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February 2019, Volume 69, Issue 1

Special Communication

Global Surgery: Building Healthy Surgical Systems

Authors: Taylor Leposa  ( The Honors College, East Carolina University, North Carolina, USA )
Bria Johnston  ( Department of Surgery, Duke University, North Carolina, USA. )
Sohail Dogar  ( Department of Surgery, Aga Khan University, Karachi, Pakistan )
Henry Rice  ( Duke Global Health Institute, Duke University, North Carolina, USA )
Tamara Fitzgerald  ( Surgery and Global Health, Duke University School of Medicine, Durham, NC. )

Abstract

Global Surgery (GS) is a movement that advocates access of every individual to safe and affordable surgery despite geographic location or socioeconomic status. It has recently received increased attention within the global health arena, but many patients are still without access to care because of geographical, social and economic disparities. Due to the multi-disciplinary nature of surgical services, GS requires that a worldwide network of healthy surgical systems be developed and sustained. Healthy surgical systems have many components, and this paper will briefly address 3 of those components: Improved access to care, safety and quality, and multidisciplinary
strengthening.
Keywords: Global surgery, Healthcare disparities, Surgical safety, Surgical systems, Access to care.

Introduction

Global Surgery (GS) is a movement that advocates access to safe and affordable surgery for every individual regardless of geographical location or socioeconomic
status. Historically, surgery has been the focus of medical missions in many parts of the world or largely ignored because it was thought to be too complicated and
expensive to implement on a wide scale in challenging areas. GS has recently received increased attention due to the Lancet Commission on Global Surgery,1 and the inclusion of surgical ser vices in the Sustainable Development Goals (SDGs) of the United Nations.2 Therefore it is emerging as a topic of discussion with increasing emphasis. If all people are to have access to safe and affordable surgery, then a worldwide network of healthy surgical. systems will be required. In both high-income countries (HICs) and low- and middle-income countries (LMICs) there are diverse challenges to providing safe and affordable surgery. Healthy surgical systems have many components, and the current paper was planned to briefly address three of them: improved access to care, safety and quality, and multidisciplinary strengthening.

Improved Access to Care

A surgical system is only effective to patients when it is accessible, and in many parts of the world significant obstacles still exist. Barriers to surgical care have been described in a 3-delay model: delay in seeking care, delay in reaching care, and delay in receiving care.3 Patients may delay seeking care due to geographical distance to the nearest healthcare facility, fears regarding the expense of treatment, lack of education or trust in traditional healers. Delays in reaching care are mainly attributed to geographical distances and lack of reliable and affordable transportation. Delays in receiving care occur when the nearest hospital does not provide the services that the patient needs, or the hospital is simply overwhelmed with the backlog of pending surgical cases and cannot accommodate new patients 1 In many countries, there are limited numbers of healthcare facilities, often concentrated in urban areas, while large numbers of the population live in rural areas. Lack of reliable transportation, harsh terrains, and poor travel infrastructure create geographical barriers.4 This geograph ical separati on between patients and healthcare facilities has been documented in diverse regions of the world, such as communities in Mexico where individuals must travel an average of 30km to reach the nearest health facility5 or in Ethiopia where
individuals must travel 15-18km on foot before reaching a town that offers motorised transport to the nearest medical facility.6 In HICs as well, many patients in rural areas struggle with access to care compared to those in urban areas.7 More tragic is that reaching the nearest facility does not always ensure that it will have the equipment, supplies or physicians that patients require.3 It is not uncommon that traditional healers are easily accessible in many communities and patients may receive societal and religious pressure to seek these healers primarily.8 Due to the combination of these obstacles, individuals may allow an illness to advance significantly before deeming that it is necessary to overcome the challenges of travel to a medical facility.9
In addition to the physical burden of travelling these extreme routes, many individuals must consider the financial costs of travel and healthcare.4 The Lancet Commission estimated that 33 million individuals face catastrophic expenses from the cost of surgical procedures a lone and anoth er 48 mi llion face catastrophic expenses from non-medical costs directly related to receiving the necessary treatment.1 Although many government hospitals provide 'free care', other essential services are often not provided. These may include radiological studies, certain medications and nutrition.10 In addition, many families must travel with their dependents and then cannot afford food or
accommodations for these members.11 Delays in seeking care may result in progression of disease, resulting in a requirement for more urgent, risky and expensive procedures. This contributes to a cycle which further intensifies obstacles and increases delays . Often the healthcare facility most accessible to the patient may not have the adequate resources, materials or skilled physicians. This results in referral to a private hospital or a more distant hospital. Because of the frequency of these situations, larger hospitals often have tremendous backlogs and can be overcrowded up to 200-300% of maximum capacity.12 Consequently, the lack of essential resources and extensive wait periods contribute to a lack of trust in these hospitals' ability to care for them. The challenge of distrust can stem from both traditional beliefs and situational encounters. Many communities have limited experience with modern healthcare options, which may be perceived as foreign and threatening.13 For example, in parts of the world, it is a widely held belief that obstructed labour occurs as a consequence of infidelity. It is expected that if the woman in labour admits to the infidelity, then childbirth will proceed as it should, and intervention from modern medicine would neither be required nor preferred. 3,6,14 The need for surgical intervention can also be perceived as weakness and some may fear that anaesthesia results in death. Surgical procedures have been perceived to result in a patient being 'half-human' and minor procedures could lead to an individual being regarded as less than whole, resulting in stigmatisation.15 When patients encounter healthcare facilities, and these facilities do not possess the resources to provide safe and timely care, it can further propagate distrust in the medical system. Additionally, visiting teams from HICs, while well-intentioned, can result in a perception of lack of quality and distrust in the country's own more permanent healthcare systems, creating a vacuum of care when these teams leave.16

