Jaymie Ang Henry

Value innovation: an important aspect of global surgical care.

IntroductionLimited resources in low- and middle-income countries (LMICs) drive tremendous innovation in medicine, as well as in other fields. It is not often recognized that several important surgical tools and methods, widely used in high-income countries, have their origins in LMICs. Surgical care around the world stands much to gain from these innovations. In this paper, we provide a short review of some of these succesful innovations and their origins that have had an important impact in healthcare delivery worldwide.ReviewExamples of LMIC innovations that have been adapted in high-income countries include the Bogotá bag for temporary abdominal wound closure, the orthopaedic external fixator for complex fractures, a hydrocephalus fluid valve for normal pressure hydrocephalus, and intra-ocular lens and manual small incision cataract surgery. LMIC innovations that have had tremendous potential global impact include mosquito net mesh for inguinal hernia repair, and a flutter valve for intercostal drainage of pneumothorax.ConclusionSurgical innovations from LMICs have been shown to have comparable outcomes at a fraction of the cost of tools used in high-income countries. These innovations have the potential to revolutionize global surgical care. Advocates should actively seek out these innovations, campaign for the financial gains from these innovations to benefit their originators and their countries, and find ways to develop and distribute them locally as well as globally.

The benefits of international rotations to resource-limited settings for U.S. surgery residents.

BACKGROUND U.S. surgery residents increasingly are interested in international experiences. Recently, the Residency Review Committee approved international surgery rotations for credit toward graduation. Despite this growing interest, few U.S. surgery residency programs offer formal international rotations. We aimed to present the benefits of international surgery rotations and how these rotations contribute to the attainment of the 6 Accreditation Council for Graduate Medical Education (ACGME) competencies. METHODS An e-mail-based survey was sent in November 2011 to the 188 members of Surgeons OverSeas, a group of surgeons, residents, fellows, and medical students with experience working in resource-limited settings. They were asked to list 5 benefits of international rotations for surgery residents. The frequency of benefits was qualitatively grouped into 4 major categories: educational, personal, benefits to the foreign institution/Global Surgery, and benefits to the home institution. The themes were correlated with the 6 ACGME competencies. RESULTS The 58 respondents (31% response rate) provided a total of 295 responses. Fifty themes were identified. Top benefits included learning to optimally function with limited resources, exposure to a wide variety of operative pathology, exposure to a foreign culture, and forming relationships with local counterparts. All ACGME competencies were covered by the themes. CONCLUSION International surgery rotations to locations in which resources are constrained, operative diseases vary, and patient diversity abound provide unique opportunities for surgery residents to attain the 6 ACGME competencies. General surgery residency programs should be encouraged to establish formal international rotations as part of surgery training to promote resident education and assist with necessary oversight.

Surgical and anaesthetic capacity of hospitals in Malawi: key insights

Background Surgery is increasingly recognized as an important driver for health systems strengthening, especially in developing countries. To facilitate quality improvement initiatives, baseline knowledge of capacity for surgical, anaesthetic, emergency and obstetric care is critical. In partnership with the Malawi Ministry of Health, we quantified government hospitals’ surgical capacity through workforce, infrastructure and health service delivery components. Methods From November 2012 to January 2013, we surveyed district and mission hospital administrators and clinical staff onsite using a modified version of the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool from Surgeons OverSeas. We calculated percentage of facilities demonstrating adequacy of the assessed components, surgical case rates, operating theatre density and surgical workforce density. Results Twenty-seven government hospitals were surveyed (90% of the district hospitals, all central hospitals). Of the surgical workforce surveyed (n = 370), 92.7% were non-surgeons and 77% were clinical officers (COs). Of the 109 anaesthesia providers, 95.4% were non-physician anaesthetists (anaesthesia COs or ACOs). Non-surgeons and ACOs were the only providers of surgical services and anaesthetic services in 85% and 88.9% of hospitals, respectively. No specialists served the district hospitals. All of the hospitals experienced periods without external electricity. Most did not always have a functioning generator (78.3% district, 25% central) or running water (82.6%, 50%). None of the district hospitals had an Intensive Care Unit (ICU). Cricothyroidotomy, bowel resection and cholecystectomy were not done in over two-thirds of hospitals. Every hospital provided general anaesthesia but some did not always have a functioning anaesthesia machine (52.2%, 50%). Surgical rate, operating theatre density and surgical workforce density per 100 000 population was 289.48–747.38 procedures, 0.98 and 5.41 and 3.68 surgical providers, respectively. Conclusion COs form the backbone of Malawi’s surgical and anaesthetic workforce and should be supported with improvements in infrastructure as well as training and mentorship by specialist surgeons and anaesthetists.

The Amsterdam Declaration on Essential Surgical Care

On behalf of the supporting organisations and all participants of the international symposium ‘Surgery in Low Resource Settings’, November 2014, in Amsterdam, we present the ‘Amsterdam Declaration on Essential Surgical Care’. The situation with regard to a lack of surgical capacity in LMICs is untenable, and urgent action is required to alleviate the situation. Many thousands of patients are dying unnecessarily every day because there is no one trained to operate on them. As a consequence, the death toll of surgical conditions in low resource settings currently outnumbers the death toll of HIV, malaria and TB combined. Rarely has there been such unanimity in the field of global surgery, and there is urgent action needed. The lack of surgical care will be on the agenda during the World Health Assembly in May 2015. We solicit international health policy makers to support the initiative towards a WHA resolution on ‘Strengthening Emergency and Essential Surgical Care and Anaesthesia as a component of Universal Health Coverage’. We need to make the world realize that we completely forgot something: Surgery should be part of the United Na-

