Introduction

An estimated 5 billion people worldwide lack access to timely, affordable, and safe surgical care, including anesthesia and obstetrics, as highlighted by the Lancet Commission on Global Surgery (LCOGS) in 2015. The commission reported that 143 million additional surgeries are needed annually to meet global demand. Up to 81 million people experience financial catastrophe due to the direct and ancillary costs associated with surgical care which is exacerbated by the lack of financial risk protection. The lack of access disproportionately affects low- and middle-income countries (LMICs) and is responsible for approximately 18 million preventable deaths annually, which is over four times the mortality due to HIV, tuberculosis, and malaria combined.[1] This article will explore the concept of global surgery, its key achievements, ongoing challenges, and future directions. 

Background

Surgery has historically been marginalized as the ‘neglected stepchild of global health’, as global health efforts traditionally have primarily focused on combating high-burden communicable diseases such as HIV, tuberculosis, and malaria.[1-2] However, there has been a growing recognition in recent years of the need to strengthen health systems as recent epidemiological transitions have highlighted the need for surgical interventions to address non-communicable diseases, maternal health, and trauma. In 2015,  the World Health Assembly adopted resolution 68.15 titled ‘Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage.’[3] This resolution marked a significant step in integrating surgical care into the global health agenda and emphasized the importance of strengthening surgical services in achieving Universal Health Coverage (UHC). It called for Member States to develop and implement National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) as a strategy aimed at scaling up surgical systems to improve the health of some of the world’s most impoverished populations. 

Key achievements in global surgery

Global surgery and the United Nations Sustainable Development Goals (SDG) 2030

The evolution of global surgery has been marked by numerous innovations aimed at making surgical care accessible, safe, and affordable for all. The Bellagio Essential Surgery Group was formed with support from the Rockefeller Foundation,which held conferences between 2007 and 2009.[4] The group brought together diverse experts to strategize on improving surgical care in LMIC. The Disease Control Priorities third edition identified 44 priority surgical procedures that could prevent 1.5 million deaths annually if universally accessible.[8] Since the Lancet Commission on Global Surgery in 2015, surgical care has been recognized as an essential component to achieve universal health coverage and within the United Nations Sustainable Development Goals (SDG) 2030. This recognition supports various SDGs, including the elimination of poverty (SDG 1), promoting good health and well-being (SDG 3), promoting economic growth (SDG 8), and reducing inequalities (SDGs 5 and 10).[5]

Surgical champions in the national implementation of surgical, obstetric, and anesthesia plans

Countries like Ecuador in Latin America, and Ethiopia and Zambia in Sub-Saharan Africa have been at the forefront of developing and implementing NSOAPs. Launched in November 2023, Ecuador’s ‘National Surgical System Strengthening Plan’ is the first of its kind in Latin America, aiming to enhance surgical care within Ecuador and throughout the Americas, reflecting the country’s commitment to advancing its surgical care agenda.[6] In 2015, the Ethiopian Federal Ministry of Health developed the Saving Lives through Safe Surgery initiative to improve national surgical care, with the development and implementation of 15 surgical key performance indicators to standardize surgical data collection practices. They set exemplary models for other nations to integrate policies by incorporating these plans into national health policies to address systemic health gaps in surgical care. 

Global initiatives in the expansion of surgical care services

These efforts are complemented by various global surgery initiatives, including the Blood D.E.S.E.R.T Coalition, which has successfully implemented innovative blood transfusion strategies to combat critical shortages in global ‘blood deserts’.[7] The World Health Organization (WHO) Global Initiative for Emergency and Essential Surgical Care works to enhance surgical access and improve service quality worldwide, while the Global Initiative for Children Surgery focuses on improving surgical care for children in low-resource settings. Additionally, the COVIDSurg initiative, led by the NIHR Global Health Research Unit on Global Surgery, has also made significant contributions by shaping global surgical guidelines during the pandemic. Educational platforms like SURGHub, the United Nations Global Surgery Learning Hub, in partnership with the United Nations Institute for Training and Research (UNITAR) facilitate knowledge distribution and collaboration, further advancing the field. Global Surgery fellowship programs, such as the Harvard Program in Global Surgery and Social Change and the Operation Smile Global Surgery Fellowship, have provided rigorous training and mentorship opportunities for young professionals. Grassroots advocacy and student-led initiatives from organizations such as International Student Surgical Network (InciSioN) and Gender Equity in Global Surgery (GEIGS) have mobilized young professionals and students to champion surgical equity through research, policy, and advocacy work.

