Reimagining Universal Health Coverage: Safe and Affordable Surgery

I. INTRODUCTION

Strengthened health system is a foundation for universal health coverage (World Health Organization, 2021b). For UHC to be genuinely inclusive, a transition must be made from health systems organized around diseases and institutions towards health systems for people. This is the goal of the sound health system as the primary health care system underlies the commitment to social justice, equity, solidarity and participation (World Health Organization, 2021a). It is founded on the notion that the enjoyment of the highest attainable standard of health is one of every human being’s fundamental rights (World Health Organization, 2021a). Thus, strengthened health system is rendered more crucial necessity for UHC.

The world has been stricken hard by the COVID-19 pandemic. However, the value of stable health system has never been more evident. While progress has been made in primary health care, more solid policies, and more socially encompassing participation are all necessary for UHC. WHO stated that member nations are falling behind in attaining the 2019 UN General Assembly’s aim of UHC for everyone in the world by 2030. Despite progress in average levels of service coverage, 710 million people still lack access to health services, compared to the aim of 1 billion people benefiting from UHC (Prince, 2021). According to Tedros, the Director General of WHO, “the world is far behind.”

Surgical care is one of the topics which have been largely overlooked in the global health sector (Farmer, 2008). Despite the concerted efforts of the world’s governments and individuals to bring about UHC, it has allocated relatively little time and attention in improving surgical care than it has in other sectors. Regardless of the fact that surgery can address a substantial proportion of the world’s critical public health problems, the value of surgical treatments is yet to be fully appreciated, but rather treated as the “neglected stepchild of global health” (Farmer, 2008). Undeniably, however, surgical care is an indispensable component of UHC (Roa, et al., 2019). It is estimated that surgical intervention is required for one-third of the global burden of disease. Every year, 18 million people die from surgically treatable diseases (Meara & Greenberg, 2015b). Furthermore, potential deaths avoidable by surgery and anesthesia (16.9 million in 2010) exceed historical communicable disease deaths including tuberculosis (1.2 million), HIV (1.46 million) and malaria (1.17 million) combined (National Academies of Sciences, Engineering, and Medicine, 2017). In spite of the great need and potential impact of the global surgery movement, when comparing to the Global Fund for HIV, Malaria, and TB, which has an annual budget of over $4 trillion, the funding for surgical, obstetrical and anaesthesia has no similar mechanism (Global Surgery Foundation, n.d.). Furthermore, despite the significant worldwide burden of surgical diseases, surgery and anesthesia are overlooked in many national health policies and plans (Truché et al., 2020).

One reason surgery is continuously discounted in the global agenda is due to the myth that surgery is costly. This misguided perception acts as an impediment to universal acceptance of its potential role in accomplishing global health goals, specifically when compared with other public health measures such as vaccines or antiretroviral treatment. The uncertainty about efficacy of surgical intervention in the prevention of death and disability, and recognized criteria for surgical care quality call into doubt the value of surgery in such a setting (Chao et al., 2014).

To make matters worse, there is a clear disparity in surgical capacity between high-income and low-and middle-income countries (LMICs). In comparison to United Kingdom, which has 14.7 theatres and 30.5 general surgeons per 100,000 people, Kenya has 1.1 theatre and 0.55 general surgeon per 100,000 people (Dell, 2016). Only 3.5% of the 234 million surgeries conducted each year are performed in the world’s poorest regions, which spend less than $100 per capita on health care, but accounting for 34.8% of the worldwide population (Weiser, 2008). This consequential equity gap must be bridged by expanding people’s access to critical surgical treatment (United Nations Institute for Training and Research, UNITAR, 2020). After recognizing the need to reduce such gaps, the Lancet Comission on Global Surgery (LCoGs) recommended the development of the National Surgical, Obstetric, Anaesthesia Plan (NSOAPs) in 2015 to systematically respond to them (Peck & Hanna, 2018b). NSOAPs are strategic plans to increase access to essential surgical services by incorporating them into the broader national health plans and UHC benefits packages which are critical to ensure national implementation and scale (UNITAR, 2020).

