Surgery – Beyond the Noble Profession

“Surgery has been the neglected stepchild of global health.” A very well-known saying across the world of surgery first introduced by Dr. Paul Farmer. Has it ever crossed your mind why surgery is viewed that way? Allow us to take you on a journey of hope where motivation is formed by the touch of a scalpel!

<Muna Rommaneh>

On a sunday night, while looking for something to watch, a quick look at TV news is enough to help you notice the amount of crisis, disaster and conflict across the world. Has it ever occurred to you how these people get access to surgical care? These three major problems are usually linked to displacement. The case only gets worse when the population is underserved. Healthcare has been one of the most important topics discussed globally. Improving healthcare is the current ultimate goal. As human beings, it is our right to have access to health care including safe surgery. Unfortunately, global surgery has been neglected during the majority of these discussions though it is a key factor in improving healthcare.

Surgery is a noble profession.[1] When referring to something with the word “noble”, it must  possess outstanding qualities such as eminence and dignity, have power of transmitting by inheritance, or indicate superiority or commanding excellence of mind, character, or high ideals or morals. Without a doubt, these three attributes befit the profession of surgery. Though many surgeons have tried to set standards of ethical and humane practice and have made magnificent contributions in education, clinical care and science; we still have a long way to go!

Looking at surgery today, we notice that profound changes are taking place at all levels. These changes have caused surgeons and those involved in the surgical profession to come across both new challenges and opportunities. These changes are occurring on a global level, on the national level, in science and technology, in healthcare, and in surgical education and practice. Surgical care has been revolutionized throughout the years. As a result, we have seen significantly improved longevity and the quality of human life. Needless to say, surgery must keep evolving with time.

Why should anyone lose a loved one because they did not have access to safe surgical care? A condition that needs a few tens of minutes to be treated may have to wait up to months in some areas leading to fatal results. Who is responsible for improving surgical care globally? WE ARE! Join us today on #GlobalSurgeryDay to say loud and clear: “Safe surgery is our right!”. Your voice matters and it is indeed very valuable!

References:

  1.   Debas HT. Surgery: A Noble Profession in a Changing World. Ann Surg. 2002 Sep;236(3):263–9.

Global Paediatric Surgery

Recent estimates revealed that approximately 5 billion people lack access to safe and quality surgical care globally (1); the need for pediatric surgical care is similarly significant. (2) Given that pediatric conditions can occur during development, many have an added risk of mortality or disability. (3)

<Varshini Cherukupalli>

Although approximately 85% of children in low- and middle-income countries (LMICs) will have a condition that can be treated by surgery by the age of 15 years, the global burden of pediatric surgical care remains to be determined. (2) To address this gap in research, the Surgeons OverSeas Assessment of Surgical Need (SOSAS) instrument has been utilized in Rwanda, Uganda, Sierra Leone, and Nepal as a household survey-based approach to determining surgical need.  An analysis of these results demonstrated that an estimated 3.7 million children are living with a surgical need in these four LMICs. (4)

Image source: Northwestern University, Division of Paediatric Surgery

Addressing pediatric surgical conditions can reduce costs and create opportunities for investment.  An economic analysis of pediatric surgical care in LMICs suggests that surgical services such as inguinal hernia repair, trichiasis surgery, cleft lip/palate repair, congenital heart surgery, and orthopedic surgeries should be considered essential pediatric procedures. (5)  Thus, by raising awareness for the need for pediatric surgery, we can provide societal economic benefits and most importantly, save the lives of future generations.

References:

  1. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet (London, England). 2015;386(9993):569–624.
  2. Bickler SW, Rode H. Surgical services for children in developing countries. Bulletin of the World Health Organization. 2002;80(10):829–35. Pmid:12471405
  3. Ozgediz D, Poenaru D. The burden of pediatric surgical conditions in low and middle income countries: a call to action. Journal of pediatric surgery. 2012;47(12):2305–11. Pmid:23217895
  4. Butler K, Tran TM, Nagarajan N, Canner J, Fuller AT, Kushner A, et al. Epidemiology of pediatric surgical needs in low-income countries. PLOS One. 2017.
  5. Saxton AT, Poenaru D, Ozgediz D, Ameh EA, Farmer D, Smith ER, RIck HE. Economic Analysis of children’s surgical care in low- and middle-income countries: A systematic review and analysis. PLOS One. 2017.

