Introduction

In 1980, Halfdan Mahler, the then Director-General of the WHO, identified surgery as a critical part of primary healthcare and challenged the global health community to address the gross inequities in access to surgical care that were present at that time.1 However, over 30 years later, 5 billion people—a number greater than the world's total population at the time of Mahler's speech—are unable to access safe, affordable surgical and anaesthesia care when needed.1–3 Concerted action from multiple sectors in all countries is required to ensure that the world will have made progress in closing the access gap by 2030.4

Despite clear evidence of the role of surgery in meeting health targets such as reducing maternal and child mortality, surgery was until recently dismissed as a global health priority.5 ,6 Since 1990, non-communicable diseases (NCDs) have attracted only 1.5% of development assistance for health (DAH), and in 2014 funding for health systems strengthening received only 6.4% of donor funds.6 Country-level spending specific to surgical care remains largely untracked,7 but in countries which spend little on health, surgical systems are inadequate for population need.8–10

However, the landscape is shifting. While the Millennium Development Goals (MDGs) focused on interventions to improve the well-being of specific populations, the new Sustainable Development Goals (SDGs) aim to improve the well-being of all of humanity through an integrated set of 17 systematic goals. In this context, new evidence has emerged showing that surgical conditions are responsible for nearly one-third of the world's burden of disease,11 and that providing surgical treatment can be highly cost-effective.12 The Essential Surgery volume of the Third Edition of Disease Control Priorities (DCP-3) identified 44 surgical procedures deemed essential for public health. Authors argued for the early inclusion of surgery within efforts to achieve universal health coverage on the basis of a 10:1 economic benefit: cost ratio.13 Targeted funding towards surgery and anaesthesia will be critical to reaching the health-related SDGs:14 every Global Burden of Disease subcategory requires surgical intervention at least some of the time.15 In completing the ‘unfinished business’ of the maternal health agenda,16 achieving further reductions in child mortality, eliminating extreme poverty, treating the growing burden of NCDs or simply ensuring healthy lives, investing in surgery is imperative.

On 6 May 2015, representatives from around the world gathered in Boston, Massachusetts, for the North American launch of the Lancet Commission on Global Surgery. This launch followed an 18-month research and consensus-building process involving collaborators in over 110 countries. The purpose of this event was twofold: to bring the findings of the Commission to the attention of high income country (HIC) clinicians and policymakers, and to discuss a multicountry, multisectoral approach to improving access to surgery globally.

The launch consisted of panels and presentations addressing the role of various groups: surgical colleges and academic medical centres (AMCs); HIC trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy groups. Panelists included members of the global health and global surgery communities, as well as partners in industry, philanthropy and journalism. They represented both HIC and low and middle income country (LMICs) perspectives. This article reviews the relevant literature and provides a unified call to action for each cadre of HIC actors.

Colleges and AMCs: create responsibility for addressing global health inequities

The world faces a severe shortage of surgeons, anaesthesiologists and obstetricians (SAO providers). The Commission found that at least 1.27 million new SAO providers will need to be trained by 2030 to reach a conservative benchmark of 20 SAO providers per 100 000 population, a target correlated with improved population health outcomes.17 Workforce deficits are intensified by unequal distribution of surgical providers, with a greater SAO density in urban, compared with rural, regions.18 Therefore, LMIC surgical colleges and AMCs face the dual challenge of training and retaining SAO clinicians where they are most needed.

The primary domestic role of surgical, anaesthesia and obstetric colleges is to encourage and maintain standards for training, continuing professional development and ethical practice to promote quality care and patient safety.19–22 Colleges play varied roles in hospital and training programme accreditation processes, which are designed to promote national and regional recognition of these standards. Achieving this recognition can be challenging for colleges in LMICs, as is maintaining funding for college activities.23 HIC colleges have partnered with LMIC colleges to overcome these challenges.24 The partnership between the Royal College of Surgeons of Ireland (RCSI) and the College of Surgeons of East, Central, and Southern Africa (COSECSA), for example, has led to the implementation of surgical skills courses with a train-the-trainer approach, an online surgical curriculum designed to meet the needs of COSECSA trainees, and a training programme for COSECSA surgeon–scientists.24 Using another model, the Royal Australasian College of Surgeons has strengthened surgical training in its region by partnering with the Fiji School of Medicine, Ministries of Health and the Pacific Island Surgical Association.25 AMCs serve as a locus for complex clinical care and research, and they have also engaged in the global training effort.26 Such engagement has ranged from single-institution relationships to country-wide health workforce initiatives such as Rwanda's Human Resources for Health Program.26 ,27 This programme aims to train over 500 new physicians, treble the number of specialists, bolster the nursing and midwifery workforce, and train 150 new health managers over a 7-year period.27 Further research is needed to determine how to maximise the effectiveness of these high-level partnerships in growing a resilient global workforce.

