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COMMENTARY
Year : 2018  |  Volume : 62  |  Issue : 3  |  Page : 211-213  

Surgical conditions - A neglected aspect of public health: Call to action


1 Senior Adviser, Public Health Foundation of India, Gurugram, Haryana, India
2 Surgeon and Public Health Specialist, WHO Collaborating Centre for Research on Surgical Care Delivery in Low and Middle Income Countries, Surgical Unit, BARC Hospital, Mumbai, Maharashtra, India
3 Vice President - Academics, Public Health Foundation of India; Director, Indian Institute of Public Health (PHFI), Gurugram, Haryana, India

Date of Web Publication12-Sep-2018

Correspondence Address:
Lalit Kant
B 95 Gulmohar Park, New Delhi - 110 049
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_3_18

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   Abstract 


The burden of surgical conditions is large, though unrecognized. Surgical interventions are cost – effective, but thought to be otherwise. Investments aimed at including surgery at primary care level are affordable. Globally, a momentum is being created to strengthen surgery infrastructure especially for the poor in the low and middle income countries – who bear the burden most. In India, the Association of Rural Surgeons of India, and a body for implementing Lancet Commission of Global Surgery, India are taking lead. A blue print of activities needed to bring surgery on the centre stage of public health in India has been developed. The IPHA can play a catalytic role and use its convening power in getting various associations of public health professionals in India to partner surgeons in this effort. Integration of surgery in public health has the potential to improve equity, access, and universal health coverage.

Keywords: India, integration, public health, surgery


How to cite this article:
Kant L, Roy N, Zodpey SP. Surgical conditions - A neglected aspect of public health: Call to action. Indian J Public Health 2018;62:211-3

How to cite this URL:
Kant L, Roy N, Zodpey SP. Surgical conditions - A neglected aspect of public health: Call to action. Indian J Public Health [serial online] 2018 [cited 2018 Dec 18];62:211-3. Available from: http://www.ijph.in/text.asp?2018/62/3/211/241095




   Introduction Top


Although recognized as an essential component of public health, surgery has been waiting in the wings as a neglected stepchild, for more than a century.[1] The situation must change if universal health coverage is to be ensured.

Surgical care is essential for managing diverse health conditions – such as injuries, obstructed labor, malignancy, infections, eye conditions especially cataract, and cardiovascular disease. Surgical care requires coordination of skilled human resources, specialized supplies, and infrastructure.

This neglect is due to various reasons. Public health and surgery are seen as being at opposite ends of the spectrum of health care. One develops inexpensive preventive interventions which improve health and save lives at the population level. While the other is seen as one-to-one, expensive clinical procedures which save individual lives. It is erroneously believed that conditions requiring surgical care are very few and that surgical interventions are very expensive to be cost-effective.

The gains made by public health programs have started to plateau, to bend the curve further, the role surgery can play is becoming obvious. For example, the identification and management of complications in obstetric patients has improved due to increased institutional deliveries; however, the maternal mortality rate is not falling further, as the provision of essential and emergency cesarean section surgery is lacking at district-level hospitals in many parts of the low- and middle-income countries (LMICs).

The Lancet Commission on Global Surgery, in its report, released in 2015, put forth a forceful argument in favor of strengthening the surgery infrastructure.[2] The commission has identified three surgical conditions (i.e., peritonitis, compound fracture, and Caesarean section) as the bellwether procedures for which infrastructure should be made available.

In the same year, the World Health Assembly adopted a resolution A68/31 for “Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage.”[3] India is also a signatory to this resolution.

Global burden

We now know that an estimated 17 million lives were lost in 2010 from conditions requiring surgical care. About 30% of the global burden of disease can be attributed to surgically treatable conditions.[4] This figure is more than the combined global deaths caused by HIV, tuberculosis (TB), and Malaria.[5]

The burden of untreated surgical conditions falls heaviest on individuals living in LMICs.[6] Moreover, within LMICs, people with the lowest income, those living in rural areas, and those who are marginalized bear the brunt.[7]

Burden in India

The burden of conditions requiring surgery is not readily available in India but can be gauged from the results of a nationally representative mortality survey which estimated that there were about 72, 000 deaths from acute abdominal conditions alone in 2010.[8] This number is far in excess of deaths due to maternal causes.[9] If this is the number of acute abdomen conditions, then the total for all conditions needing surgical intervention would be much higher. The appalling fact is that most of the 72,000 patients received little or no care, forcefully driving home the trilogy of tragic delays – the delay in seeking care, the delay in reaching care, and the delay in receiving care.