This article intends to accentuate the need for LMICs to integrate NSOAPs into their national health policy in order to deal with the health equity gaps. It argues that Surgical Obstetric and Anaesthesia (SOA) care should be prioritized through the establishment of NSOAPs, as doing so is indispensable to achieving the United Nations Sustainable Development Goals (SDGs) and UHC. The paper will consider what NSOAPs is and then study the cost incurred from maintaining the status quo if the world does not adopt NSOAPs. We will then take a look at the cases of Zambia and Pakistan and how these countries incorporated NSOAPs into the national health plans, which will serve as examples. Lastly, the significance of NSOAPs will be analyzed and suggestions for other countries that are yet to adopt the NSOAPs will be made.

II. What IS NSOAPs AND WHAT DOES IT DO?

Many LMICs have devised systematic plans to integrate surgery into national health goals. These goals aim to help nations or regions in identifying and closing gaps as they work toward reaching the fundamental surgical standards required to offer UHC and meet WHA 68.15 commitments by 2030 (Peters et al., 2020). The NSOAP process is critical because it provides the knowledge foundation, technical competence, and political capital required to incorporate a contextualized surgical package inside UHC. Typically, the establishment of NSOAPs is overseen by ministries of health. The procedure prioritizes inclusiveness and accountability, with participation from all key stakeholders who will be impacted by the policy (Citron et al., 2018; Nyberger et al., 2018). Its inclusive and transparent characteristics serve to attract political support, create legitimacy, decrease policy opposition, and increase acceptance of the health system reform endeavor. The process also includes the participation of technical experts from various disciplines such as public health, economics, and health policy, as well as clinicians and epidemiologists in order to generate the evidence and knowledge needed to address health system gaps in workforce, infrastructure information systems, service delivery, information management, and governance (Nyberger et al., 2018).

The NSOAPs framework offers a systematic approach to improving surgical systems by addressing five health-care domains. Equipping five domains of the NSOAPs accordingly will aid in the integrations of safe, timely and affordable surgical, obstetric and anesthesia care in the LMICs.

III. MACROECONOMICS OF SURGICAL CARE: THE COST OF DOING NOTHING

Many academics developed a case for investing in surgical care based on the macroeconomics of surgical care and the cost of inactivity. For decades, they have researched the relationship between health and economic output, developing a variety of models. We would like to offer these economic models, which show that the economic costs of inactivity are substantial.

IV. THE NSOAP MODELS: CENTRALIZED AND PROVINCIAL MODELS

Countries worldwide have begun to develop NSOAPs in order to extend access to SAO care in a sustainable manner. In this paper, we present cases of Zambia and Pakistan which each represent the centralized and decentralized model. These countries concentrated on resolving health system deficiencies, incorporating surgical policies into wider national policies and including and consulting all key stakeholders in the planning process according to their respective model.

V. COVID-19 AND SURGICAL CARE

The article demonstrated in earlier parts why surgical care should be prioritized in the global agenda in terms of welfare, economic growth, and health – particularly focusing on attainment of two major global goals, UHC and SDGs. Aside from these reasons, LMICs could reframe surgical system strengthening as part of pandemic preparedness strategy. This can only be done via expanding surgical capacity (Park et al., 2020b). This is clearly demonstrated by the way the surgical system, with its “staff, stuff, space and system” is being repurposed for the treatment of COVID-19. Countries with professional surgical competence are likely to have resilient health systems, which helps coping with worldwide epidemics such as COVID-19.

The incorporation of essential and emergency surgical care into district hospitals serves as a facilitator, increasing the ability to provide additional health care services, other than just surgeries (The PLoS Medicine Editors, 2008). Because of such an intricacy (Farmer, 2008), the provision of safe surgery and anesthesia indicates the presence of a responsive health care system’s staff, stuff, space and systems (BostonGlobe, 2014, Meara et al., 2015). A system such as this is capable of not just delivering surgical care, but also of managing a wide variety of health issues, such as malnutrition, obstetric difficulties, trauma, disaster response, and infectious disease epidemics and pandemics (Kucchal et al., 2020). According to World Bank President Jim Kim’s remarks at the Commission’s first meeting, “surgery is an indivisible, indispensable part of health care” (Shrime et al., 2015).

