I was interested to see this new publication from the World Bank, part of a series to be published in 2015 and 2016 which delineates ‘essential intervention packages — such as the essential surgery package in this volume — and their related delivery platforms. This information will assist decision makers in allocating often tightly constrained budgets so that health system objectives are maximally achieved’.

Essential Surgery. Disease Control Priorities – Third Edition

Editors: Haile T. Debas, Peter Donkor, Atul Gawande et al.

International Bank for Reconstruction and Development/The World Bank, 2015

445pp.20.2 MB(!):

https://openknowledge.worldbank.org/bitstream/handle/10986/21568/9781464803468.pdf?sequence=5

‘Essential Surgery identifies and studies a group of “essential” surgical conditions and the procedures needed to treat them. These surgical conditions can be

defined as those that (1) are primarily or extensively treated by surgery, (2) have a large health burden, and (3) can be successfully treated by surgical procedures that are cost-effective and feasible to promote globally. To address these conditions, the authors derive a set of 44 essential surgical procedures. These include procedures to treat injuries, obstetric complications, abdominal emergencies, cataracts, and congenital anomalies, among others. We estimate that universal access to this package of essential procedures would prevent about 1.5 million deaths per year or 6 to 7 percent of all preventable deaths in low- and middle-income countries.’

EXTRACTS (selected by Neil PW)

‘Measures to expand access to surgery, such as task-sharing, have been shown to be safe and effective while countries make long-term investments in building surgical and anesthesia workforces. Because emergency procedures constitute 23 of the 28 procedures provided at first-level hospitals, such facilities must be widely geographically available.’

‘We point to estimates that full coverage of the component of UCES applicable to first-level hospitals would require slightly more than $3 billion annually

of additional spending and yield a benefit:cost ratio of better than 10:1. It would efficiently and equitably provide health benefits and financial protection, and

it would contribute to stronger health systems.’

Below is the list of 44 procedures, showing which procedures could be provided at community level, first-level hospital (‘first-level hospitals imply fairly well-developed surgical capabilities with doctors with surgical expertise; otherwise, many of the procedures would need to be carried out at higher-level facilities’), and second and third-level hospitals. (I have reproduced this manually for the benefit of those who may not have immediate web access. Please refer to the original table on pages 4-5, which has important explanatory notes)

COMMUNITY FACILITY AND PRIMARY HEALTH CENTER

• Dental Extraction / Drainage of dental abscess / Treatment for caries
• Obstetric: gynecologic, and family planning / Normal delivery
• General surgery: Drainage of superficial abscess / Male circumcision
• Injury: Resuscitation with basic life support measures / Suturing laceration  / Management of nondisplaced fractures

FIRST-LEVEL HOSPITAL

• Obstetric, gynecologic, and family planning: Cesarean birth / Vacuum extraction/forceps delivery / Ectopic pregnancy / Manual vacuum aspiration and dilation and curettage / Tubal ligation / Vasectomy / Hysterectomy for uterine rupture or intractable postpartum hemorrhage / Visual inspection with acetic acid and cryotherapy for precancerous cervical lesions
• General surgery: Repair of perforations: for example, perforated peptic ulcer, typhoid ileal perforation / Appendectomy / Bowel obstruction / Colostomy / Gallbladder disease, including emergency surgery / Hernia, including incarceration  / Hydrocelectomy / Relief of urinary obstruction: catheterization or suprapubic cystostomy
• Injury: Resuscitation with advanced life support measures, including surgical airway / Tube thoracostomy (chest drain) / Trauma laparotomy / Fracture reduction / Irrigation and debridement of open fractures / Placement of external fixator; use of traction / Escharotomy/fasciotomy (cutting of swelling) / Trauma-related amputations/  Skin grafting / Burr hole
• Non-trauma orthopaedic / Drainage of septic arthritis / Debridement of osteomyelitis

SECOND- AND THIRD-LEVEL HOSPITALS

• Obstetric, gynecologic, and family planning: Repair obstetric fistula
• Congenital: Repair of cleft lip and palate / Repair of club foot / Shunt for hydrocephalus / Repair of anorectal malformations and Hirschsprung’s Disease
• Visual impairment: Cataract extraction and insertion of intraocular lens / Eyelid surgery for trachoma

A footnote to the above reads: ‘All of the procedures listed under community health and primary health centers are also frequently provided at fi rst-level and second-level hospitals. All of the procedures under first-level hospitals are also frequently provided at second-level hospitals. The column in which a procedure is listed is the lowest level of the health system in which it would usually be provided. Not included in the table are prehospital interventions, such as fi rst aid, basic life support procedures, or advanced life support procedures done in the prehospital setting. Health systems in different countries are structured differently, and what might be suitable at the various levels of facilities will differ. In this table, community facility implies primarily outpatient capabilities (as would be used to provide the elective procedures such as dental care), whereas primary health center implies a facility with overnight beds and 24-hour staff (as would be needed for procedures such as normal delivery). First-level hospitals imply fairly well-developed surgical capabilities with doctors with surgical expertise; otherwise, many of the procedures would need to be carried out at higher-level facilities. Referral and specialized hospitals (which could also be considered as second- and third-level hospitals) imply facilities that have advanced or subspecialized expertise for treatment of one or more surgical conditions, not usually found at lower-level facilities.’

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org  

The critical issue about surgical service is hands-on skill acquisition which can be achieved only by apprenticeship in the true definition of the word.

This is the challenge in Nigeria in the last three decades and current trainers have not been pragmatic like our teachers. http://www.medicalworldnigeria.com/2013/11/new-trend-in-surgical-residency-in-nigeria-by-oluyombo-awojobi  and http://dailytrust.info/index.php/health/15928-lack-of-mentorship-bane-of-medical-practice-in  [*see note below]

Since May 2012, we have shown that a consultant surgeon in a busy practice can train six medical officers annually to be proficient in primary care surgery, basic surgical pathology, abdominal ultrasonography and hospital administration. http://www.ifrs-rural.com/MEDRACE%20ISSUE%20SEPTEMBER.pdf

Another important aspect of the provision of safe and essential surgery at the primary and secondary levels is the generation of confidence of the populace in the health care delivery system.

Yombo.

HIFA profile: Oluyombo A Awojobi is a Consultant Rural Surgeon at Awojobi Clinic Eruwa, Oyo State, Nigeria. oluyombo2 AT yahoo.co.uk