THE NEW FACE OF PRIMARY HEALTH CARE: WHO's Global Initiative for Emergency and Essential Surgical Care

By Tharani Kandasamy, MD & Whitney Berta, PhD

Consider, if you will, the following clinical encounters: a 20 years old woman with obstructed labor; a 10 years old boy injured in a motor-vehicle accident; a 40 years old woman with third-degree burns and a 60 years old man with an abdominal bleed. Although these common surgical emergencies can be associated with any number of complications, chances are exceedingly high that in developed countries, the majority of these patients will undergo life-saving surgical procedures and ultimately be discharged home in a timely manner. Now, imagine these same patients presenting, not to an urban tertiary care academic center, but to a local district hospital in a low or middle-income country (LMIC). How will these patients fare?

Truth is, we don't really know; as with other conditions prevalent in resource-limited settings, there is a paucity of reliable epidemiologic data on surgical diseases in these settings ¹. Still, what little we do know makes a sufficiently compelling case for the significant burden posed by surgically treatable conditions in low and middle-income countries ^1,2,3. According to WHO, each year, nearly one million people die from injury-related causes, including trauma and unintentional injuries and more than half a million women die from pregnancy-related complications.3 Young people, between the ages of 15 and 44 years old, in particular, bear a significant burden of the surgical diseases in LMICs. In addition to obstetric deaths among women of reproductive age, individuals between the ages of 15 and 44 years old account for almost 50% of the world's injury-related mortality ^1,4,5. Among young men, road traffic injuries constitute the second highest cause of ill health and premature death worldwide, second only to HIV and AIDS ³. The fact that common complications of HIV infections (such as abscesses, anorectal disorders, lymphadenopathies, lipoatrophy or mild forms of Kaposi sarcoma) often require simple surgical interventions further highlights the significant burden posed by lack of access to basic surgical services ².

As developing countries rapidly urbanize and motorize, the situation is likely to worsen. It is projected that by 2020, surgical conditions will account for up to half of the global burden of disease ^1,4,5. Unintentional injury will rank third behind coronary artery disease and depressive disorders in the global burden of diseases in developing countries ⁵. These projections highlight not only the importance of recognizing surgically treatable conditions as a leading cause of preventable morbidity and mortality in developing countries but also the urgent need to address the gross deficiencies in the provision of surgical interventions in resource-limited settings ².

It is estimated that only one-third of severely injured patients in rural areas of developing countries ever reach a healthcare facility ⁶. For those that do reach a facility, the outlook remains grim as the majority of these first referral level (district or rural) health facilities are ill-equipped to provide basic resuscitation or perform simple life-saving surgical procedures such securing the airway with intubation or chest tube insertion ^7,8. Further, given the geographic isolation and poor transportation infrastructure of many of these remote facilities, basic surgical and anesthesia care cannot be safely postponed until the patient is transferred to a distant referral-level health facility. Consequently, these typically urban referral-level facilities are unable the meet the needs of patients in more remote and rural districts that disproportionately bear the burden of surgical disease mortality ⁸.

While the inability of health systems in resource-limited settings to meet the needs of surgical patients is rooted in part in the pervasive deficits in infrastructure, physician and human resources for health in LMICs, the effects of these factors on the provision of surgical interventions have been further compounded by the neglect of surgical diseases, including burns, fractures and abdominal and obstetric emergencies in large-scale public health projects in developing countries ^1,2. Until recently, surgical interventions were overlooked in public health services planning and programming, citing rationale that surgical and anesthetic services were high-cost interventions that are incongruent with the traditional public health focus on low-cost broad coverage interventions ^1,2.

However, emerging evidence counters this notion and suggests that surgical services, including opthalmological, obstetrical, gynecological and thoraco-abdominal, might prove cost-effective primary health interventions ^1,2,9,10,11. This recognition of surgical diseases as an important public health problem is underscored by the dedication of an entire chapter in the second edition of the World Bank book Disease control Priorities in Developing Countries to this topic ¹. The authors argue for the cost-effectiveness of surgical interventions in resource-limited settings and call for the integration of basic surgical services into primary-health programmes.

In response, the World Health Organization (WHO) has launched a major effort, the Global Initiative for Emergency and Essential Surgical Care (GIEESC), to place surgery in the public health agenda in developing countries by prioritizing the need to strengthen surgical systems and build surgical capacity ^2,12. The specific objectives of this global collaboration were to strengthen capacity to deliver effective emergency surgical care at the district hospital and to ensure safe and appropriate use of emergency and essential surgical procedures in resource-limited facilities. Through this initiative, evidence-based surgical care is promoted by collaborating with national ministries of health and health care professionals to develop training and education programs to implement evidence-based cost-effective surgical interventions at target sites ^12,13.

