Skip to main content

Advertisement

SpringerLink
Log in

Essential Surgery: The Way Forward

  • Original Scientific Report
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Introduction

Very little surgical care is performed in low- and middle-income countries (LMICs). An estimated two billion people in the world have no access to essential surgical care, and non-surgeons perform much of the surgery in remote and rural areas. Surgical care is as yet not recognized as an integral aspect of primary health care despite its self-demonstrated cost-effectiveness. We aimed to define the parameters of a public health approach to provide surgical care to areas in most need.

Methods

Consensus meetings were held, field experience was collected via targeted interviews, and a literature review on the current state of essential surgical care provision in Sub-Saharan Africa (SSA) was conducted. Comparisons were made across international recommendations for essential surgical interventions and a consensus-driven list was drawn up according to their relative simplicity, resource requirement, and capacity to provide the highest impact in terms of averted mortality or disability.

Results

Essential Surgery consists of basic, low-cost surgical interventions, which save lives and prevent life-long disability or life-threatening complications and may be offered in any district hospital. Fifteen essential surgical interventions were deduced from various recommendations from international surgical bodies. Training in the realm of Essential Surgery is narrow and strict enough to be possible for non-physician clinicians (NPCs). This cadre is already active in many SSA countries in providing the bulk of surgical care.

Conclusion

A basic package of essential surgical care interventions is imperative to provide structure for scaling up training and building essential health services in remote and rural areas of LMICs. NPCs, a health cadre predominant in SSA, require training, mentoring, and monitoring. The cost of such training is vastly more efficient than the expensive training of a few polyvalent or specialist surgeons, who will not be sufficient in numbers within the next few generations. Moreover, these practitioners are used to working in the districts and are much less prone to gravitate elsewhere. The use of these NPCs performing “Essential Surgery” is a feasible route to deal with the almost total lack of primary surgical care in LMICs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Notes

  1. ICES consists of a group of surgeons, international leaders, public health specialists, and educators who aim to promote the effective provision of safe, essential low-cost surgical care to deal with the significant burden of surgical disease in LMICs. The group strives to 1. Advocate and promote the need for essential surgery. 2. Identify essential surgical procedures that are cost-effective and indispensible to a community. 3. Promote and support education and training programs. 4. Identify local and regional training centers to coordinate essential surgical care delivery. 5. Support local surgical societies in training activities. 6. Encourage established surgical societies to include surgical care to poorly served communities within their mission statement. 7. Facilitate international cooperation for educational efforts, research, and advocacy in support of the essential, safe surgical for all initiative. 8. Work across health care networks to recognize essential surgery as a significant component of Public Health.

References

  1. Cotton MH (2005) Rural international surgery Letter. World J Surg 29(4):413. doi:10.1007/S00268-005-1104-8

    Article  PubMed  Google Scholar 

  2. Contini S (2007) Surgery in developing counries: why and how to meet surgical needs worldwide. Acta Biomed 78(1):4–5

    PubMed  Google Scholar 

  3. Ozgediz G, Dunbar P, Mock C et al (2009) Bridging the gap between public health and surgery: access to surgical care in low and middle-income countries. Bull Am Coll Surg 94(1):14–20

    PubMed  Google Scholar 

  4. Ozgediz SD, Riviello R (2008) The “other” neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med 5:e121

    Article  PubMed Central  PubMed  Google Scholar 

  5. Farmer PE, Kim JY (2008) Surgeery and global health : a view from beyond the OR. World J Surg 32(3):533–536. doi:10.1007/s00268-008-9525-9

    Article  PubMed Central  PubMed  Google Scholar 

  6. Debas HT, Gosselin R, McCord C, et al (2012) Surgery. Promoting essential surgery in low- income countries; a hidden cost-effective treasure. In: Jamison DT, Breman JG, Measham AR, et al (ed). Disease Control Priorities in Developing Countries. 2nd ed. OUP, New York 1245–60. http://files.dcp2.org/pdf/DCP/DCP67.pdf

  7. Norton R, Kobusingye O (2013) Global health: injuries. New Engl J Med 368(18):1723–1730

    Article  CAS  PubMed  Google Scholar 

  8. Meo G, Andreone D, De Bonis U et al (2006) Rural surgery in Southern Sudan. World J Surg 30(4):495–504. doi:10.1007/s00268-006-0306-z