Cost effectiveness of surgical interventions

Data has shown that contrary to general belief simple surgical procedures that save lives and prevent disabilities are cost-effective and compare favorably with other standard public health interventions in terms of disability-adjusted life years (DALYs) averted. For example, ORS interventions at district level hospitals in LMICs;[10] Bacillus Calmette–Guérin vaccination for prevention of TB; HIV treatment with multidrug therapy.[11] Many areas of children's surgical care are extremely cost-effective in LMIC and provide substantial societal benefits.[12] The cost of obstetric emergency care at a rural hospital in Bangladesh compared favorably to many other primary interventions such as Vitamin A distribution; acute lower respiratory tract infection; or measles immunization.[13],[14]

Return on investments: Improve access

If the surgical and anesthesia services are improved, we can reduce losses due to economic productivity and save up to US$ 12.3 trillion in LMICs, and also prevent reduction of annual gross domestic product growth by as much as 2%.[4] By providing basic, life-saving surgical care we would be able to avert each year at least 77.2 million DALYs.[15]

The investments should be able to improve access of 5 billion people to safe, affordable, surgical, and anesthesia care when needed. In the world's poorest countries, over 80% of individuals face impoverishing expenditure (being pushed below the poverty line) if they need surgery. It should be possible to prevent 33 million individuals from facing catastrophic health expenditure due to payment for surgery and anesthesia each year.

The investment in surgical and anesthesia is thus affordable, saves lives, and promotes economic growth.

What is being done in India?

To draw attention to increased focus of global health on surgery the Association of Rural Surgeon of India (ARSI) had in a meeting in Karad in December 2015 drafted a consensus statement identifying key areas of focus for the rural surgery agenda. The statement focused on three areas for immediate action: work force improvement, blood products safety, and their availability.

In March 2016, the first meeting of India National Surgery Forum focused on the three issues identified in the Karad Consensus Statement as key to ensuring universal access to surgical care. It agreed to conduct baseline assessment of surgical capacity, and facility assessment and that planning should occur at state-level with efforts to be led by surgeons from respective states.

Later in July 2016, an “implementing Lancet Commission of Global Surgery, India” (iLCoGS) has been created to undertake activities to implement the recommendations of LCoGS. The iLCoGS would play the advisory role in facilitating and training needed for such assessments. The next steps identified include generation of awareness about the importance of surgery among public health officials; address rural-urban disparity, and conduct baseline assessment and feasibility assessment in each of 29 states.[16]

Role the associations of public health can play

For too long public health has failed to see surgery as its integral part, it is time to change this paradigm in India. The four lenses that are needed to view the various dimensions of surgical access are that of geographical access and distance from a functioning hospital, the availability of the essential infrastructure and workforce, the ability to perform surgery safely under appropriate anesthesia and finally, its affordability. The associations of public health/community medicine/preventive and social medicine can play a very constructive role in this endeavor. The ARSI has already chalked out a program of year-wise activities for health delivery and management, augmenting workforce and making surgery affordable with the various health schemes. The associations of professionals of public health in India should reach out to their counterparts in surgery to give specific technical inputs in this vast multidisciplinary area. Conceiving, designing and conduct of surveys; performing cost-effective and cost-benefit analysis; health financing; and economic feasibility studies are squarely within the purview of public health, not the surgeons. It is important for public health professionals to partner the surgeons in these research activities.

It is a golden opportunity for the public health professionals to contribute in strengthening national surgery systems and improve clinical outcomes. The issue is not how surgery benefits by getting on the public health stage, but rather how public health can improve equity, access, and universal health coverage by integrating surgery. The WHO has included in its 100 core Health Indicators, six measures of national surgical system strength recommended by the LCoSG.[2] These six indicators measure the preparedness of a surgical system to deliver care; the volume and quality of care provided; and the financial impact of the care provided. Each country is expected to generate data on these indicators. We too, need to generate data on the indicators which will provide a baseline from which to strengthen surgical infrastructure and monitor the progress.

Working together public health and surgeons' associations should expedite:

  1. Conduct of a baseline survey on all WHO indicators covering all states and union territories
  2. Forming multidisciplinary teams with professional surgical associations for surgical system strengthening, mainly at the District hospital.