Working closely with LMIC partners, WHO has developed integrated training programmes that promote the ability of primary healthcare workers at local district hospitals to perform emergency and essential surgical procedures ^2,13. Emphasis is placed on simple and cost-effective surgical interventions including - basic resuscitation, anesthesia, and select surgical interventions such as wound debridement, chest tube insertion and incision and drainage of abscess ⁸. Workshops are carried out on site at the facilities, in collaboration with the Ministry of Public Health and capacity is built by training local health care workers as trainers who will to continue the teaching efforts at other sites in their home country ¹².

To date, 24 WHO-led emergency and essential surgery workshops have been completed and 2 major international GIEESC meetings have convened ^2,12,13. World-wide GIEESC collaborating partners, many of whom are surgeons from tertiary care academic centers, are engaged in research and awareness initiatives to promote the integration of basic surgical services into primary-health programs. In effect, GIEESC is calling for a fundamental shift in the traditional health systems models that view primary public health care and tertiary care surgical facilities as mutually exclusive and distinct services. But, these are but the early steps. In moving the research agenda forward, a broader coalition of research, clinical and policy experts are needed in establishing the true magnitude of the burden of surgical diseases in LMICs, in accurately assessing the surgical capabilities at the facility and national level and in rigorously evaluating the impact of the WHO emergency and essential surgery initiative at the patient, healthcare worker, health systems level. Instead an expanded model of public health that includes life-saving surgical interventions is proposed in order to ensure that life-saving surgeries are to benefit those who need it the most regardless of the clinical setting. As Dr. Meena Cherian, who heads the GIEESC intiative from WHO says, "why should a child die from appendicitis, or a mother and child succumb to obstructed labour, when simple surgical procedures can save their lives?"

Tharani Kandasamy is a surgical resident and masters of science candidate from the University of Toronto. A former contributor to Global Pulse, she is currently participating in an internship in the Department of Essential Health Technologies of the WHO in Geneva, working with Dr. Meena Cherian to accelarate research interest and efforts in the area of surgical diseases in resource-limited settings. She can be contacted for questions or comments at tharani.kandasamy@utoronto.ca.

Whitney Berta, PhD, is an Associate Professor of the Deparment of Health Policy Management and Evaluation at the University of Toronto, in Ontario, Canada. She can be reached for questions or comments at whit.berta@utoronto.ca.

References:

¹ Debas, H.T., R. Gosselin, Colin McCord, and A. Thind. 2006. "Surgery." In Disease Control Priorities in Developing Countries, 2nd ed., ed. D.T. Jamison, J.G. Breman, A.R. Measham, G. Alleyne, M. Claeson, D.B. Evans, P. Jha, A. Mills and P.Musgrove, 1245-60. New York: Oxford University Press.

² Spiegel DA, Gosselin RA. Surgical services in low-income and middle-income countries. Lancet. 2007 Sep 22; 370 (9592):1013-5.

³ World Health Organization. World Health Report. Geneva, Switzerland: World Health Organization; 2003.

⁴ E. G. Krug, G. K. Sharma and Q. Lozano. 2000. The Global Burden of Injuries. American Journal of Public Health 90: 4 523 - 26.

⁵ M. Peden and A. A. Hyder. 2002. Road Traffic Injuries Are a Global Health Problem British Medical Journal 324: 7346 1153 - 54.

⁶ C. N. Mock. 2003. Improving Prehospital Trauma Care in Rural Areas of Low Income Countries Trauma 54: 6 1197 - 98.

⁷ Cherian MN, Noel L, Buyanjargal Y, Salik G. Essential emergency surgical procedures in resource-limited facilities: a WHO workshop in Mongolia. World Hosp Health Serv 2004; 40: 24-29.

⁸ WHO. Surgical care at the district hospital, 2003. http://www.who.int/surgery/publications/scdh_manual (accessed March 10, 2008).

⁹ Gosselin RA, Thind A, Bellardinelli A, Cost/DALY averted in small hospital in Sierra Leone: what is the relative contribution of different services? World J Surg 2006: 30: 505-11.

¹⁰ McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet 2003; 81:83-92.

¹¹ Javitt JC. The cost effectiveness of restoring sight. Arch Ophtholmol 1993; 111: 1615.

¹² WHO. Report WHO meeting towards Global Initiative for Emergency and Essential Surgical Care. http://www.who.int/entity/surgery/mission/GIEESC2005_Report.pdf (accessed March 10, 2008)

¹³ WHO. Workshop reports. http://www.who.int/surgery/education_training (accessed March 10, 2008)

¹⁴ WHO. Basic surgery training to save lives and prevent disability. http://www.who.int/mediacentre/news/notes/2007/np30/en/index.html (accessed March 10, 2008)

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- Medical students interested can learn more about the initiative from the GIEESC website HERE.

- Interested students can advocate for inclusion of surgery component in the respective undergraduate medical school curriculum on global health.

- Internship opportunities with the WHO Department of Essential Health Technologies are available for interested students HERE.