Congenital Heart Defects

 

<Dominique Vervoort>

Congenital heart defects (CHD), defined as clinically significant structural heart disease, are the most common birth defect worldwide, and the most common cause of birth defect related deaths worldwide. As a result, every year, 100,000 babies (children under one) will not live to celebrate their first birthday.

Globally, an estimated 8-12 babies per 1,000 live births suffer from some form of CHD that needs treatment or is present at a year of age, although incidence does not vary much between countries and regions.1 These do not include other more benign cases, such as small muscular ventricular (VSD) and atrial septal defects (ASD), which generally close spontaneously before a year of age.

In the past decades, advances in pediatric cardiac surgery have made it possible to repair or palliate most CHDs, which makes that over 85% of operated cases are expected to survive to adult life. However, because of the lack of (human) resources in most developing countries, less than 1.5% of children with CHD are able to undergo the surgery they need.2

Although some babies are diagnosed during pregnancy or at birth, the diagnosis is often not made until later in life. Sometimes, especially in developing countries, CHD is not detected until adolescence or adulthood, during which the condition is often already associated with complications such as heart failure, pulmonary hypertension and severe polycythaemia. Moreover, children with CHD often suffer from associated defects and up to 50% of these patients present with some neurodevelopmental problems.3
Nevertheless, the earlier CHD is detected and treated, the higher the chances of survival and the less long-term health complications. One important preventable complication is the risk of infective endocarditis, which has a 20-year mortality of over 50% in patients with CHD.

The burden of supporting CHD patients falls heavier on countries with higher fertility rates, which tend to have the lowest incomes per capita, which only accentuates the disparity. Costs for open heart surgery are high and are accompanied by additional medical (treatment and follow-up) and non-medical (e.g., transport, which is especially difficult in rural areas or developing countries) costs. Moreover, there is a loss of parental working time when taking children to a medical center, which further puts a financial burden on these families.5

With the epidemiological transition from communicable to non-communicable diseases globally, there is an increasing interest in conditions such as CHD. Nevertheless, because of absolute and relative (maldistribution) shortages of the health workforce and diagnostic and therapeutic equipment, urgent measures need to be taken. After all, children should have the right to live, to live in full health, and be able to play with other children of their age without being harmed by such misfortune.

References:

  1. Hoffman JI. The global burden of congenital heart disease. Cardiovascular Journal of Africa. 2013;24(4):141-145. doi:10.5830/CVJA-2013-028.
  2. Young JN, Everett J, Simsic JM, et al. A stepwise model for delivering medical humanitarian aid requiring complex interventions. J Thorac Cardiovasc Surg 2014;148:2480–9.e1.
  3. Marino BS, Lipkin PH, Newburger JW, et al. Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management: a scientific statement from the American Heart Association. Circulation 2012; 126: 1143–1172.
  4. Delahaye F, Ecochard R, de Gevigney G, et al. The long term prognosis of infective endocarditis. Eur Heart J 1995; 16(Suppl B): 48–53.
  5. Hewitson J, Zilia P. Children’s heart disease in sub-Saharan Africa: Challenging the burden of disease. S Afr Heart J 2010; 7: 18–29.

