Joint response from the International Collaboration for Essential Surgery (ICES), Alliance for Surgery and Anesthesia Presence (ASAP), and Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT)
We applaud the recommendation of the High Level Panel (HLP) to “eradicate extreme poverty in the context of sustainable development.” We agree that no one should be left behind and that if we ever hope to attain true progress as a human race, we need to focus on the most vulnerable, disadvantaged, and marginalized segment of society. We would like to echo the statement that “the new agenda must tackle the causes of poverty, exclusion and inequality” (p.7) and emphasize the importance of ensuring “access to and availability of adequate health care as an issue of basic social justice.” Moreover, we support the statement that “many people living in poverty have not had a fair chance in life because they are victims of illness or poor healthcare…”
Every year, more than 100 million people are affected by injuries, up to 3 million women live with severely debilitating obstetric fistulas, 5 million children suffer from congenital conditions such as cleft lip/palate and clubfoot, and 20 million suffer from cataracts. Yet stark inequality in accessing basic surgical services is a reality. Only 3.5% of all surgical procedures worldwide are performed in the poorest third of the world, with 75% of of procedures performed in the richest third. 2 billion people worldwide lack access to the most basic surgical care and health systems in low resource countries do not have adequate resources to meet the great need.
There is a clear link between disability and poverty. In recognizing this, we should implement goals and frameworks which prevent severe disability, such as improving the quality and safety of healthcare, ensuring access to timely essential surgical care such as cesarean section for obstructed labour, emergency care for victims of trauma and injury, and essential surgical care for vulnerable children born with congenital defects.
We agree wholeheartedly that a paradigm shift is imperative. This needs to reach the neediest and most vulnerable populations, starting with developing strategies to strengthen and expand health services to ‘reach those not adequately covered by existing programmes.’ (p.8) In this regard, we support the second transformative shift, namely putting sustainable development at the core, but we would wish to emphasize that investments in strengthening health systems should be a priority.
We also support the idea that local authorities “form a vital bridge between national governments, communities and citizens and will have a critical role in a new global partnership” especially in setting and executing priorities and engaging with local communities. Local authorities should be empowered to deliver essential health services to local and rural populations. There is a need to improve and strengthen the capacity of hospitals at district level to provide essential medical and surgical care, with a focus on prevention of death as well as severe disabilities and consequences of delayed presentation.
Lastly, we commend the emphasis on improved data collection for monitoring and evaluation. This exercise serves to measure the burden of disease, helps to set targets for improvements, and builds the case for the need to expand services. Improved data collection tools for surveillance and monitoring of service delivery, particularly in the provision of essential surgical care, will serve to guide policies and quality improvement initiatives.
No one left behind?
Although we accept the emphasis on eradicating extreme poverty and building sustainable development, the report fails to address some vital issues.
There is no mention of essential surgical services, which are crucial to saving lives and preventing permanent disability. These services include surgical care for maternal complications of childbirth, which accounts for 20-30% of maternal deaths. It also includes correction of congenital deformities, which occur in one in every thousand births. It has been estimated that essential trauma care, through surgery, could save 2 million lives every year. Injury alone causes 24.4% more deaths and 23.3% more disability* than HIV, TB and malaria combined. Every year, between 30 – 130,000 women develop an obstetric fistula in Africa alone, resulting in significant social and economic consequences. Furthermore, this disease is one example of the failure of the health system to provide women with adequate surgical care.
Despite doubling of investments in maternal health in the last 5 years, only 13 countries are on track to reach the 5th Millennium Development Goal, which is to improve maternal health. More than 250,000 children are born every year with clubfoot, and about 250,000 more are born with cleft lip and palate, both of which are amenable to surgical correction, sometimes through simple techniques which could be made locally available such as the Ponseti method for clubfoot correction. Many children go untreated and live their lives with this disability which has resulting social and economic consequences. There are currently no national, international, or global frameworks for addressing these conditions at the policy level. Surgical care continues to receive little attention or funding. It is not currently recognized as a political priority among public health professionals, governments, funding agencies, and ministries of health despite growing evidence of its magnitude and the simplicity of many of its solutions. Basic, essential, and life-saving surgical care does not exist in many parts of the world. Moreover, the surgical health workforce is scarce and often ill-equipped to provide even the most basic surgical care in remote and rural areas. If we are aiming to “leave no-one behind,” (p.13) we need to explicitly address these surgical issues as part of a primary care strategy at the public health level, and call for a paradigm shift in public health service delivery.