    Article  PubMed  Google Scholar 

  9. King M, Bewes P, Cairns J et al (eds) (1990) Primary surgery. OUP/GTZ, Oxford, Delhi

    Google Scholar 

  10. Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry AF, Enright AC et al (2010) Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet 376(9746):1055–1061

    Article  PubMed  Google Scholar 

  11. Clegg HA (1971) Editorial. Trop Doct 2(2):1–2

    Google Scholar 

  12. Mahler H. (1980) Surgery and Health for All. Address 22nd Biennial World Congress International College of Surgeons. Mexico City, 29 June. http://www.who.int/surgery/esc_component/en/index.html

  13. Rennie JA (1994) The poor cousin of medicine. Trop Doct 24(1):5–6

    CAS  PubMed  Google Scholar 

  14. Kitamura T, Obara H, Takashima Y et al (2013) World Health Assembly agendas and trends of international health issues for the last 43 years: analysis of World Health Assembly agendas between 1970 and 2012. Health Policy 110(2–3):198–206

    Article  PubMed  Google Scholar 

  15. Grimes CE, Law RSL, Dorgstein ES et al (2012) Systematic review of met and unmet need of surgical disease in rural sub-Saharan Africa. World J Surg 36(1):8–23. doi:10.1007/s00268-011-1330-1

    Article  PubMed  Google Scholar 

  16. Weiser TG, Regenbogen SE, Thompson KD et al (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372(9633):139–144

    Article  PubMed  Google Scholar 

  17. Linden A, Sekidde FS, Galukande M et al (2012) Challenges of surgery in developing countries: a survey of surgical and anesthesia capacity in Uganda’s public hospitals. World J Surg 36(5):1056–1065. doi:10.1007/s00268-012-1482-7

    Article  PubMed  Google Scholar 

  18. World Health Organization. Emergency and Essential Surgical Care Programme. http://www.who.int/surgery/publications/Planning_toolEESC.pdf, Accessed April 2014

  19. Cotton MH (2005) The Delivery of Surgery in the Developing World (abstract). East & Cent Afr J Surg 10:89

    Google Scholar 

  20. World Health Organization. Maternal Mortality (2014). http://www.who.int/mediacentre/factsheets/fs348/en/index.html, Accessed April 2014

  21. Ronsmans C, Holz S, Stanton C (2006) Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet 368(9546):1516–1523

    Article  PubMed  Google Scholar 

  22. United Nations Population Fund and Gender Health (2003) Obstetric fistula needs assessment report: findings from nine African countries. United Nations Population Fund and Gender Health, New York (NY)

    Google Scholar 

  23. Hilton P (2003) Vesicovaginal fistulas in developing countries. Int J Gynaecol Obstet 82(3):285–295

    Article  CAS  PubMed  Google Scholar 

  24. Chandran A, Hyder AA, Peek-Asa C (2010) The global burden of unintentional injuries and an agenda for progress. Epidemiol Rev 32(1):110–120

    Article  PubMed Central  PubMed  Google Scholar 

  25. Lagarde E (2007) Road traffic injury is an escalating burden in Africa and deserves proportionate research effoirts. PLoS Med 4(6):170

    Article  PubMed Central  Google Scholar 

  26. Lozano R, Naghavi M, Foreman K et al (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859):2095–2128

    Article  PubMed  Google Scholar 

  27. Weston HK, Boikhubo N, Bachani AM, et al (2013) Health Policy Planning 4 Oct

  28. Peden M, McGee K, Sharma G (2002) Injury chart book: a graphical overview of the global burden of injuries. WHO, Geneva

    Google Scholar 

  29. Van Rooyen M. (2009) Know before you go: International Emergency Medicine. Am Coll Emergency Physicians: Annual Scientific Meeting. Boston 8 Oct

  30. Krug E, Sharma G, Lozano Q (2000) The global burden of injuries. Am J Public Health 90(4):523–526

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  31. Peden M, Hyder A (2002) Road traffic injuries are a global health problem. BMJ 324(7356):1153–1154

    Article  PubMed Central  PubMed  Google Scholar 

  32. Editorial Mock C (2013) Confronting the global burden of surgical disease. World J Surg 37(7):1457–1459. doi:10.1007/s00268-013-2102-x

    Article  Google Scholar 

  33. Parry E (1999) Essential surgery. Trauma Quarterly 14(3):329–333

    Article  Google Scholar 

  34. Mock C, Cherian M, Juillard C et al (2010) Developing priorities for addressing surgical conditions globally: furthering the link between surgery and public health policy. World J Surg 34(3):381–385. doi:10.1007/s00268-009-0263-4