Robotic Surgery: An Overview and Reflection

<Ankit Raj>

What is robotic surgery?
Robotic surgery, or robot-assisted surgery is a type of minimally invasive surgery where miniaturized surgical instruments are fitted through a series of quarter-inch incisions. When performing surgery, these miniaturized instruments are mounted on three separate robotic arms, allowing the surgeon maximum range of motion and precision. A fourth arm that contains a magnified high definition 3-D camera provides stereoscopic view to the operating surgeon.[i]

Robotic surgery has evolved from its first use in a robot-assisted neurosurgical biopsy in 1985 to the approval of ground-breaking da Vinci Surgical System by FDA for general laparoscopic surgery in 2000.[ii]

Applications
Robots are currently used for procedures such as prostate surgery, hysterectomies, the removal of fibroids, joint replacements, open-heart surgery and kidney surgeries. They can also be used along with MRIs to provide organ biopsies. Coupled with telesurgery (surgery from a distance), it can be used by institutions and surgeons to perform operations in far and remote areas with otherwise limited human resources and infrastructure. Imagine a neurosurgeon sitting in Boston performing a decompressive craniectomy on a patient lying on an operating table in sub-Saharan Africa. This not only solves the concern of performing highly complex procedures in hospitals with under-staffing or inadequate infrastructure, but also cuts on hospital expenditures This principle can also be used for performing surgeries in war-torn and crisis-affected territories where surgeons are often not so keen to go.[iii]

Advantagesii
Robotic surgery is at the cutting edge of precision and miniaturization in the realm of surgery. It provides improved diagnostic abilities, a less invasive and more comfortable experience for the patient, and the ability to do smaller and more precise interventions. Like any other minimally invasive surgery, it offers advantages of fewer post-operative complications, such as surgical site infection, less pain and blood loss, quicker recovery and smaller, less noticeable scars. It can also provide a better work environment for the physician by reducing strain and fatigue.

Considerationsii
Along with improved patient care and surgical efficacy, another aim of robotic surgery is to significantly reduce medical and surgical costs. This is not possible when most of the robotic surgical systems cost more than $1 million to purchase and $100,000 a year or more to maintain. This means that hospitals and institutions must evaluate the benefits of robotic surgery against benefit of traditional surgeries. Reduced post-operative stay and quicker recovery following a robotic surgery cuts down on hospital expenses. There is also a reduction in the number of resource personnel needed during a robotic surgery, thus cutting down on hospital expenditure. Yet, it is still disproportionate to the expenses of installing and maintaining robotic surgical systems and training human resources for operating and programming these systems.

With very little competition in robotic surgery market, the few manufacturers have the freedom to set their own price, making robotic surgery highly unaffordable and prohibitive for huge proportions of hospitals, healthcare institutions and governments across the world. This becomes especially problematic in Low- and Middle-Income Countries (LMICs) where human resources are limited and healthcare expenditure is minuscule. Take India, for example, where per capita healthcare expenditure is a meagre $267 and where there is one of the highest out-of-pocket expenditure.[iv] A robotic radical prostatectomy at All India Institute of Medical Sciences, the premier-most government funded health institute of India, costs around INR 1.3 lakhs per case (USD 2025), which is way above than per capita healthcare expenditure.[v] This does not include robotic surgeries at private hospitals which are neither funded by government nor get instruments at a subsidized rate.

The main strength of robotic surgery is that it significantly improves surgical accuracy, particularly among the less-skilled. It was expected that rapid technological developments will make these systems cheaper, smaller, smarter and portable. Imagine the lives saved by a portable robot surgeon rushed to a motorway accident, or to a nuclear accident, a battlefield or to any disaster where one surgeon could carry out several procedures at the same time with help from medical assistants at the scene. But have we actually followed up on this technological advancement and exploited this opportunity in places where it matters? Have the benefits of robot-assisted surgery actually been employed in war-torn Syria or in Fukushima after its nuclear disaster? Sadly, more than 30 years after the first use of robot in a surgery, its use still remains confined within the exorbitant walls of sophisticated operating theatres in first-world.[vi]

