Surgery for All
On a recent trip to India, I hailed a rickshaw that was pedaled, I soon noticed, by a man with a lame leg. It turns out that a few weeks earlier, the driver had been hit by a car while navigating the busy streets of New Delhi. Although he had managed to obtain medication from a local pharmacy for the agonizing pain – probably because his leg was broken – he could spare neither the time nor the money to see a surgeon
This type of tragic calculus is strikingly common. The Lancet Commission on Global Surgery estimates that some five billion people – almost 70% of the world’s population – lack access to safe, affordable surgical and anesthetic care, while 33 million people are saddled with unbearably high health expenses. Not surprisingly, the global poor suffer disproportionately: while low-income countries are home to close to 35% of humanity, they account for just 3.5% of all surgical procedures.
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One of the biggest obstacles to achieving universal health coverage – which the United Nations has declared a global goal – is financing. And, paradoxical as it may sound, one of the best ways that governments can get the money they need to expand coverage is by making surgery more widely available.
Time-sensitive health problems – such as injuries from traffic accidents and pregnancy-related complications – are among the leading causes of death and disability in low- and middle-income countries. But untreated or undertreated conditions requiring surgery also hurt economic productivity. For example, the Lancet study estimated that the failure to improve surgical care in developing countries would translate into $12.3 trillion of lost economic output by 2030. Failure to maintain strong surgical capacity could even undercut economic gains made by middle-income countries, reducing total GDP growth by approximately 2% annually.
For many leaders, the common perception is that provision of surgical care is not sustainable or cost-effective. When faced with tough budget choices, governments often favor programs that combat infectious and chronic diseases, leaving people like my rickshaw driver in the lurch.
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But a growing body of evidence suggests that these views are misplaced. When researchers at the Harvard Medical School analyzed surgical interventions in low- and middle-income countries, they found a remarkable disconnect between economic assumptions and reality. For example, they calculated that money spent on cesarean sections and joint surgeries yields higher returns than spending on the management of HIV or heart disease.
To be sure, chronic and infectious diseases need our attention, too; we cannot restructure health systems overnight, nor should we turn our backs on those being treated for non-surgical illnesses. But reforms that focus more attention on the importance of surgery would boost economic productivity and help create more equitable health care for everyone.
For starters, health ministries and physician organizations should formally recognize that surgical and anesthetic care are an essential part of universal health coverage. To make this case, health-care providers will need to improve their collection and analysis of data on surgical outcomes, which would increase transparency on mortality and morbidity and strengthen overall accountability. Decisions about how to expand services could be guided by the Lancet commission’s core indicators on “preparedness,” “delivery,” and “impact” of surgical care.
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Second, to pool risk and guard against cost overruns, countries that are considering universal coverage policies should put surgical care under publicly financed plans. While some funding for expanding surgical services could come from taxation, health-care providers should also explore innovative financing options – such as “social justice models,” whereby people pay according to their means.
Finally, to streamline resources and increase surgical capacity, hospitals should explore task-sharing, whereby non-emergency cases are referred to licensed nurses and physician assistants. Longer-term strategies include investing more in medical education to bolster the ranks of doctors and surgeons.
The tremendous economic progress that many developing countries have made in recent decades has been largely driven by vibrant, young, and ambitious populations. One of the most effective ways to maintain this growth and development is to ensure access to safe and affordable healthcare – including surgery. While the cost of providing it may be high, the cost of not providing it is even higher.
Junaid Nabi, a physician and public health researcher, is a 2018 Aspen New Voices Fellow. @JunaidNabiMD
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