruptions to non-pandemic care [48]	Risk of redirection of domestic budget away from surgical care Risk of foreign ICOs withdrawing funding Risk of reduced independence and development of local surgical infrastructure globally Risk of catastrophic health expenditure from surgical disease
Information management	Zero-rating telemedicine apps by carriers Deployment of government sponsored network technology Use of non-traditional information technology for training, patient information and collaboration	Cost of broadband makes telemedicine prohibitively expensive Telemedicine is still a nascent technology with low uptake Pandemic offers an opportunity to accelerate adoption
Governance	Resume work on NSOAP planning, reschedule planning meetings using video conferencing technology	Risk of stalled NSOAP planning