Ethical standpoint
The main argument to robotic surgery is whether the costs are ethically justifiable. It is, in fact, unethical to approve new technologies that will add to the cost of medicine, given the number of people, especially in LMICs, with no or minimal access to essential health services, safe surgery, women and child health, health insurance and disproportionate out-of-pocket expenditure.iii A WHO and World Bank report shows that 400 million people do not have access to essential health services and 6% of people in LMICs are tipped into or pushed further into extreme poverty because of out-of-pocket expenditure.[vii] Should not then our concern be focused first on providing universal health coverage, identifying gaps and raising the standard of healthcare in marginal and impoverished community? Should not this excessive expenditure be focused on developing basic health infrastructure in these regions rather than spending it on ethically irrational and doubtful practice? This unfair allocation of health resources and expenditure is surely a deadlock for possible development and further acceptance of robotic surgery across several nations.

Another fundamental disagreement against robotic surgery by large swathes of professionals and societies is its dubious and vacillating ethical ramifications. Where favorable media reporting and hospital advertisements have been partly responsible for unchallenged popularity of robotic surgery, data is still incomplete on its actual effectiveness and advantages. Where this data is present, it shows no outstanding advantage of robotic surgery over conservative surgery.iii A surgeon may also be influenced unconsciously by career benefits and elevated social status that follows after including robotic surgery in his protocol.

There are also issues with latency. This refers to the time lapse between the moments when the physician moves the controls and when the robot responds. Also, there is still a chance for human error if the physician incorrectly programs the robot prior to surgery. Computer programs cannot change course during surgery, whereas a human surgeon can make needed adjustments.ii

It is clear that robotic surgery brings with it the risk of patient harm from insufficiently trained surgeons. There are individual differences among surgeons too on inadequate training on robotic surgery. Some find it easy and feel comfortable with the device, while others have individual differences.[viii]

Lastly, there is also the dissension among bioethicists and philosophers that the sick and vulnerable need human contact. The touch and sound of a doctor gives comfort and sense of security to a person on an operating table. A robot, either controlled or automated, fails to do any of that.

Towards an ethically judicious future
Although robotically-assisted surgery has been steadily increasing in popularity among surgeons and patients, that could end quite suddenly if public perceptions change. Grumbling of complaints and medical malpractice lawsuits are snowballing. Priority should be to reduce the costs of robotic surgery and develop an ethical framework and guidelines on its practice.

Francis Daniels Moore, a pioneer in numerous experimental surgical treatments, offers three criteria to make “surgical innovation acceptable”: (i) sufficient laboratory experience before conducting innovative procedures, (ii) sufficient intellectual and technical expertise available in the institution, (iii) good “institutional stability” based on its resources, support systems and staff.[ix]

A regulatory body should be established to certify that a surgeon is qualified. This should be based not on the number of procedures performed, but on a criterion level of skill. Anything else is ethically indefensible. Institutions should have the right level of in-house technical expertise by ensuring that they have well-trained and knowledgeable support staff with an understanding of the robot. We also need more surgical robotics companies to create a competitive environment that drives innovation and reduces costs.iii

An ethical framework is needed that is grounded in notions of patient autonomy, dignity, wellbeing, privacy and fair allocation of resources, and it needs to accommodate the ethics of care practice. Patients must be told of negatives and offered cheaper equivalent procedures if available. Hospitals must constrain their marketing to the facts and be wary of conflicts of interest so that informed consent is not compromised.ii

To quote Alexander Pope, “Be not the first by whom the new are tried, nor yet the last to lay the old aside”. Robotic surgery is still an evolving technology with no great data on its cost-benefit analysis yet. We need to reconsider our priorities and focus on offering equitable distribution of healthcare at places where it is much needed rather than indulging ourselves in fancy toys.

 

References:

[i] https://med.nyu.edu/robotic-surgery/physicians/what-robotic-surgery

[ii] http://allaboutroboticsurgery.com/surgicalrobots.html

[iii] Robotic Surgery: On the Cutting Edge of Ethics. Sharkey N, Sharkey AJ. Computer 46(1):56-64. 2013. DOI: 10.1109/MC.2012.424

[iv] http://data.worldbank.org/indicator/SH.XPD.PCAP.PP.KD

[v] Current Status of Robotic Surgery in India. Dogra P.N. JIMSA. 25 (3). 145. 2012.

