The 2015 World Health Assembly (from 18 May) will commit to strengthening member states’ capacity to deliver basic surgical and anaesthetic services in primary health care and at the district hospital level. The Assembly will have before it a report from the WHO Secretariat A68/31 [http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_31-en.pdf] and a draft resolution (EB136.R7) [http://apps.who.int/gb/ebwha/pdf_files/EB136/B136_R7-en.pdf] forwarded from the meeting in January of WHO’s Executive Board (EB).

Background

The Secretariat report, A68/31, reviews the global burden of surgical conditions, the importance and cost effectiveness of surgery and reviews some significant gaps in surgical and anaesthetic services globally. The report surveys a number of areas for action at the country level and current action at the Secretariat level.  

Highlighted in the section on country level action were: awareness raising, access to and quality and safety of emergency and essential surgical services, strengthening the surgical workforce, better data on surgery for policy making, monitoring and evaluation, and global collaboration and partnerships.

Actions by the Secretariat which are highlighted include: the Integrated Management for Emergency and Essential Surgical Care (IMEESC) toolkit; the WHO-CHOICE  project on cost-effectiveness of interventions; and the WHO Global Initiative for Emergency and Essential Surgical Care [http://who.int/surgery/globalinitiative/en/]. The Secretariat will work with MS to ensure that “surgical services at district and subdistrict levels of care are assessed and monitored”.

There was an extended discussion on this issue at the Executive Board meetings in May 2014 (EB135) and January 2015 (EB136) where there was widespread support for progressing this issue. The case for strengthening essential and emergency surgical and anaesthetic services was not contentious although many of the challenges were canvassed. See reports of discussion at EB135 [https://docs.google.com/document/d/1lKv0CXH5uh0HnzuS_lXvyaH0U3r-ntgC6yMSGS-21RI/edit#heading=h.nqpfzl541kt8] and EB136 [https://docs.google.com/document/d/1uva8FMfstqwhEyKJ-GMNU54bBFYqEgonOkZhm7KtHBY/edit#heading=h.cjdo4t746yqz].  

Developing a PHM commentary

PHM’s WHO Watch collective (more here [http://www.ghwatch.org/who-watch]) is keen to hear comments from activists in PHM’s country circles, regional networks and affiliates and other interested civil society and professional organisations on the priorities for strengthening surgical and anaesthetic services and the particular challenges to be overcome in different countries and localities.  Does the report in A68/31 correspond to your local realities? Does the proposed resolution, EB136.R7, address all of the key issues for you? What are the issues which need to be flagged at the WHA? Is there scope for building a broader people’s health movement through action around access to effective, safe and affordable surgical services?  

A draft PHM commentary on this item can be found here [https://docs.google.com/document/d/1sZ3-mfKl4FrCcNoUVDOqv3OBJS4Hoo7e37_HderR1O8/edit].  Comments and suggestions will be most welcome.  Please write to PHM Global Secretariat (globalsecretariat[AT]phmovement.org) with ‘WHO Watch / Surgery’ in the subject line.  

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PHM Comment

This is an important area and it is good that WHO is moving to adopt a formal integrated strategy and plan of action.

The issues canvassed in the Secretariat paper (EB136/27) are important. The following issues are of particular importance to PHM: models of service organisation and service delivery, surgical and anaesthetic task distribution within the health workforce, efficacy and effectiveness: evidence, clinical guidelines, clinical audit, safety and quality, clinical governance and clinical accountability, professional accountability and public policy control over training, regulatory frameworks and financing, the role of informed public and community involvement in policy, planning, management and institutional accountability.

It will be important to explore and evaluate the options with respect to service organisation and service delivery in different settings as part of planning this initiative. This will involve surveying existing models and developing criteria for assessing options.  

Ensuring a high return on investment with respect to any expansion of surgical services will depend on: focusing surgery for conditions where surgical treatment has demonstrated efficacy; ensuring high quality and safety with respect to environments and practice; sustainable financing and payment arrangements; and appropriate workforce policies.

There are many lessons from the experience of surgery in rich countries including what to avoid: unreasonable reimbursement, exploitation of professional monopoly power, inappropriate and unsafe practices.  Likewise there are valuable models from resource poor settings (eg the Aravind Eye Care System).

One of the key issues for L&MICs is ensuring appropriate workforce profiles. Surgery in rich countries is highly specialised, relatively autonomous both in clinical decision making and entry control (associated with long training programs), and generously remunerated.  However, many surgical (and anaesthetic) procedures can be performed by personnel with more limited training and less generous remuneration.  The use of such practitioners in a supportive organisational context can ensure greater cost-effectiveness, reach and access. Carefully designed training programs for these practitioners, including rich continuing in-service training, is critical.

Developing models of service delivery will involve identifying in broad terms the types of surgery which might be carried out in local (often quite isolated) hospitals, those which might be restricted to the referral centres, and the more complex but less urgent surgery which can be scheduled for visiting teams.  In many L&MICs properly equipped mobile surgical teams play a critical role in facilitating access. Mobile teams can also play an important role in providing in-service training. Surgery should be integrated within existing PHC programs; it should not be constructed as a new vertical program. Provision should be made for adequate supplies, maintenance and technical support to ensure that surgical facilities in isolated areas and for mobile teams are safe for both patients and staff. It may be necessary to include security for mobile teams in some settings.

PHM urges a return to the district health system model. The roles assigned to the district hospital are critical.  These include both the provision of first level hospital services, including basic surgery and anaesthetics, but also a range of functions that would strengthen and support primary health care and other district-level services.  

Organisational policies and information systems to ensure that surgical services provided are efficacious and effective are critical.  This will require systems for reviewing and synthesising evidence and the availability and observance of clinical guidelines.  Safety and quality are critical. This will require clinical governance arrangements which ensure professional accountability – to peers, to management, to communities and to families and patients. Excessive professional autonomy of the surgical and anaesthetic professions is to be avoided. This requires that arrangements are in place for effective public policy control over training, regulatory frameworks and financing (including remuneration).

The process of expanding access to surgery in low resource settings will be fraught with risks and challenges.  One of the prerequisites for success will be to ensure that policy making, service planning and operational management are all embedded within an environment of public and community accountability.

There will be no ‘one size fits all’ model for expanding surgical services.  While general principles and strategies can be elaborated, institutional arrangements and operational details will need to respond to local and national context. Adapting general principles to local context will require developing local capacity for operations research before, during and after the roll out.

The development of any future strategy and action plan for WHO will need to break away from the prevailing culture of prolonged training, high specialisation, high clinical autonomy, private practice and high remuneration. We urge that whatever expert committees are assembled for this exercise they include people with experience in delivering surgery in low resource settings and that the process includes careful documentation and analysis of existing models of service delivery.  

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