The funding landscape in surgical systems

Funding plays a crucial role in the establishment of effective surgical systems; for instance, Harvard Medical School received a generous $50 million donation from the Cummings Foundation to honor the legacy of Paul E. Farmer, which will enhance global partnerships, such as the Harvard Medical School-University of Global Health Equity in Rwanda.[9] This funding includes exchange programs and clinical training opportunities with an initial focus on building surgical capacity and surgical health innovation in low-resource settings. Furthermore, the NIHR Global Health Research Unit on Global Surgery awarded £7 million in 2022 to support research centered on building surgical infrastructure in LMIC.[10]

Challenges in the provision of surgical care

One of the most significant challenges in global surgery is the lack of adequate funding and effective mechanisms to mobilize investments leading to impoverishment and further economic instability. Cost-effectiveness of surgical care is comparable to well-funded public health interventions, a clear reason for expanding surgical care access.[11] Despite the high burden of surgical conditions, investments in surgical systems remain low. Traditional funding streams are underinvested, and innovative financing strategies are needed to address the unmet needs for surgical care. 

Enhanced collaboration among organizations and integration of surgical care into broader health system strengthening efforts are essential for evaluation to inform policy. The global surgery community tends to operate in silos, resulting in duplication of efforts and inefficient use of resources. Enhanced collaboration among organizations and integration of surgical care into broader health system strengthening efforts are essential for sustainable progress. Political contexts and policy windows are critical for influencing decision-makers, hence, need to be opportunistic in financing support for both research and service delivery. 

Access to quality surgical care in many LMICs are limited by a significant workforce shortage of trained surgical providers and inadequate infrastructure and equipment. Many healthcare facilities lack essential resources, such as electronic health records for databases and registries, which hinders the ability to monitor progress in driving evidence-based health policies.[12]

Future directions

The Lancet Commission on Global Surgery in 2015 has identified core indicators together with the World Bank’s World Development to provide economic data and analysis that supports the assessment of financial aspects of surgical career. These indicators include quantitative measures of surgical preparedness, delivery, and financial impact, and are intended for national data collection and global reporting. They are crucial for monitoring progress, shaping evidence-based policies, and evaluating surgical interventions worldwide. However, the adoption of these indicators has been slow, partly due to the need for a consistent standard denominator in reporting to enable evaluation of improvements in surgical care delivery on a large scale.

In addition, innovative financing mechanisms are crucial for building resilient and sustainable surgical systems. Traditional funding sources often fall short in addressing the comprehensive needs of global surgery. Therefore, new financial models, including public-private partnerships, global health funds, and innovative insurance schemes, are being explored. These mechanisms aim to secure long-term investments in surgical infrastructure, workforce training, and essential medical supplies. 

To achieve the global health agenda, there is a pressing need to upscale surgical systems through health systems strengthening. This involves integrating surgical care into broader health policies and frameworks, ensuring that surgical services are in lieu of achieving UHC in the global health agenda 2030. Strengthening surgical systems also requires robust training programs for surgeons, anesthesiologists, and other healthcare professionals. Ministries of health, national and state-level policymakers, academic institutions and international partnerships play an important role in collaboration to provide the necessary education and training to build local capacity and ensure the consistent delivery of high-quality surgical care.

Conclusion

Surgical and anesthesia care are critical to achieving UHC by 2030, with the potential to significantly improve health outcomes and reduce global inequalities. Despite progress since the 2015 Lancet Commission on Global Surgery report, challenges remain in providing universal access to safe, affordable surgical, anesthesia, obstetrics, and gynecology care in LMIC. Collaborative partnerships and efforts in research, policy, and innovation are essential for advancing global surgery and achieving health equity and well-being for all.