HIC trainees and training programmes: move away from surgical colonialism

Training a strong global workforce will also require the integration of global health into medical and public health curricula.28 Roughly 30% of North American medical students pursue electives in global health,29 and up to 94% of surveyed European medical students desired more global health training.30 ,31 Trends are similar for global surgery. Both Canadian and American surgical trainees are interested in international training opportunities, up to 92% in one study.32 ,33 While one study documented that only 13% of general surgery programmes in the USA offer rotations in global surgery (likely under-reported), this number is growing quickly.34 The perceived benefits of surgery rotations in LMICs include exposure to a greater breadth of pathology, learning to manage resource limitations, personal enrichment, appreciating the global burden of surgical disease and bilateral institutional benefits.35 ,36

This type of trainee engagement is not, however, without risks to health systems, patients and trainees and its benefits can be one-sided. In a survey of Ugandan trainees, most agreed that foreign visitors improved their education, but despite conducting research alongside these teams, none had published as a coauthor.37 Risks to trainees include occupational exposure to infectious diseases and the lasting negative emotional consequences of witnessing the impact of health systems failures on patients.38 ,39 While it should be noted that these risks are faced by trainees in LMICs on a daily basis, this does not obviate the need for HIC training programmes to take appropriate action to mitigate these when they permit their trainees to travel abroad. HIC trainees may view rotations in LMICs merely as an opportunity to boost case logs, particularly for open (as opposed to laparoscopic) procedures that are less commonly performed in HIC settings. We term this surgical colonialism, a phenomenon that poses a risk to the training experience of LMIC trainees, and there are immediate risks to patient safety if HIC trainees engage in unsupervised work. These risks are only now being quantified in the literature. To minimise harms and maximise benefits, guidelines exist on how HIC individuals at all levels of training should engage in establishing partnerships.40 Many training programmes have indeed built rich, academically productive global collaborations.41

Internationally, medical students have modelled a particularly enthusiastic and anticolonial approach to health systems and global surgery advocacy.42 The International Federation of Medical Students’ Associations allows students from around the world to work collectively for sustainable development. Federation membership is priced on a sliding scale using World Bank Income Groups, with a common constitution and by-laws across income groups. To capitalise on trainee enthusiasm, and to provide the infrastructure necessary for sustainable benefit, major universities can create centres for global surgery and contribute to global consortia for health systems strengthening.28 ,43

Academia: support the conduct of research by surgeons in LMICs

In the nascent field of global surgery, many knowledge gaps remain.3 ,13 Only 4.1% of global health research activity is surgical, and, of all surgical research worldwide, only 4.3% is relevant to underserved populations.44 While new modelled data are useful for global analyses, primary data are required to make detailed national assessments, evaluate problems and solutions, and track progress.3 ,13 This is not possible without the full engagement of surgical researchers in LMICs, but human resources for research in LMICs are lacking. India, Africa and Latin America are home to 42% of the world's population but only 7.9% of the world's researchers,45 and few new researchers are studying health systems. Despite the great need for health systems strengthening in many sub-Saharan African countries, only 3.8% of health sciences PhD students in the region study health services and systems research.46 African solutions to these issues exist, including the development of a new Africa Center for Biostatistical Excellence.47 This centre is designed to make the region less dependent on foreign statisticians for competitive grant writing, advanced data analysis, publication of health research, and teaching statistics. Furthermore, the INDEPTH Network has taken up the gargantuan task of collecting robust health and demographic data. This is a network of 45 centres in 20 LMICs that actively surveys the health of 3 million people.48 The data that this effort will provide will inform health systems strengthening efforts for decades to come.

Surgeons in LMICs who wish to contribute to global surgical research face systemic barriers to conducting research. The most commonly cited barriers are a lack of sustainable funding and protected time for research, a lack of research training, the absence of a culture of research, the competing demands of private practice, and difficulties with record keeping and data management.49 Health research capacity strengthening efforts should work to overcome these barriers while addressing disincentives to conducting research, to ensure local ownership of the research and to build trust, cooperation and a locally relevant agenda.50 ,51 In this spirit, HIC academic surgeons can help build a global network of researchers to make surgical research relevant to all settings.