    Article  PubMed  Google Scholar 

  35. Chu K, Rosseel P, Gielis P et al (2009) Surgical task shifting in Sub-Saharan Africa. PLoS Med 6(5):e1000078

    Article  PubMed Central  PubMed  Google Scholar 

  36. International Collaboration for Essential Surgery (2014) www.essentialsurgery.org

  37. Mullan F, Frehywot S (2007) Non-physician clinicians in 47 sub-Saharan African countries. Lancet 370(9605):2158–2163

    Article  PubMed  Google Scholar 

  38. S B. (2012) Repairing the surgery deficit. New York Times. http://opinionator.blogs.nytimes.com/2012/08/08/repairing-the-surgery-deficit/?_php=true&_type=blogs&_r=0, Accessed on April 2014

  39. McCord C, Mbaruku G, Pereira C et al (2009) The quality of emergency obstetrical surgery by assistant medical officers in Tanzanian district hospitals. Health Aff 28(5):w876–w885

    Article  Google Scholar 

  40. van Amelsfoort JJ, van Leeuwen PA, Jiskoot P et al (2010) Surgery in Malawi–the training of clinical officers. Trop Doct 40(2):74–76

    Article  PubMed  Google Scholar 

  41. Pereira C, Cumbi A, Malalane R et al (2007) Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery. BJOG 114(12):1530–1533

    Article  CAS  PubMed  Google Scholar 

  42. White SM, Thorpe RG, Maine D (1987) Emergency obstetric surgery performed by nurses in Zaire. Lancet 330(8559):612–613

    Article  Google Scholar 

  43. Sani R, Nameoua B, Yahaya A et al (2009) The impact of launching surgery at the district level in Niger. World J Surg 33(10):2063–2068. doi:10.1007/s00268-010-0611-4

    Article  PubMed Central  PubMed  Google Scholar 

  44. Hounton SH, Newlands D, Meda N et al (2009) A cost-effectiveness study of caesarean section deliveries by clinical officers, general practitioners and obstetricians in Burkina Faso. Hum Resour Health 7:34–43

    Article  PubMed Central  PubMed  Google Scholar 

  45. Sohier N, Frejacques L, Gaganye R (1999) Design and implementation of a training programme for general practitioners in emergency surgery and obstetrics in precarious situations in Ethiopia. Ann R Coll Surg Engl 81(6):367–375

    PubMed Central  CAS  PubMed  Google Scholar 

  46. De Brouwere V, Dieng T, Diadhiou M, Witter S, Denerville E (2009) Task shifting for emergency obstetric surgery in district hospitals in Senegal. Reprod Health Matters 17(33):32–44

    Article  PubMed  Google Scholar 

  47. Chu KM, Ford NP, Trelles M (2011) Providing surgical care in Somalia: a model of task shifting. Confl Health 5:12–16

    Article  PubMed Central  PubMed  Google Scholar 

  48. Leet SM, Gai AK, Adek A et al (2012) Can primary health care staff be trained in basic life- saving surgery? S Sudan Med J 5(3):69–71

    Google Scholar 

  49. Indian Medical Association (2013) June 17. http://www.ima-india.org/Opinion_requested_on_course_Curriculum.html. Accessed Dec 2013

  50. Pereira C, Bugalho A, Bergström S et al (1996) A comparative study of Caesarean deliveries by assistant medical officers and Obstetricians in Mozambique. Br J Obstet Gynaecol 103(6):508–512

    Article  CAS  PubMed  Google Scholar 

  51. Vaz F, Bergstrom S, Vaz ML et al (1999) Training medical assistants for surgery. Bull World Health Organ 77(8):688–691

    PubMed Central  CAS  PubMed  Google Scholar 

  52. Bewes P (2004) Trained medical assistants can successfully do work of doctors. (Letter). BMJ 329(7475):1184

    Article  PubMed Central  PubMed  Google Scholar 

  53. Chiloopora G, Pereira C, Kamwendo F et al (2007) Postoperative outcome of caesarean sections and other major obstetric surgery by clinical officers and medical officers in Malawi. Hum Resour Health 5:17–23

    Article  Google Scholar 

  54. Wilhelm TJ, Thawe IK, Mwatibu B et al (2011) Efficacy of major general surgery performed by non-physician clinicians at a central hospital in Malawi. Trop Doct 41(2):71–75