Safety and quality


It is essential that as surgical systems develop, they be built upon a foundation of quality and safety, which in turn inspires trust. A culture of safety must be valued
and implemented over time to minimise post-operative complications (POCs) and infections. In particular, POCs have lasting economic consequences through lost days of work and higher healthcare costs, all of which contribute to poverty 17 For children, the burden of POCs contributes to decreased school attendance and poor quality of life.18 The implementation of comprehensive programmes to control POCs and infections, and address other patient safety challenges are critical to ensure that surgery can be provided at low risk.
Many factors contribute to the high burden of POCs, including limited healthcare infrastructure, inadequate surveillance tools, lack of trained personnel, and inadequate infection control programmes. In LMICs, the prevalence of hospital-acquired infections may be as high as 25%, which adds billions of dollars annually to
already struggling healthcare systems.19 Critical needs include POC reporting systems, understanding of the epidemiology of POCs, programmes to improve the safety culture, and tools to control infection. Building clinical and research capacity in patient safety is essential to develop effective interventions that are tailored to local context and implementation challenges. Challenges to the reduction of POCs include addressing many social determinants of health, including complex cultural, social, environmental and political challenges.20 Despite the high burden of POCs in LMICs, there is a lack of high-quality data on the epidemiology of POCs as well as tools to reduce the risk. In many healthcare facilities, there is a lack of functional surveillance programmes as well as of personnel trained in infection control and health research infrastructure.21 Concerns about patient safety have driven the dissemination of tools to improve patient safety, such as pre-procedural checklists 22 or programmes to improve clinical bacteriology.23 However, sustained implementation of individual programmes to control POCs and improve patient safety are often unsuccessful, with barriers including high costs, lack of research capacity, and limited human resources.19,20,23,24 Studies have highlighted the need for training of local interdisciplinary teams of experts in patient safety, such that these stakeholders can drive the implementation of programmes to reduce POCs within a local context.24 Training programmes should emphasise the value of improving a hospital's organisational functioning as a first step to improving patient safety. Fundamental is the belief that most errors in healthcare are the result of a breakdown in systems rather than the fault of individuals. A 'Just Culture' is a learning environment that is constantly improving and is characterised by accountability and error identification.25 In 'To Err Is Human', the US National Academy of Medicine highlights the impor tance of building a safety culture as a prerequisite to improving healthcare safety and quality.26 Through a focus on defects attributable to system design as the root cause of medical harm, safety science has moved from a focus on individuals to contextual factors. This 'system approach' proposes that healthcare systems require safeguards to mitigate human error.27 A growing body of literature from HICs has shown that modification of the safety culture can improve patient outcomes and organisational performance.28-30 Effective leadership is necessary to build interdisciplinary teams to address quality and patient safety.31 "The role of leadership is to establish the value system in the organisation; set strategic goals for activities to be undertaken; align efforts within the organisation to
achieve those goals … When leaders begin to change their responses to mistakes and failure, asking what happened instead of who made the error, the culture within their institutions will begin to change."32 Leadership must be cultivated at the local and national levels. In addition to managing technically-challenging
cases, surgeons must often play a role in hospital decision-making, communication, teamwork across disciplines and stress management.33 These roles are often intensified and more challenging in resourceconstrained environments where adequate numbers of leadership positions may be lacking and surgeons are called upon to fulfill these roles in addition to their clinical responsibilities. Therefore, it is necessary to prioritise leadership skills and training, as positive organisational leadership has been shown to mitigate physician burnout and improve job satisfaction.34

Multidisciplinary strengthening

To improve the quality and safety of surgical care, there must be strengthening at a multidisciplinary level.35 In some locations, there are significant shortages in healthcare workers,36 while in other locations these
healthcare workers may be present in adequate numbers, but may lack physical resources, mentorship or further training.37 Surgery has always been a team effort, and it is easy to understand that surgery cannot be performed without the participation of other disciplines such as anaesthesia and peri-operative nursing care.38 For example, critical care physicians and nurses are essential to improve outcomes after emergency surgery for trauma, intra-abdominal catastrophes, septic events and any surger y requiring post- operative continued ventilatory or haemodynamic support.39 Neonatologists are essential in the peri-operative care of infants and neonates.40 Diseases such as biliary atresia involve coordination between paediatric surgery, hepatology and transplant surgery, and efforts such as internetbased communication platforms have been proposed to increase collaborations across HIC institutions.41
Multidisciplinary care for cancer involves treatment coordination by oncologists, surgeons, radiation oncologists, radiologists, pathologists and others 42,43Multidisciplinary cancer meetings are rapidly emerging
in LMICs and many of these efforts are resulting in improved outcomes 44 Emergency medical services, such as ambulances and emergency medical technicians, have been shown to be crucial to trauma care. In fact,
increasing the number of surgeons does not reduce mortality from road traffic accidents (RTAs) unless these other essential emergency medical services are also increased.45 The treatments we can offer to patients have increasingly become more precise and complex, and they require a diversity of expertise. It is not beneficial to patient care or healthy for physicians to work in isolation. If GS is to succeed, then there must be a strengthening across the entire healthcare system.

Conclusion

Global Surgery is gaining increasing consideration and support, yet there is much work to be done. Many patients globally are still without access to care because of
geographical, social and economic disparities. Now more than ever, leaders are needed within our healthcare systems and government structures to champion the cause of increasing our standards in safety and quality of care. This will require teamwork and interdisciplinary collaboration. The idea that all individuals should be able to access safe and affordable surgery is a lofty yet achievable goal for us all.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.

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