Introduction
Recently, surgical services have been gaining greater attention as an integral part of public health in low-income countries. Up to 11% of the global burden of disease is estimated to be secondary to surgical conditions, led by injuries, complications of childbirth, congenital anomalies, and cancer. This estimate does not include acute abdominal emergencies and surgical infections that are likely to also contribute substantially to the burden [
1]. Evidence suggests a tremendous unmet need for surgical services in low-income countries; only 3% of global surgical output occurs in poor or low health expenditure countries compared to 75% in richer countries [
2]. The significant preventable morbidity and mortality from surgical conditions has prompted leading experts in public health to refer to surgery as the “neglected stepchild” of global health [
3], and others to point to the essential role of surgical services in meeting the Millennium Development Goals [
4]. The recent Copenhagen Consensus also ranked essential surgery as one of the highest priority investments to improve the health of the world’s poor [
5]. Despite these calls to action, there has been very limited discussion about the key aspects of health policy development to improve access to surgical services in low-income settings.
In Uganda, the most recent burden of disease estimates, from 1995, showed especially high mortality from complications of pregnancy and trauma [
6]. More recent evidence from nine rural hospitals also suggests high unmet need for surgical services, with surgical output similar to estimates from over a decade ago [
7‐
9]. To address this lack of adequate surgical services in Uganda, a diverse group of local stakeholders, including providers of surgical and perioperative services in the public and not-for-profit sectors, policy-makers, public health experts, and academic leaders, met in Kampala, Uganda, on May 12, 2008 to share recent research, prepare for the second meeting of the Bellagio Essential Surgery Group [
10], and develop a roadmap of key policy actions that would improve surgical services. More specifically, participants included surgeons (general surgery, orthopedics, urology, plastic), obstetrician-gynecologists, and anesthetists from the primary medical schools (Makerere and Mbarara Universities), including officers of the Association of Surgeons of Uganda, Ministry of Health officials (divisions of Clinical Services and Human Resources), World Health Organization officials, Makerere University School of Public Health faculty (Epidemiology), representatives of the Uganda Catholic and Protestant Medical Bureau, and the Nursing Department at Makerere Medical School (see the
Appendix for list of participants). This was the first such multidisciplinary meeting in Uganda with a focus on surgical services.
A primary goal of this meeting was to generate a list of priority areas of health policy to improve surgical services in Uganda. This article summarizes the consensus recommendations of the group that were generated during this meeting, with references to recent supporting literature. The authors are surgeons who organized the meeting and have experience with surgical practice in Uganda, some with primary practice in Uganda (SL, MG, JM) and others as part of a international partnership to improve capacity for surgical services (DO, SJ). The stakeholders developed this list and agreed to share it with the international community in order to promote the importance of surgical services within health policy discussions. The priority areas of action are considered in three areas: (1) human resources, (2) health systems, and (3) research and advocacy. While discussed separately, these areas also have considerable overlap.
Key aspects of research and advocacy to raise the profile of surgery within public health
The research agenda related to the role of surgery in health systems in resource-constrained settings is very broad. The burden and epidemiology of surgical conditions, economic evaluation of surgical services, and best practices for human resources to improve surgical and perioperative care need to be studied carefully. This evidence must be shared in the public arena and with policy-makers. Context-specific gaps in knowledge related to surgical services must be identified. This could be facilitated by the creation of a databank of questions and needed research at the academic centers. For example, the role that illness has on inducing poverty has been shown by others [
35]. This link must be studied further for surgical conditions that can have severe financial consequences for patients and families; the corollary is that improved surgical care can directly impact poverty reduction.
Raise public awareness about surgical services
We must raise public awareness and educate the community about the management of surgical conditions. Successes in surgery can be shared with the community and can help build the image of the health care system as a whole. By publishing “before and after” photos or testimonials to show the miracles of modern surgery, surgeons can demonstrate treatments that are available to the public. Unfortunately, the common public perception is that having an operation in theater means life or death and that the operating theater is a dangerous place. This needs to be addressed. Surgeons do not interact with the media enough to dispel such myths. For example, traditional healers have more airtime on radio than surgeons. Indeed, studies have shown that patients with fractures are more likely to go to a bone-setter than a physician [
36]. By being our own advocates, we can help improve the image of surgery in the community. The public perception of the high costs of surgery must also be addressed with help from the Ministry of Health.
