Thanks to Kathleen Casey from the American College of Surgeons Operation Giving Backfor echoing and replying to our post on the draft report - health in the post - 2015 development agenda and to Lifebox for their blog mentioning our comment and making their statement for global surgery.
We need to start creating a critical mass to push the envelope for a more serious conversation on the need for safe, essential surgical care, globally.
Response from the International Collaboration for Essential Surgery (ICES), a group of surgeons who are members and leaders of the International Surgical Society (ISS), International Federation of Surgical Colleges (IFSC), International Federation of Rural Surgery (IFRS), Association of Surgeons of Great Britain and Ireland (ASGBI), and Royal College of Surgeons (RCS), among others. We welcome the opportunity to review and comment on this draft. We have two major comments:
1.) The 'emerging health priorities' mentioned on p.18 aptly describes the epidemiological shift in disease pattern 'from communicable, maternal, neonatal and nutritional causes, towards NCDs, mental illness, and injuries.' Indeed, in 2010, 5 million people died from injuries alone and almost 8 million people died from cancer compared with 3.8 million from HIV, TB and malaria combined. Millions more suffer from disability and impairment as a result of NCDs and injuries.
1.) The 'emerging health priorities' mentioned on p.18 aptly describes the epidemiological shift in disease pattern 'from communicable, maternal, neonatal and nutritional causes, towards NCDs, mental illness, and injuries.' Indeed, in 2010, 5 million people died from injuries alone and almost 8 million people died from cancer compared with 3.8 million from HIV, TB and malaria combined. Millions more suffer from disability and impairment as a result of NCDs and injuries.
While we support a global effort to prevent and control NCDs and injury, we firmly believe that investments in health systems are integral to preventing premature death and severe, crippling disability from conditions requiring surgical care, especially injuries and emergencies. This was rightly pointed out on p.19, with mention of the "need for action to strengthen the building blocks of national health systems, including…infrastructure (including surgical capacity)." Many lives can be saved with simple, timely and cost-effective surgical interventions. It is estimated that approximately 2 million lives could be saved if services and systems for care of the injured are strengthened. These lives lost are usually the most economically-productive individuals in society and hence, places a severe economic burden on developing countries.
However, surgical care continues to receive little attention, funding and priority among public health professionals, governments, funding agencies, and ministries of health. 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 many parts of the world. Unless the conversation changes in terms of public health priorities, there is little reason to believe that surgical health systems will really be strengthened.
2.) We applaud the goal of Universal Health Coverage (UHC) and agree that "access to quality health services is a vital component of efforts to improve healthy life expectancy." On p.23, it was mentioned that "Access to needed services (primary, secondary, and tertiary including surgical care) improves or maintains health, allowing people to earn incomes and children to learn, thus providing them with a means to escape from poverty."
We would like to stress that surgical care is not merely a 'tertiary' service; rather, certain surgical procedures are 'primary' in that they are, as defined in the declaration of Alma-Ata, "essential health care that are practical and cost-effective and should be made universally accessible to every individual in the community."
Simple surgery must be seen as a primary health need, as trauma is a disease of epidemic proportions affecting mainly the young and healthy in the prime of life. Examples of necessary primary health care include emergency surgical services, especially immediate care of the injured to prevent premature death and unwanted crippling disability. Health care cannot be considered universal if mothers continue to die from lack of cesarean section when faced with obstructed labor or lack of surgical means to control severe hemorrhage from childbirth, or when injured patients cannot return to a full healthy state because of lack of simple wound or fracture care, or when children cannot be given opportunities to thrive because of an unmanipulated clubfoot.
We argue that building surgical capacity in health systems is the most holistic strategy to strengthen it. The crosscutting nature of surgery allows simultaneous service for maternal and child health, injury, NCDs, HIV prevention, treatment for certain infectious disease sequelae, and blindness. Furthermore, the provision of safe surgical care, whose results are immediately seen, builds the profound trust of the community in the health system.
ICES would therefore like to propose and support:
1. High-level attention and priority on building surgical capacity as a primary care component in national health systems not only on infrastructure, but more importantly in training the health workforce to provide the most basic, essential, life-saving and disability-preventing surgical care.
2. A focus on strengthening human resources for health by strengthening training in primary surgical services for health care providers (including non-surgeons) at health posts and district-level facilities, including modular training in basic essential surgical procedures.
3. A call to government agencies to create policies to provide incentive for trained surgical healthcare professionals to cooperate in strengthening surgical capacity in underserved areas by mentoring health workers to provide basic essential surgical care and to create a framework for career development for health workers, thus increasing retention.
4. Global advocacy for surgical care with public-private partnerships to leverage private sector resources as part of the recipe for targeted improvements in health care. The World We Want post-2015 is a society moving towards strong, robust and integrated health systems that utilizes current medical and surgical knowledge to provide appropriate and safe care, where citizens who have fallen from accidents or who stand on the brink of death or disability from untoward incidents may also be given a real chance to gain their life and health back so they may live, grow and be productive.