    Article  PubMed  Google Scholar 

  55. Syed NZ, McQueen KAK (2011) Surgery, public health, and Pakistan. World J Surg 35(9):2625–2634. doi:10.1007/s00268-011-1304-3

    Google Scholar 

  56. Cometto G, Belgrano E, De Bonis U et al (2012) Primary surgery in rural areas of southern Sudan. World J Surg 36(3):556–564. doi:10.1007/s00268-011-1403-1

    Article  PubMed  Google Scholar 

  57. Wilson A, Lissauer D, Thangaratinam S et al (2011) A comparison of clinical officers with medical doctors on outcomes of Caesarean Section in the developing world: meta-analysis of controlled studies. BMJ 342:d2600

    Article  PubMed Central  PubMed  Google Scholar 

  58. Hickman R (1999) From tennis courts to transplants. Arch Surg 134(4):451–452

    Article  CAS  PubMed  Google Scholar 

  59. Kristof ND. (2005) The Illiterate Surgeon. New York Times June 12. http://www.nytimes.com/2005/06/12/opinion/12kristof.html

  60. Groen RS, Samai M, Stewart KA et al (2012) Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet 380(9847):1082–1087

    Article  PubMed  Google Scholar 

  61. Kabia SA, Koroma ST, Bouré A et al (2008) Enhancing the capacity of regional & district facilities for emergency essential surgical care. WHO, Freetown

    Google Scholar 

  62. Kingham TP, Kamara TB, Cherian MN et al (2009) Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care. Arch Surg 144(2):122–127

    Article  PubMed  Google Scholar 

  63. Petroze RT, Nzayisenga A, Rusanganwa V et al (2012) Comprehensive national analysis of emergency and essential surgical capacity in Rwanda. Br J Surg 99(3):436–443

    Article  CAS  PubMed  Google Scholar 

  64. Henry JA, Frenkel E, Borgstein E, Mkandawire N, Goddia C (2014) Surgical and anaesthetic capacity of hospitals in Malawi: key insights. Health Policy Plan. doi:10.1093/heapol/czu102

  65. Henry JA, Windapo O, Kushner AL et al (2012) A survey of surgical capacity in rural Southern Nigeria: opportunities for change. World J Surg 36(12):2811–2818. doi:10.1007/s00268-012-1764-0

    Article  PubMed  Google Scholar 

  66. Luboga S, Macfarlane SB, von Schreeb J et al (2009) Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group. PLoS Med 6(12):e1000200

    Article  PubMed Central  PubMed  Google Scholar 

  67. Bansal S.(2012) Repairing the Surgery Deficit. Opinionator, New York Times Aug 8. http://opinionator.blogs.nytimes.com/2012/08/08/repairing-the-surgery-deficit

  68. Graduate Medical Education National Advisory Committee (GMENAC) report to the Secretary of the Department of Health and Human Services (http://mcacs.org/files/2010/Massachusetts-Surgeon-Map.pdf)

  69. Hostettler S, Kraft E (2014) Neuste Zahlen und Uebersicht zur Aerztestatistik 2013. Schw. Aerztezeitung 95(12):467–473

    Google Scholar 

  70. Mensah KMM, Henry L (2005) The ‘Skills Drain’ of Health Professionals from the Developing World: a Framework for Policy Formulation. Med Act, London

    Google Scholar 

  71. Kuehn BM (2007) Global shortage of health workers, brain drain stress developing countries. J Am Med Assoc 298(16):1853–1855

    Article  CAS  Google Scholar 

  72. World Health Organization. (2006) Working together for health. The World Health Report 12–14

  73. Ramsay Smith S (1984) How might we improve surgical services for rural populations in developing countries? BMJ 289(6443):494–495

    Article  Google Scholar 

  74. Atiyeh BS, Gunn SW, Hayek SN (2010) Provision of essential surgery in remote and rural areas of developed as well as low and middle income countries. Intern J Surg 8(8):581–585

    Article  Google Scholar 

  75. Monjok E (2009) The neglect oft he global surgical workforce: experience and evidence from Uganda (Letter). World J Surg 33(1):150–151. doi:10.1007/s00268-008-9700-z

    Article  PubMed  Google Scholar 

  76. Watters DA, Bayley AC (1987) Training doctors and surgeons to meet the surgical needs of Africa. BMJ 295(6601):761–763