The COVID-19 pandemic illustrated worldwide the value of surgical and anesthetic services in pandemic response. COVID-19 made no distinction between wealthy and low-income countries as it affected any country with inadequate critical care capacity worldwide. On the contrary, certain countries with appropriate surgical capability were able to react promptly (Kucchal et al., 2020). Surgeons, scrub nurses, and paramedics were re-deployed to pandemic activities where surgical capacity was confined to necessary emergency and category-1 operations (Ahmed et al., 2020). By lowering baseline operating volumes, Intensive Care Unit (ICU) resources for the patients with fatal symptoms were freed up (Ahmed et al., 2020). Unused anaesthesia machines were repurposed as ward ventilators (Rajan & Joshi, 2020). Personal Protective Equipment (PPE) normally kept for operational purposes functioned as a backup for PPE resources during case increases, until more supplies could be secured. Surge capacity gained through provision of surgical and anesthesia services proved critical in a successful pandemic response (Kucchal et al., 2020). Equipping surgical beds, ICUs, and operating theaters in tandem with a cadre of trained staff meets the population’s huge unmet surgical demands while also providing urgent treatment capacity in the times of a pandemic (Park et al., 2020b).

VI. DISCUSSION

Despite the belief that surgical treatment is complicated and expensive, surgery has been proved to be cost-effective. Scaling up surgical care to address the surgical burden of illness in surgical treatment is one of the most economical interventions in public health, comparable with well-known cost-effective interventions (UNITAR, 2020). This means that there is no reason to delay adopting surgical interventions into the national health policies of LMICs and the most appropriate tool for this is the NSOAPs.

To achieve the SDGs, SOA care is necessary Patient-focused surgical care integration is necessary to fulfill the SDGs. Increased support for SOA care is capable of making significant impact on most of the SDGs, both in regard to poverty reduction and better health and productivity. Six of the SDGs are especially dependent on the improvement of SOA: SDGs related to good health and well-being (SDG 3), SDGs related to gender equality (SDG 5), and SDGs related to economic improvement, including an end to poverty (SDG 1), decent work and economic growth (SDG 8), reduced inequalities (SDG 10) and creating the partnerships necessary to make this a reality (SDG 17). Among six goals, the goal that is most directly associated with the SOA care is SDG 3: Good Health and well-being (UNITAR, 2020).

Because surgical treatment is necessary for a hefty portion of global burden of illness, it is impossible to fulfill SDG 3 on health and well-being in LMICs without undertaking this burden. SDG 3 has nine objectives that are directly associated with SOA care. Among the nine objectives, four of them cannot be met unless SOA care is improved: 3.1 (reduce maternal mortality), 3.2 (reduce infant and under-5 mortality), 3.4 (reduce premature deaths from NCDs) and 3.6 (reduce the number of deaths and disabilities from road traffic accidents). The target 3.8 of UHC is particularly significant, since it serves as the groundwork for all other targets. It encompasses increased SOA care, which is required for reaching other objectives. To improve the maternal mortality ratio to less than 70 per 100,000 population (SDG 3.1) and the perinatal death rate to 12 per 1000 live births, scaling up SOA care will be imperative (SDG 3.2). Empirical data (Betran et al., 2015) shows that maternal and perinatal mortality will be reduced when Comprehensive Emergency Obstetric and Newborn Care (CEmONC) is available. Maternal mortality due to obstructed labour occur in around 8% of cases, and some of these women end up with obstetric fistula, a disabling and stigmatized obstetrical complication. The research done by Molina et al. (2016) studied over 22.9 million caesarean sections and found that having a national caesarean section rate up to 19% was associated with a reduced newborn death rate (2016). Not only obstructed labor but also ectopic pregnancies, obstetric fistula repair, cervical cancer, and other gynecological tumors all require surgical treatment (UNITAR, 2020).

SDG 3.4 aspires to curtail the premature mortality rate due to non-communicable diseases by one-third. As previously stated, a large percentage of malignancies, including 60% of all cancers will necessitate surgery and a robust perioperative surgical system (UNITAR, 2020). To help treat cardiovascular illness, surgical procedures such as minimally invasive or open cardiac and vascular methods are essential. The neurosurgical capability is also necessary to help alleviate the related health issues caused by a stroke (UNITAR, 2020).

