Authors: John L. Dutton, Desmond T. Jumbam and Libby Bunker
The COVID-19 pandemic has eroded and exposed fragile health systems globally.
Health care workers have been overwhelmed by the sheer numbers of patients needing intensive care, which has devoured already limited resources, stretched tenuous supply chains and spread thin the efforts of those one the front lines.
Sadly, essential surgical services, including live-saving surgeries to repair cleft lip and cleft palate, cesarean sections and many more, which were already in strikingly short supply, especially in low- and middle-income countries, have been made worse by the pandemic.
Much progress and change need to be made so that reactive health care systems can become proactive in the face of crises. That paradigm shift is also essential if we are to achieve the U.N.’s lofty goals for universal health coverage – access to the health services that all people need, when and where they need it without experiencing financial hardship – by 2030.
Surgical nongovernmental organizations (NGOs) must play a key role in achieving these goals.
COVID-19 has directly led to significant disruptions in surgical care. Data from 112 countries shows that half of these countries are providing 70% less surgeries than before the pandemic with the greatest reduction in low-income countries. Most of these interruptions have been justified, as evidence from The Lancet has shown that half of patients who become infected COVID-19 before or after surgery develop pulmonary complications and are more likely to die after an operation.
Prior to the pandemic, more than 100 million additional surgical procedures were needed annually in low- and middle-income countries. Current surgical delays exacerbate this unmet need: Even more mothers needing cesarean sections due to obstructed labor, more children needing their appendix removed due to infection, and more people requiring trauma surgery to repair severely fractured bones are without access to life-saving procedures.
Tragically, these and millions of others are at risk of death or disability because health systems lack adequate infrastructure and skilled health workers to address the surgical needs of their people.
In the past, investing in surgical systems – from equipment to supplies to training more skilled health workers and operating rooms – were thought to be too expensive, too complex or too daunting. However, many essential surgeries are among the most cost-effective health services as highlighted by the World Bank’s Disease Control Priorities, Vol. 3.
Moreover, as shown by the Lancet Commission on Global Surgery, we now know that reliable surgical infrastructure can strengthen an entire health system, promote economic productivity, and help hospitals weather unexpected shocks like COVID-19.
Unfortunately, in countries where those investments are most needed, progress has been slow.
In 2015, the World Health Assembly (WHA) unanimously passed resolution 68.15 and, for the first time, recognized emergency and essential surgical care and anesthesia as an integral part of universal health coverage. Dr. Tedros Adhanom Ghebreyesus, Director General of the World Health Organization (WHO) stated that “no country can achieve universal health coverage unless its people have access to safe, timely and affordable surgical services.”
Several countries including Tanzania, Zambia, Pakistan, Ethiopia and others are developing and implementing National Surgical Obstetric and Anesthesia Plans (NSOAPs), national policies for improving a country’s surgical system for the long term, to begin implementing the WHA resolution at the country level.
Despite these meaningful efforts, WHA resolution 68.15 and NSOAPs have yet to transition from policy into action in a meaningful and sustainable manner.
Surgical NGOs, with their direct links to communities and policy makers, are well-positioned to enact these policies. They can and must take a leading position in bringing these plans to fruition.
Working alongside local stakeholders, surgical NGOs will need to expand their services to include infrastructure development for hospitals, increasing research capacity and training local surgical providers. This approach strengthens overall health systems rather than solely focusing on surgeries for a specific patient population.
Some notable examples include KidsOR, which has been able to outfit 25 pediatric operating rooms in 11 countries; LifeBox, which has provided more than 22,000 pulse oximeters to over 100 countries; and Jhpiego, an organization that has trained over 275,000 health care workers globally.
Recognizing the broad social reach that surgical NGOs seek to have, it is important for them to align their services with the health needs and priorities of international governments as outlined in those countries’ NSOAPs.
Operation Smile, a surgical NGO with four decades of experience providing comprehensive cleft care to children around the world, is doing exactly this. Through projects such as the ongoing Global Essential Surgery Project, funded by the UBS Optimus Foundation, Operation Smile is improving surgical systems at hospitals in Nicaragua, Madagascar and Vietnam in collaboration with ministries of health and front-line providers.
To date, the project has trained more than 1,000 health care workers, constructed new operating rooms, implemented safe surgical protocols, trained local biomedical technicians, and engaged local communities so that their residents are aware of conditions that can be treated by surgeries offered at those hospitals.
Early results are promising: Both the number of surgical patients admitted and the number of surgeries provided within the project’s partner hospitals have increased by more than 60% since 2018. More patients are seeking care, and hospitals possess an increased ability to meet this new demand.
Importantly, the evidence generated through this project will help bridge the gap between policy and practice.
Here is our advice for surgical NGOs as they expand their roles towards universal health coverage:
· Establish equitable partnerships by equipping local health care workers with the knowledge and training necessary to provide care for the long term, drive economic progress and decrease dependency while recognizing that these efforts will take time.
· Employ a broadened approach that allows for more patients to receive the care they need while simultaneously investing in surgical systems for more ongoing and sustainable care.
· Expand funding sources by seeking additional avenues of funding. Social impact investors are ready to support sustainable programs that are measurable, repeatable and scalable.
· Collaboration with other surgical NGOs is critical and must be performed in a transparent manner. Competition will sequester results; collaboration will achieve them
· Data is vital for establishing evidence needed for scaling up impactful programs and implementing health policies. Improved data tracking processes can be integrated into local and national practices to strengthen information management systems.
· Partnering with policy makers is paramount. Universal health coverage cannot be achieved without the collaboration of ministries of health.
As we’ve passed the one-year mark since the first cases of COVID-19 and reflect on a pandemic that has so drastically changed our daily lives, we must look onward to how we will repair the flawed health systems and social inequalities that this virus has exposed.
Moving forward, surgical NGOs must act as catalysts that provide activism, partnership and leadership to drive fundamental change – change that ensures universal access to safe, timely and effective surgical care for health that lasts – no matter where you live or how much money you have.