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  77. Reid SJ, Chabikuli N, Jacques PH et al (1999) The procedural skills of rural hospital doctors. SA Med J 89(7):769–773

    CAS  Google Scholar 

  78. Simba DO, Mbembati NA, Museru LM et al (2008) Referral pattern of patients received at the national referral hospital: challenges in low income countries. East Afr J Public Health 5:6–9

    PubMed  Google Scholar 

  79. World Bank. Physicians per 1000 people. http://data.worldbank.org/indicator/SH.MED.PHYS.ZS

  80. Kruk ME, Pereira C, Vaz F et al (2007) Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique. Br J Obset Gynaecol 114(10):1253–1259

    Article  CAS  Google Scholar 

  81. Pollock JD, Love TP, Steffes BC et al (2011) Is it possible to train surgeons for Africa? A report of a successful International Program. World J Surg 35(3):493–499. doi:10.1007/s00268-012-1442-2

    Article  PubMed  Google Scholar 

  82. World Health Organization. Statements by NGOs in official relations with WHO at the WHO governing body meetings, 5.1. https://apps.who.int/ngostatements/content/51-international-federation-surgical-colleges-ifsc. Accessed Oct 2014

  83. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C et al (2012) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859):2197–2223

    Article  PubMed  Google Scholar 

  84. Grimes CE, Henry JA, Maraka J, Mkandawire NC, Cotton M (2014) Cost-effectiveness of surgery in low- and middle-income countries: a systematic review. World J Surg 38(1):252–263. doi:10.1007/s00268-013-2243-y

    Article  PubMed  Google Scholar 

  85. Walfish M, Neuman A, Wlody D (2009) Maternal haemorrhage. Br J Anaesth 103(Suppl 1):i47–i56

    Article  PubMed  Google Scholar 

  86. World Health Organization. Understanding unsafe abortion (2014). http://www.who.int/reproductivehealth/topics/unsafe_abortion/en/. Accessed Dec 2013

  87. WHO Global Burden of Disease estimates (2014). http://www.who.int/healthinfo/global_burden_disease/gbd/en/. Accessed Oct 2014

  88. Peck MD (2011) Epidemiology of burns throughout the world. Part I: distribution and risk factors. Burns 37(7):1087–1100

    Article  PubMed  Google Scholar 

  89. Irwin DE, Kopp ZS, Agatep B, Milsom I, Abrams P (2011) Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction. BJU Int 108(7):1132–1138

    Article  PubMed  Google Scholar 

  90. Kingsworth A, LeBlanc K (2003) Hernias: inguinal and incisional. Lancet 362:1561–1571

    Article  Google Scholar 

  91. Murray CJL, Lopez AD (1997) Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 349:1436–1442

    Article  CAS  PubMed  Google Scholar 

  92. Wynne-Davies R (1972) Genetic and environmental factors in the etiology of talipes equinovarus. Clin Orthop 84:9–13

    Article  CAS  PubMed  Google Scholar 

  93. IPDTOC Working Group. (2011). Prevalence at birth of cleft lip with or without cleft palate: data from the International Perinatal Database of Typical Oral Clefts (IPDTOC)

Download references

Author information

Authors and Affiliations

  1. International Collaboration for Essential Surgery (ICES), New York, USA

    Jaymie Ang Henry

  2. Department of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi

    Chris Bem, Eric Borgstein & Nyengo Mkandawire

  3. Kings Centre for Global Health, Kings College, London, UK

    Caris Grimes

  4. Academy of the International Surgical Society, Lupsingsen, BL, Switzerland

    William E. G. Thomas

  5. International Association for Humanitarian Medicine, Boigis-Bossey, Switzerland

    S. William A. Gunn

  6. International Federation of Surgical Colleges, London, UK

    Robert H. S. Lane

  7. Department of A&E, University Hospital of Canton Vaud, Lausanne, VD, Switzerland

    Michael H. Cotton

Authors
  1. Jaymie Ang Henry
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chris Bem
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Caris Grimes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eric Borgstein
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nyengo Mkandawire
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. William E. G. Thomas
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. S. William A. Gunn
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Robert H. S. Lane
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Michael H. Cotton
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael H. Cotton.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Henry, J.A., Bem, C., Grimes, C. et al. Essential Surgery: The Way Forward. World J Surg 39, 822–832 (2015). https://doi.org/10.1007/s00268-014-2937-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-014-2937-9

Keywords

Search

Navigation