Abstract
Background
Surgery has generally been neglected within the wider arena of global public health. However its importance within the global health agenda is increasingly being recognized, 1 not least with its inclusion in the second edition of the World Bank's Disease Control Priorities for Developing Countries. It has been estimated that 11% of the global burden of disease is due to surgical conditions, with Africa having the highest proportion of surgical disability-adjusted life years (DALYs) at 38 per 1000 population. 2 This figure includes injuries, malignancies, congenital anomalies, obstetric complications, cataracts and glaucoma, and perinatal conditions. However, this does not include surgical infections, wounds, abscesses, septic arthritis and osteomyelitis, or morbidity and mortality due to acute abdominal conditions such as hernia, appendicitis, gastrointestinal bleeding, et cetera, because of the paucity of available data. Wide disparities exist in global surgical care with 34.8% of the global population receiving only 3.5% of all surgical procedures. 3 It has been argued that access to surgical care constitutes part of the basic right to health. 4
Although traditionally thought of as being prohibitively expensive as a public health priority, recent cost-effectiveness studies suggest that simple, safe surgical care at district hospital level is comparatively cheap and effective in saving lives and preventing morbidity. Furthermore, it is argued that provision of simple surgical capabilities in district hospitals act as a more general ‘enabler’ across a wider range of disciplines.
This article reviews the current concepts in provision of surgical care in low-income countries and argues for a more central place for provision of essential surgical care on the global health agenda.
Burden of untreated surgical disease
It is not known how many people suffer mortality and morbidity as a result of untreated surgical disease. Estimates suggest that this burden of unmet need is enormous.3,5 A survey of 1875 households in Sierra Leone suggested that 25% of respondents were in need of surgical intervention, and that 25% of deaths in the previous year might have been averted by timely surgical intervention. 6 Other estimates suggest that the incidence of non-fatal injury in sub-Saharan Africa is at least 1690 per 100,000 population per year and mortality as a result of injury estimated to be 50–92 per 100,000 population annually. For hernias alone, there is an estimated unmet need of 175 untreated hernias per 100,000 per year in rural sub-Saharan Africa. 5
Such estimates are reinforced by measurements of district hospital surgical and anaesthetic capacity. These suggest that few rural state-run hospitals are adequately equipped. There is a paucity of electricity, running water, oxygen, supplies including pulse oximetry and basic airway support, and trained personnel. Although many district hospitals are equipped for suturing, debridement, and incision and drainage, there are inconsistencies in the ability to provide more advanced procedures such as chest tube thoracostomy, open fracture management and Caesarean section delivery. 7 Therefore, the situation of most sub-Saharan African district hospitals would suggest that they are currently unable to meet the surgical needs of the populations they serve.
Cost-effectiveness of surgical intervention
Cost-effectiveness is measured using the DALY. This combines an estimate of the amount of death caused by a given disease process (years of life lost [YLL]) with the amount of disability (years of life lived with disability [YLD]) such that:
In public health terms, this is more cost-effective than oral rehydration solution for diarrhea (US$132 per DALY averted), anti-retroviral therapy for HIV (US$350–500 per DALY averted), and BCG vaccination for children (US$40–170 per DALY averted) and compares to national immunization programmes (US10–20 per DALY averted). 11 Therefore, there is a compelling argument for upgrading and equipping district hospitals with the materials and personnel they need to provide simple, safe, essential surgical care.
Surgery and the millennium development goals (MDGs)
Although not specifically referred to within the MDGs, surgery impacts on the three health MDGs: MDG 4 (reduction of child mortality); MDG 5 (reduction of maternal mortality); and MDG 6 (combat of HIV/AIDS, malaria and other diseases) by provision of trauma services, obstetric services and general surgery including elective circumcision, 12 and has an indirect impact on MDG 1 (halving the number of people living in poverty). Therefore, improving provision of surgical care at district hospital level is essential if these goals are to be met.
Pivotal role of district hospitals
Concerns have been raised over the development of specific health silos, which are fuelled partly by the narrow focus on the three health MDGs 4, 5 and 6 which encourage vertical organization without full integration into the wider health system. 13 Other major funding organizations such as the Gates Foundation which focus primarily on HIV/AIDS, TB and malaria also encourage vertical organization of health services. Concern exists that this may perpetuate the fragmentation of global health. 14
As the main providers of care to the (majority) rural population in low- and middle-income countries investment in district hospitals is the key to provision of sustainable, long-term solutions. District hospitals should be the level at which healthcare integrates for local populations. Improving surgical district hospital care would have a specific effect not only on the MDGs but also a general effect on health by acting as an ‘enabler’ to raise the overall quality of healthcare at district hospital level. 12 Investment in district hospitals would ensure provision of local surgical care and allow proper and full integration of public health ‘vertical’ programmes improving healthcare overall.
Task shifting/task sharing
The potential problem with provision of surgical care at district hospital level is the lack of trained surgeons and anaesthetists in rural areas. 15 This has largely been overcome for provision of emergency obstetric care by the training of ‘non-physician clinicians’ (NPCs) to perform these tasks. This movement of tasks from clinicians to non-clinicians has been termed ‘task shifting’ or, perhaps more appropriately, ‘task sharing’. 16 Studies assessing outcomes of emergency obstetric surgery have shown that trained non-clinicians have as good results as trained clinicians.17,18
Outside of obstetrics and gynaecology, NPCs have also been trained in provision of orthopaedic care. For example, in Malawi, Orthopaedic Clinical Officers have been trained since 1985 in the conservative management of common traumatic and non-traumatic conditions. 16
In General Surgery, it is less clear which procedures should be deemed ‘essential’ and appropriate for provision at District Hospital level. In any such system, definition of limits, appropriate training and supervision, suitable referral systems, and adequate recognition and remuneration are important if success of such task sharing is to be achieved. 19 Some national programmes have shown some success in transfer of surgical care to district hospitals, resulting in much lower number of transfers to tertiary centres. 20 Such programmes which train NPCs, associated with appropriate remuneration, recognition and structural support, are probably the best way forward in provision of long-term sustainable surgical care at district hospital level.
Conclusion
Investment in district hospitals and provision of basic essential surgical care is likely to have wide ranging effects on the health systems of low- and middle-income countries. Central to this will be the training, supervision and support of NPCs in rural areas. Such investment will also enable integration of vertical programmes leading to a more comprehensive health system structure, and a more integrated approach to achievement of the MDGs.