Many developing countries have strategic plans to address major public health issues such as vaccinations, tuberculosis or HIV, but only four have formal plans specific to surgical conditions. To address this problem, the World Health Organization (WHO) in collaboration with the Harvard Medical School Center for Global Health Delivery, hosted its first technical workshop in Dubai on March 21st-22nd 2018 on the development of national surgical obstetrics, and anesthesia plans (NSOAPs). Here’s why this matters:
Each year, 16.9 million people die from surgically treatable diseases – more than three times the combined deaths from HIV, malaria, and tuberculosis [1,2]. Yet, recent estimates have found that over five billion people are unable to access safe and affordable surgical care when required, and the area of highest need is in low and middle-income countries (LMICs) . People in these countries are therefore disproportionately impacted by surgical diseases as their health systems are not equipped to effectively deliver surgical services. Poor health infrastructure, a limited and untrained health workforce, and inadequate surgical equipment and supplies are among the barriers inhibiting access. . Given this unmet need, and given its effectiveness and cost-effectiveness, far too few resources have been devoted to surgery relative to other aspects of global health. .
Since 2015, in tandem with the publication of high-impact research and advocacy work from the G4 Alliance, efforts to improve surgical care in LMICs have gained momentum. Publications from the World Bank and Lancet Commission on Global Surgery (LCoGS) have proposed evidence-based solutions for the expansion of surgical services in LMICs [4,2]. The pivotal year of 2015 also marked the start of a global political commitment to strengthen surgical care when the World Health Assembly unanimously passed Resolution 68.15 – a historic document formally recognizing the need for improved access, quality, safety, and affordability of surgical care and anesthesia . Furthermore, the 2015 commitment to universal health coverage outlined in the United Nations’ 2030 Agenda for Sustainable Development can have little meaning if access to safe surgery is excluded from that coverage . No longer can surgery be considered an after-thought in national planning for health.
In light of these events, several LMICs have started to prioritize surgery in their national health agendas by developing NSOAPs specific to their country’s healthcare landscape. Like national plans for addressing other major health issues, NSOAPs outline a series of prioritized and costed actions that would strengthen a country’s surgical care system. They address the various aspects of that system including human resources, infrastructure, quality assurance, monitoring and evaluation, and financing. These must work in concert if access to high-quality, appropriate care is to be made available to all those in need. Despite the centrality of NSOAPs in meeting the goals outlined by the LCoGS and the WHA Resolution 68.15, little was known about the process and resources required to develop and implement these plans.
For this reason, the WHO and Harvard Medical School Center for Global Health Delivery convened the March meeting in Dubai to support the development of NSOAPs in the Eastern Mediterranean, South Asian and African regions. The workshop was attended by a diverse array of participants including ministry of health representatives and stakeholders from academia, industry, and the nonprofit sector. In a series of discussions and presentations, various panelists shared their expertise on the processes and key principles of developing a NSOAP. This included strategies on how to 1) obtain buy-in and support from ministries of health, 2) assess a country’s unmet surgical need and its capacity to deliver surgical care, 3) engage a broad range of stakeholders, and 4) identify areas of a country’s surgical care system that should be prioritized in a national plan.
Panelists outlined the steps involved in drafting a NSOAP document including monitoring & evaluation, and assessing the cost and economic return from proposed activities. Representatives from countries who were at various stages of NSOAP planning described their early experiences and lessons learned. Industry representatives presented their achievements to date in helping to expand surgical services and discussed ways that they might create ‘win-win’ collaborations that both advance surgical access and quality and potentially open new markets for their products. The conference also highlighted the important role regional organizations, such as the African Union or the World Health Organization’s regional offices, need to play in advocating and providing technical assistance and mentorship to support NSOAP development. Moving forward, attendees agreed that it is important to identify innovative mechanisms to finance NSOAP initiatives. Finally, workshop attendees were presented with different NSOAP implementation models from national coordinators currently involved in implementing completed NSOAPs in Ethiopia and Zambia . The G4 Alliance – a coalition of 85+ organizations from across the globe, whose mission is to advocate for increase access to quality surgical, obstetrics, trauma, and anesthesia care – also lead an implementation showcase that featured work from some of its members who are actively supporting NSOAP efforts in LMICs.
Even more important than the wealth of technical information and guidance, the Dubai conference provided a forum for practitioners to network and create links that could advance NSOAP initiatives in their respective countries. Strengthening surgical care systems in LMICs will enhance economic development and the achievement of universal health coverage [2, 3]. Formulating evidence-based, coordinated, and efficient NSOAPs is an essential part of achieving these goals. The meeting in Dubai was a crash course on how to get the job done.
References: Dare AJ, Onajin-Obembe B, Makasa EM. A snapshot of surgical outcomes and needs in Africa. The Lancet. 2018 Jan 3.  Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet. 2015 Aug 14;386(9993):569-624.  World Health Assembly. Strengthening emergency and essential surgical care as a part of universal health coverage. WHA68.15. Agenda item 17.1. http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_R15-en.pdf (accessed on 12/April/2018).  Mock CN, Donkor P, Gawande A, Jamison DT, Kruk ME, Debas HT. Essential surgery: key messages from Disease Control Priorities. The Lancet. 2015 Jun 5;385(9983):2209-19.  United Nations (2015). Transforming Our World: The 2030 Agenda for Sustainable Development. New York: UN Publishing.  Albutt K, Citron I, Sonderman K, Nthele M, Bekele A, Maongezi S, Rwamasirabo E, Monono M, Johnson W, Meara J. Policy Brief: National Surgical Obstetric and Anaesthesia Planning – The Way Forward. March 2018.