Global health funders: recognise the health, welfare, and economic benefits of investing in surgery

DAH works: In 2014, health economists estimated that with an additional US$1 billion in health aid, 364 800 under 5-deaths could be prevented. This figure was based on health improvements in 140 aid-recipient countries between 1974 and 2010.52 With concerted international effort, the maternal mortality ratio fell 45% between 1990 and 2013.53 Improved spending efficiency or accelerated improvement was seen in both of these examples after the year 2000, most likely due to improved technologies and better coordination in the context of the MDGs.52 ,54 Projecting forwards from 2015 to 2030, the Lancet Commission on Investing in Health estimated that the economic benefits of investing in health systems and services would exceed costs by a factor of 9–20.55

In the context of health systems investments, safe surgery and anaesthesia are a ‘best buy’ regardless of the economic analysis framework chosen. Simple cost-effectiveness analyses reveal that surgery compares favourably with interventions such as antiretroviral therapy for HIV or bed nets for malaria.12 Cost–benefit analysis shows that the economic benefits of cleft lip and palate surgery and caesarean section far outweigh the costs.56 However, extended cost-effectiveness analysis shows that simply providing free surgery alone provides great health benefits but places the poor at increased risk of medical impoverishment due to the significant non-medical costs of care.57 ,58 Even at present, among those fortunate enough to access surgery, 33 million face catastrophic spending due to the medical costs of accessing surgery and anaesthesia care, and 48 million more are financially devastated by the non-medical costs such as transportation, food and lodging.59 Therefore, the costs attendant to getting surgery should be incorporated early into universal health coverage pathways.

Verguet et al estimated that the cost of scaling up surgical services, at an annual rate of increase of 8.9% in the number of surgeries performed, between 2012 and 2030 would be about US$420 billion.60 This cost represents only 1–8% of current annual health systems spending in LMICs and pales in comparison to the US$12.3 trillion economic productivity losses that will be incurred due to surgical conditions without urgent action.3 Much of the funding necessary for a surgical scale-up can be mobilised from domestic funds; while DAH was US$33 billion in 2012, government expenditures on health in LMICs exceeded US$700 billion.61 Even in sub-Saharan Africa, government health expenditures were more than triple the amount of DAH received.

However, the poorest countries simply may not have the required capital to invest in surgery. In these circumstances, external aid will be essential. Between 1990 and 2014, the bulk of DAH came from the US government, followed by private philanthropy and the UK government.6 Absolute contributions tell only part of the story; in 1970, the United Nations General Assembly passed a resolution that each developed country would contribute 0.7% of gross national product to development assistance by 1975.62 Unfortunately, over 40 years later, only a handful of countries have met this target. While the absolute contributions of the USA are large, it spends less on development assistance than the average Organisation for Economic Co-operation and Development country proportionally, at 0.19% of gross national income.63

New financing mechanisms and new donor countries show promise in growing the overall funding pool.64 For example, the Debt2Health model piloted by the Global Fund may be particularly fruitful in funding health systems strengthening in highly indebted poor countries.65–67 This model allows indebted countries to redirect debt repayments towards health initiatives through debt relief agreements with creditor countries.66 Furthermore, an ambitious financing facility in support of maternal and child health was announced in July 2015 at the Third International Conference on Financing for Development.68 Financing comprehensive health systems with targeted investment for improving surgical capacity will require the same global enthusiasm.

Industry: invest in markets, technologies and technicians

Biomedical devices can promote safe, effective surgical and anaesthesia care from diagnosis to discharge. An example that has attracted much attention in recent years is the pulse oximeter, which can decrease the incidence of hypoxaemia during general anaesthesia69 and is recommended by the WHO guidelines for safe surgery.70 Up to 70% of operating rooms in Eastern sub-Saharan Africa lack this basic technology.71 ,72 Technological solutions to surgical problems need not be complex or expensive: the non-governmental organisation (NGO) Lifebox has demonstrated that robust, accurate oximeters can be produced economically and at scale.73 Technology plays a central role in the delivery of modern surgical care, but there are four salient issues with respect to its optimal use in LMICs: problematic equipment donations, a mismatch between government and NGO purchase requirements and context of use, the challenge of consumables, and the challenge of long-term maintenance.