Advocate for donor support and collaborations for surgical services
Donors often set the health agenda and active recommendations by the surgical community will facilitate more allocation of resources to improve access to surgical care. We need to make clear that surgical services are not luxury items and to define a set of requirements for donors to meet to provide the essential package of medical and surgical services. Approximately $75/capita/year is spent on health in Uganda; however, only a minority of donor projects has been allocated for surgical services in recent years [
37]. A key part of this effort is overcoming the perception that resources for surgical care are too expensive by sharing recent research that supports the cost-effectiveness of investments in surgical care [
38‐
40]. Some of this work has highlighted that a hospital surgical ward has comparable cost-effectiveness in terms of burden of disease averted with other essential health interventions focused more on primary health care. In addition, specific interventions for surgical conditions have suggested that care be improved at a modest cost. The FIGO project, which focused on emergency obstetric care in the Kiboga district, is an excellent example of how international collaboration between professional organizations with donor support can improve delivery of services (US$0.86/capita/year for a district with a population of 171,000) [
41]. A basic trauma care program for lay first responders has been estimated to cost US$0.12/capita to cover the capital city of Kampala [
42]. Some of these basic estimates can be used to determine costs of scaling up care, and further prospective studies at the district level can provide greater evidence. Collaborations with international organizations and academic centers will be critical to moving forward.
Recast the role of “The Surgeon”
Delivering on the recommendations above requires that the job description of a specialty-trained surgeon and members of the surgical team be modified from the narrow perspective of a clinical provider of surgical care. In particular, given the shortage of surgical specialists, the job description must include more training and supervision rather than solely clinical care [
43]. In other words, in addition to direct clinical care, qualified surgeons must spend more time teaching and training medical students, nonphysician providers, and other members of the health-care team to identify and treat surgical conditions. In a possible model, specialist surgeons have an ongoing relationship with medical officers (often junior doctors) and clinical officers in rural district hospitals that would allow for regular visits and supervision (e.g., doing operations together) to maintain skills and provide continuing medical education. Furthermore, the conduct and professionalism of specialist surgeons immediately impacts recruiting of more surgical providers. In addition, the perception of surgeons as individual providers should be shifted more to the perception of being part of a surgical team that includes anesthesia and nursing. Overall, surgeons must get more actively involved in advocating for their patients and for the role of surgery within health systems.
Limitations
While this meeting was important to gather various constituencies and to develop a consensus of key areas of action in the policy realm in order to improve surgical services, it is a first effort and we must highlight a number of limitations that are areas for further inquiry as the group moves the agenda forward. First, while this group included a diversity of actors, there is a need for greater representation of clinicians from district hospitals and lower-level health centers. Furthermore, the group did not formally rank these recommendations, although there was an overall emphasis on the policies related to human resources. In follow-up meetings, the group may need to focus on a ranking exercise to assign some relative priority to the wide-ranging recommendations. In addition, cost estimates of the various recommendations would be necessary to guide policy-makers. No such estimates exist for the recommendations highlighted by the group (even from other countries), although the per capita cost of several specific projects has been discussed previously. A prospective study with a cost-effectiveness evaluation on interventions to “scale up” surgical services at a district level could be a logical next step.
Conclusions
Increasing access to surgical and perioperative services in Uganda requires multidisciplinary action by care providers, policy-makers, and academic leaders. Priority action areas are related to human resources for health, health systems, and research and advocacy and are summarized in Table
1. These recommendations were created by consensus during the first meeting of local stakeholders in Kampala, Uganda, and members of the group, in collaboration with local and global colleagues, continue to work toward the actions listed here. We hope that sharing this discourse with the global community can provide a road map of forward progress and can raise the profile of surgery within public health. Surgeons have a critical role to play in health policy discussions and their advocacy will be critical to improving service delivery. Finally, improvements in access and delivery of surgical services have the potential to avert a significant portion of the burden of disease and to help Uganda in meeting the Millennium Development Goals.
Table 1
Summary of key policies to improve surgical services in Uganda: results of a stakeholders meeting
Surgical human resources |
Improve the conditions of the surgical workforce (e.g., hardship allowances, housing, education for children, career advancement opportunities, occupational safety) |
Facilitate “task extension” for specialist surgeons (clarify role of midlevel providers, provide greater support and supervision to rural medical officers providing surgical services) |
Redesign undergraduate medical curriculum to recruit more surgeons |
Redesign internship curriculum to improve surgical skills of intern doctors |
Expand and improve training for anesthesia and nursing as allied disciplines |
Surgical services and health systems |
Integrate surgical services with existing programs (e.g., HIV-AIDS, childhood illness, safe motherhood, “basic package” of health services) |
Ensure that infrastructure, equipment, supplies for safe surgery are always available and functional (expand and improve biomedical engineer training, adhere to donation guidelines) |
Institute effective planning, monitoring, and evaluation of surgical services (use of WHO Safe Surgery Checklist and Situation Analysis Tool) |
Research and advocacy |
Facilitate research (i.e., burden and epidemiology of surgical conditions, economic evaluation including impact on poverty) |
Raise public awareness about surgical services (engage media) |
Advocate for donor support for surgical services |
“Recast” the role of the surgeon |
Open Access
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