The burden of surgical conditions is high, but its perception is poor. The access to surgical care is low, and the disparity among populations is great. Together we need to change this. Surgery is an indivisible, indispensable part of public health.[17] The delivery of surgical care is also critical for the realization of many of the sustainable development goals: Good health and well-being (Goal 3); no poverty (Goal 1); gender equality (Goal 5); and reducing inequalities (Goal 10).

The Indian Public Health Association is most appropriately placed to catalyze this change to ensure that essential surgical services are available to everyone who needs them and when they need them. This would contribute to promoting equity, social justice, health security, and provision of universal health care.



 
   References Top

1.
Farmer PE, Kim JY. Surgery and global health: A view from beyond the OR. World J Surg 2008;32:533-6.  Back to cited text no. 1
    
2.
Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569-624.  Back to cited text no. 2
    
3.
World Health Organization. 68th World Health Assembly. Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage. Available from: http://www.apps.who.int/gb/ebwha/pdf_files/WHA68/A68_R15-en.pdf). [Last accessed on 2017 Dec 17].  Back to cited text no. 3
    
4.
Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: An estimation from the provider perspective. Lancet Glob Health 2015;3 Suppl 2:S8-9.  Back to cited text no. 4
    
5.
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2095-128.  Back to cited text no. 5
    
6.
Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: Jamison DT, Breman JG, Measham AR, editors. Disease Control Priorities in Developing Countries. 2nd ed. Washington, DC: World Bank; 2006.  Back to cited text no. 6
    
7.
Zafar SN, Fatmi Z, Iqbal A, Channa R, Haider AH. Disparities in access to surgical care within a lower income country: An alarming inequity. World J Surg 2013;37:1470-7.  Back to cited text no. 7
    
8.
Dare AJ, Ng-Kamstra JS, Patra J, Fu SH, Rodriguez PS, Hsiao M, et al. Deaths from acute abdominal conditions and geographical access to surgical care in India: A nationally representative spatial analysis. Lancet Glob Health 2015;3:e646-53.  Back to cited text no. 8
    
9.
Montgomery AL, Ram U, Kumar R, Jha P; Million Death Study Collaborators. Maternal mortality in India: Causes and healthcare service use based on a nationally representative survey. PLoS One 2014;9:e83331.  Back to cited text no. 9
    
10.
Grimes CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Cost-effectiveness of surgery in low- and middle-income countries: A systematic review. World J Surg 2014;38:252-63.  Back to cited text no. 10
    
11.
Chao TE, Sharma K, Mandigo M, Hagander L, Resch SC, Weiser TG, et al. Cost-effectiveness of surgery and its policy implications for global health: A systematic review and analysis. Lancet Glob Health 2014;2:e334-45.  Back to cited text no. 11
    
12.
Saxton AT, Poenaru D, Ozgediz D, Ameh EA, Farmer D, Smith ER, et al. Economic analysis of children's surgical care in low- and middle-income countries: A systematic review and analysis. PLoS One 2016;11:e0165480.  Back to cited text no. 12
    
13.
McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: What it can mean for emergency obstetric care. Int J Gynaecol Obstet 2003;81:83-92.  Back to cited text no. 13
    
14.
Gosselin RA, Thind A, Bellardinelli A. Cost/DALY averted in a small hospital in Sierra Leone: What is the relative contribution of different services? World J Surg 2006;30:505-11.  Back to cited text no. 14
    
15.
Bickler SW, Weiser TG, Kassebaum N, Higashi H, Chang DC, Barendregt JJ, et al. Global burden of surgical conditions. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors. Essential Surgery. Disease Control Priorities. 3rd ed., Vol. 1. Washington, DC: World Bank; 2015. p. 9-40.  Back to cited text no. 15
    
16.
World Health Organization. Surgical Care Systems Strengthening: Developing National Surgical, Obstetric and Anaesthesia Plans; 2017. Available from: http://www.apps.who.int/iris/bitstream/10665/255566/1/9789241512244-eng.pdf. [Last accessed on 2017 Dec 17].  Back to cited text no. 16
    
17.
Kim JY. Opening Address to the Inaugural the Lancet Commission on Global Surgery Meeting. Boston, MA, USA: The World Bank; 2014. Available from: http://www.globalsurgery.info/wp-content/uploads/2014/01/Jim-Kim-Global-Surgery-Transcribed.pdf. [Last accessed on 2017 Dec 17].  Back to cited text no. 17
    




 

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