There is a need to focus on strengthening health systems as an essential part of sustainable development. The workforce shortage in developing countries serves as a major barrier in the provision of and access to quality healthcare services. There is an estimated global deficit of 4.2 million health workers. In 2006, the World Health Organisation (WHO) estimated that 57 countries were at crisis point with fewer than 2.3 nurses, doctors and midwives per 1,000 people. This particularly affected sub-Saharan Africa and parts of Asia.
It is imperative that attention and priority is focused on building surgical capacity as a primary care component in national health systems. Although infrastructure is desperately needed, it also essential that the health workforce is trained to provide the basic, essential, life-saving and disability-preventing surgical care. Such care is not expensive or complicated. Moreover, there needs to be a focus on strengthening training in primary surgical services for health care providers at rural clinics and district-level facilities. This may best be implemented by the provision of modular training in essential surgical procedures.
Lastly, there should be a call to government agencies to create policies to provide incentives for trained surgical healthcare professionals to cooperate in strengthening surgical capacity in underserved areas by the training of health workers to provide essential surgical care, and the creation of incentives such as career development in order to increase retention.
ICES, ASAP and CCBRT remain committed to post-2015 discussions to ensure that essential surgical services are recognized as part of the basic human right to health. Surgery has the potential to result in a tremendous impact on society and has the capacity to restore disabled individuals into active, economically-productive members of society through relatively simple measures. Surgery should no longer be considered as a privilege only for the rich of the world.
The 12 goals
We commend the HLP for the 12 illustrative goals and evidence of impact, and particularly welcomes goals 1, “End Poverty,” 2, “Empower Girls and Women andAchieve Gender Equality,” and 4, “Ensure Healthy Lives.”
We believe that providing the poor with social protection systems and enabling them to build resilience can result in the empowerment of people to lift themselves out of poverty. It also provides them with the tools necessary to achieve health and well-being.
We fully support the desire to address social issues involving women such as ending violence and child marriage, which itself leads to maternal health problems and resulting surgical disease.
A strong emphasis on “ensuring healthy lives” is crucial to building healthy and economically- productive societies. We support a strong emphasis on health systems and are encouraged by the inclusion of ‘local surgical capacity’ as an affordable and available solution. However, we note that this is not included as a targeted goal under ‘reducing the burden of disease.’
We strongly recommend the following amendments.
Goal 4 “Ensure Healthy Lives”
Universal access to basic healthcare must encompass access to safe essential surgical care.
Target 4e: Reduce the burden of disease from HIV/AIDS, tuberculosis, malaria, neglected tropical diseases and priority non-communicable diseases.
This target should include essential surgical services not only as part of non-communicable diseases, but also because of the surgical complications which result from infectious disease. Simple, affordable solutions exist that are feasible to implement at the public health level and these should be available to local communities. Moreover, the target should involve sensitizing the communities to seek early and proper medical service. The group has targeted 15 essential surgical interventions which, in previous studies, have shown to address approximately 80% of the basic surgical needs of any developing country. These priority surgical services should be part of national health policies. Strategies for training providers, implementation and strengthening of district level services as well as improving the referral system to tertiary institutions need to be advanced.
We believe that true universal health care cannot be achieved without a focus on a comprehensive set of health services. Surgery is in a unique position in that it impacts on almost every other medical specialty. Furthermore, there is anecdotal evidence that equipping local and rural hospitals with the ability to provide simple essential surgical care acts as an enabler, raising the quality of care across the hospital. It also increases the credibility of the hospital.
It is no longer acceptable that mothers die in childbirth because of lack of access to surgical services, or that 75% of children fail to reach their 1st birthdays because of easily correctable congenital deformities, or that men, women and children of all ages die or become severely disabled from injuries because of a lack of access to timely emergency care. If we are going to address healthy lives in the truest sense, this cannot and must not be ignored.
Silos and ‘vertical’ programs fail to address the power of strong, integrated health systems that maximize use of resources for the good of the community. Trained surgical workers can also take care of the non-surgical needs of the community. The ability to provide high quality, safe surgical services builds the community’s trust in the health system.
Contributors: Jaymie Ang Henry (ICES) Caris Grimes (ICES) Tamaly Lutufyo (CCBRT) Kelly McQueen (ASAP)