Essential Surgery: The Way Forward

IntroductionVery little surgical care is performed in low- and middle-income countries (LMICs). An estimated two billion people in the world have no access to essential surgical care, and non-surgeons perform much of the surgery in remote and rural areas. Surgical care is as yet not recognized as an integral aspect of primary health care despite its self-demonstrated cost-effectiveness. We aimed to define the parameters of a public health approach to provide surgical care to areas in most need.MethodsConsensus meetings were held, field experience was collected via targeted interviews, and a literature review on the current state of essential surgical care provision in Sub-Saharan Africa (SSA) was conducted. Comparisons were made across international recommendations for essential surgical interventions and a consensus-driven list was drawn up according to their relative simplicity, resource requirement, and capacity to provide the highest impact in terms of averted mortality or disability.ResultsEssential Surgery consists of basic, low-cost surgical interventions, which save lives and prevent life-long disability or life-threatening complications and may be offered in any district hospital. Fifteen essential surgical interventions were deduced from various recommendations from international surgical bodies. Training in the realm of Essential Surgery is narrow and strict enough to be possible for non-physician clinicians (NPCs). This cadre is already active in many SSA countries in providing the bulk of surgical care.ConclusionA basic package of essential surgical care interventions is imperative to provide structure for scaling up training and building essential health services in remote and rural areas of LMICs. NPCs, a health cadre predominant in SSA, require training, mentoring, and monitoring. The cost of such training is vastly more efficient than the expensive training of a few polyvalent or specialist surgeons, who will not be sufficient in numbers within the next few generations. Moreover, these practitioners are used to working in the districts and are much less prone to gravitate elsewhere. The use of these NPCs performing “Essential Surgery” is a feasible route to deal with the almost total lack of primary surgical care in LMICs.

Global Surgical Care in the UN Post-2015 Sustainable Development Agenda

The 2015 Millennium Development Goals (MDGs) provided the global development community with an opportunity to reflect on the triumphs and challenges encountered over the last 15 years. Despite great strides in achieving maternal and child health targets, significant disparities in maternal surgical care persist [1]. Investments and scale-up of obstetric surgery and anaesthesia care are critical to close the gap in maternal mortality [2]. These and other essential surgical interventions address inequalities in health that remain outside the defined scope of the international global health agenda. Although the international community fell short of prioritizing surgical care as part of the MDGs, the post-2015 sustainable development agenda represented a rare opportunity for surgical care to be recognized as a global priority. As part of this multi-year agenda setting process, governments and members of civil society have been coming together through a number of processes to develop a core list of goals, targets, and indicators to guide development around the world (Fig. 1). Despite efforts to raise the profile of surgical care as a critical public health issue, it has remained conspicuously absent from post-2015 discussions [3]. This critical omission deserves further examination, and warrants the mobilization of stakeholders in surgical care and anaesthesia from around the world to unite in support of the neglected surgical patient.

Essential Surgery: The Way Forward: Reply.

To the Editor, We thank Monjok, E. for his comments on our article [1] regarding essential surgical training in Sub-Saharan Africa [2]. Indeed, the character and type of training; i.e., 3 versus 5 years, focused versus comprehensive, and rural versus urban posting; should remain within the purview of the local training institution which has the best gauge of the surgical needs of their community. Training patterns in high-income countries should merely serve as guides, but should not be expected to account for the contextual realities in lowand middle-income countries. Training general practitioners (GPs) or family medicine physicians (FPs) in surgery is not a novel phenomenon. GPs who underwent a 6-month training program in Ethiopia were found to be able to provide life-saving surgical care at a modest cost. [3] The challenge, however, lies in ensuring appropriate quality training with adequate delineation of scopes of competence and responsibility and ability to recognize the need to refer patients when needed, but also to recognize when referral itself may prove deleterious because of local conditions. There is a balance to be made on the amount of training and supervision provided for GPs, FPS, and non-physician clinicians (NPCs), as well as adequate incentives to encourage retention. We accept the feedback on the terminology ‘Non-surgeon Physician’ and agree that ‘Surgical Medical Officer’ is a viable option. However, many countries will wish to retain their own nomenclature. As validating a cadre of health worker necessitates political buy-in, Ministers of Health and other members of the health community need to be included in these discussions to achieve appropriate endorsement and legalization to achieve the ultimate goal of providing access to safe, quality, essential surgical care for all.

Cost-effectiveness of Dental Surgery Procedures: A Call for Strengthening the Evidence: Reply

We thank Benzian and Neiderman [1] for their comments regarding the lack of evidence for the cost-effectiveness of dental surgery in the literature in their response to our article [2]. Indeed, neglect of cases requiring immediate dental extraction is an important cause of sepsis in lowand middleincome countries (LMICs) which can ultimately be life threatening. As part of the International Collaboration of Essential Surgery, we believe that essential surgical procedures, defined as simple interventions that save lives and prevent disability, should be available and accessible to all, and that includes dental extraction for neglected caries. We agree with their call for more cost-effectiveness studies to be done on tooth extraction to dispel the myths that surgical interventions are costly. We also call again for more studies to be done on the cost-effectiveness of other neglected simple surgical interventions for common disabling and life-threatening surgical conditions. We note an increasing interest in atraumatic restorative treatment for dental caries, which removes the need for drills, electricity, or running water and which has been specifically developed for LMICs [3]. Studies on comparative costs and benefits of this technique are also apposite. We join with Benzian and Neiderman in calling for the inclusion of basic oral surgery in the armamentarium of Essential Surgeons.