First, donations of equipment from well-meaning organisations or individuals that do not meet the WHO guidelines fail early or do not meet local needs. The WHO reports that a large majority of this equipment is never used.74 ,75 Unused and broken medical equipment causes hundreds of millions of dollars in unacceptable waste and is a barrier to improved health outcomes.76 ,77 Second, whether donated or purchased, equipment considered for use in LMICs must be context appropriate. For example, a large number of hospitals (as many as 64% in a study of 8 LMICs) do not have consistent electricity available.78 While solving upstream infrastructural deficits is important for long-term growth, devices should be able to accommodate the present infrastructure. For situations where existing equipment and devices cannot fulfil the unique needs of LMICs, the process of designing tailored solutions should involve extensive consultation with end-users, as this is critical to promoting correct device use and protecting patient safety.79–81 This local engagement can extend to the manufacturing process; HIC-based companies can partner with local organisations to develop and produce equipment to meet regional needs.82 In appropriate circumstances, this can stimulate the economy, reduce the costs of production and transport, and improve the reliability of supply.82 Third, after clinicians adopt medical devices into clinical practice, regular maintenance must be performed to ensure ongoing availability; in a study of over 110 000 pieces of biomedical equipment in LMICs, 40% was found to be non-functioning.83 Most problems with equipment can be solved with a limited set of basic skills and a minimum of spare parts.84 A programme of biomedical equipment training, which teaches these basic skills has been implemented by Duke University, the GE Foundation and Engineering World Health. In addition to increasing the proportion of working equipment, this programme generates opportunities for skilled employment.79 Scaling such training can be facilitated by government investment and hospital commitment to remunerate biomedical technicians fairly. Finally, consumables are components that are intended to be discarded after every use, which in an HIC context might even include surgical instruments and sensor probes. Many equipment donation programmes targeting LMICs focus almost exclusively on the initial purchase cost of a device, as opposed to the long-term cost of consumable components, which in a brief period can exceed many multiples of the original purchase price.76 To greatly reduce the cost of ownership, purchasers must demand that partners in industry produce washable and reusable components.

In the light of an estimated 143 million additional procedures required each year and an active scale-up of surgical systems underway in some countries, equipment for surgery has become a growth industry.3 ,60 This growth creates obvious incentives for the private sector to engage in LMIC markets. In doing so, manufacturers have a responsibility to engage in a manner that addresses the needs of health systems, health professionals, patients and investors. Finally, as markets for medical devices develop and change rapidly, the regulatory role of national governments must evolve.85 Only 49% of countries have a health technology policy, and only 44% have national lists of medical devices approved for procurement or reimbursement.86 Strategies for regulating quality, safety, pricing and use of devices require careful context-specific study and implementation to promote access while avoiding unintended consequences.85

Press and advocacy: use data and personal stories to develop public support

Strengthening surgical systems globally will require national surgical planning, the inclusion of surgery within basic health coverage packages, generation of external funding where domestic funds are insufficient, and public education to encourage care-seeking when needed. In each of these domains, global surgery stakeholders and the media can play a powerful role in building public and political support.

Media attention to global health problems tends to correlate strongly with funding, although causality in this relationship is unclear.87 This may be related to the phenomenon that the public perceives diseases more frequently represented in the media as being of higher severity.88 Yet what drives media attention is not the magnitude of a disease's burden on population health. For example, paediatric pneumonia, diarrhoea and measles, which are leading causes of mortality in children, attract far less news coverage than the Global Fund diseases: AIDS, tuberculosis, and malaria.87 Similarly, surgical disease has historically attracted little attention from the HIC news media compared with communicable diseases.89 Therefore, global surgery advocates must take the lead on actively shifting the current discourse towards the vast global disparity in access to surgical and anaesthesia care. In doing so, global surgery advocates can learn from campaigns for another class of under-reported diseases, the Neglected Tropical Diseases (NTDs).90 News stories for these diseases (eg, leishmaniasis) tend to cluster around distinct events such as conferences, scientific breakthroughs and the awarding of large academic grants, and are typically driven by selected journalists with a personal interest in these diseases.90 Global surgery advocates must engage in concerted, strategic media outreach, and build relationships with informed health reporters.

Gaining political and public awareness requires the pathos that comes with telling the stories of real patients as well as the logos of scientific data. Universities and academics are still the most commonly cited voices in global health reporting.90 ,91 Academic global surgeons, therefore, have an opportunity to illustrate the evidence base for the expansion of surgical care and direct the global action plan to achieve it. Media training can help academic global surgeons achieve the ethos needed to attract attention to the field. Op-Eds are an excellent medium to bring together pathos and logos to seed this ethos, and academic global surgeons have an inherent advantage in securing placement in top-tier national and global media outlets due to their expertise and affiliations.

Finally, collective advocacy will allow for the voices of surgical patients to be heard above the noise of the information age. Over 50 organisations within the global health landscape have come together to form an alliance to advocate for greater political and public health prioritisation of neglected surgical issues. The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care, or the G4 Alliance, provides a platform for member organisations to advocate for important global surgical issues, bringing structure to existing informal partnerships and collaborations within the global surgical community.

The global surgery and anaesthesia community has a unified message to deliver and has overcome the fragmentation that has sidelined global surgery in the past, both prerequisites to developing domestic and global political priority.92 There are now data on the costs and benefits of surgery,3 ,13 a cohesive set of demands,93 political opportunities for prioritising surgery,14 and a set of time-bound targets against which progress can be measured.3 These are imperfect and are likely to evolve over the course of the SDGs, but the global advocacy effort must unite behind them to achieve success. While highlighting the ongoing tragedy of the global access gap, there is good reason to communicate optimism towards narrowing it by 2030.