Another specific goals of the SDGs, is to reduce the number of fatalities and injuries caused by road traffic accidents by half. For the treatment of trauma patients, comprehensive SOA care, as well as robust pre-hospital and emergency care systems, are necessary. Many of those who do not require intervention in the operating theatre will require surgery and anaesthetic services for correct evaluation and stabilization (UNITAR, 2020).

Furthermore, SOA care is necessary to meet UHC targets and primary health care coverage. Following the unanimous passage of resolution WHA 68.15 in 2015, emergency and essential surgery and anaesthetic treatment are major elements of UHC. UHC is defined by WHO as “ensuring that all people have access to needed promotive, preventive, curative, and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services.” 80% of all basic health care and 100% protection from out-of-pocket expenditures by 2030 are defined as objectives for universal coverage by World Bank and WHO. To reach the objectives for UHC, we will need to expand the number of people who have access to SOA care by 250% by 2030 (UNITAR, 2020). The best estimate is that up to 80%–90% of all surgical problems may be handled by district hospitals (UNITAR, 2020), so SOA care should be implemented in all attempts to enhance primary health care. To recognize this, the most effective method to increase global wellbeing was “improved surgical treatment at the district hospital,” (The PLoS Medicine Editors, 2008) as revealed in the Copenhagen Consensus.

For SOA care to function well, the cooperation of various components of the health care system is needed. In addition to the operating room environment and postoperative rehabilitation capability, other aspects include community education, prehospital care, emergency department care, strong consumable supply chains and laboratory services. Because many of these services are shared, increasing SOA care capacity can also enhance the functioning of several other aspects in the hospital. A stable supply of antibiotics for surgery, for example, not only helps to decrease postoperative sepsis in surgical patients, but it will also help reduce under-5 mortality from pneumonia. Critical care capacity combined with improved anaesthesia increases the volume and complexity of surgical treatment, but it also allows the provision of life-saving medical care for patients who are critically ill (UNITAR, 2020).

VII. SUGGESTIONS

It is critical to gain Ministry support and ownership. The first and perhaps most crucial step in effectively implementing an NSOAP is garnering support from the MoH. To increase the likelihood of NSOAP incorporation into health strategic plan (NHSP) and NSOAP execution, buy-in, support, and leadership from the MoH are essential. MoH understands country priorities, present health care environment, financial and resource capacity and implementation capabilities. Ministries are also in charge of policy creation and drafting, as well as carrying the most up-to-date knowledge of current programs and priorities, which can assist to minimize fragmentation and duplication. It is beneficial to determine where the NSOAP will be located within the MoH early in the process. Practically this can assist in establishing sustainability of leadership, governance, and accountability for the NSOAP within the MoH, particularly during the times of government transition (UNITAR, 2020).

A thorough situation analysis and baseline evaluation is essential for creating evidence-based policy. A thorough review of a country’s surgical system contributes to defining the baseline status and identifying key gaps in treatment. This can be accomplished through taking a number of approaches, including on-the-ground hospital inspections, literature studies, and analysis of existing national data. The six surgical measures proposed by LCoGs and included in the WHO core 100 Health Indicators in 2015 and 2018 might serve as a suitable starting point (UNITAR, 2020).

It is critical to include diverse stakeholders and establish priorities. A wider group of stakeholders in the planning process, including the clinical providers, professional and civil societies, academic institutions, funders and implementers, should be invited to represent the opinions and expertise of various stakeholders. NSOAPs target the entire surgical system, which may be split into six key areas to be addressed by several stakeholder groups. Taking a methodical approach to tackling each area can aid in guaranteeing that the strategy is comprehensive. Such an approach may begin with a discussion of baseline assessments, then identification of issues and prioritization of possible solutions, defining of goals and targets, and finally offering of a monitoring and evaluation strategy (UNITAR, 2020).

VIII. CONCLUSION

To sum up, to achieve the UHC and SDGs by 2030 increasing the surgical capacity of LMICs can make a significant contribution towards it. Although surgical care is the area that does not get enough attention it deserves, by integrating SOA care into national policies of LMICs, millions of people’s lives will be saved , and billions in economic losses averted. Also, increasing the surgical capacities in LMICs in the times of global pandemic will help build resilient health system and prepare for future pandemics. It is imperative that donor countries, including South Korean government, take part in the global surgery movement including the NSOAP development by countries. This will promote the strengthened health system globally.