[vi] Don’t dismiss robot surgeons. Noel Sharkey.

[vii] http://www.who.int/mediacentre/news/releases/2015/uhc-report/en/

[viii] Ethical Reflections on Health Care Robotics. Senthilkumar S., Shanmugapriya T. IJIRCCE. 2 (2). 2014.

[ix] Moore F.D. Ethical problems special to surgery: surgical teaching, surgical innovation, and the surgeon in managed care. Arch of Surg 135:14-6, 2000

 

 

Global Orthopaedics

As Global Surgery Day 2017 (May, 25th 2017) approaches, InciSioN’s Advocacy team will be publishing a series of blogs in an effort to emphasize the global need for timely access to safe, and affordable surgical care.

Global Orthopaedics

<Varshini Cherukupalli>

Globally, musculoskeletal disease is a major cause of mortality, morbidity, and increasing health care costs. (1) In 2013, 973 million individuals sustained injuries and 4.8 million people died from injuries. (2) In particular, the burden of injuries is rapidly growing in low- and middle-income countries (LMICs). Reasons for this phenomenon include more road traffic crashes, fewer orthopedic surgeons in developing countries, and higher prevalence of obesity and sedentary lifestyles. (2)

Historically, orthopedic conditions were not included in public health agendas, as the focus was on communicable and nutritional illnesses. In order to address this paucity of data and insufficient infrastructure to treat orthopedic conditions, during the Bone and Joint Decade (2000-2010), the World Health Organization, World Bank, and United Nations emphasized that more research on musculoskeletal conditions in LMICs must be performed. (3)  Treatment of open fracture is also included as one of three Bellwether procedures, or essential procedures that any first-level hospital must be able to provide. (4)

A recent study revealed that, as compared to a Level I trauma center (highest level of care) in an industrialized country, a referral hospital in an LMIC handles a disproportionate amount of trauma cases, severe fractures, and infections. (1)  As such, the burden of orthopedic conditions continues to significantly affect the developing world.  Increased awareness and further research of the burden of musculoskeletal disease are necessary in order to effectively target injuries in LMICs.  
References:

  1. Brouillette MA, Kaiser SP, Konadu P, et al. Orthopedic surgery in the developing world: workforce and operative volumes in Ghana compared to those in the United STates. World J Surg. 2014;38(4):849-857.  
  2. Haagsma JA, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2014. Inj Prev. 2016;22(1):3-18.
  3. Lidgren L. The bone and joint decade 2000–2010. Bull World Health Organ 2003;81:629
  4. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.

InciSioN Rwanda – Global Surgery Workshop – University of Rwanda

Saturday (May, 6th 2017), the National Working Group (NWG) in Rwanda -InciSioN Rwanda- organized their first global surgery workshop at the University of Rwanda, with the aim of introducing local students and doctors to the actual surgical needs in developing countries, such as Rwanda.
<Dominique Vervoort, Isaac Ndayishimiye>
The event was built around means of coping with the lack of access to surgical care in low- and middle-income countries (LMICs). The event was an interactive competition with three teams (participants) and judges (local surgeons), starting off with a brainstorming session on surgical care needs in Rwanda, wound management and surgical infections. This was followed by a session on capacity building by Dr. Christian Ngarambe -Head of Department of Surgery at the University Teaching Hospital of Butare (Centre Hospitalier Universitaire de Butare – CHUB)- and ended with a practical surgical skills session by Dr. Ahmed Kiswezi (CHUB).
From left to right: Dr. Philemon (CHUB – Dep. of Surgery), Dr. Christian Ngarambe (CHUB – Head of Dep. of Surgery), Dr. Ahmed Kiswezi (CHUB – Dep. of Surgery)
With the initial interest of participants already being high, the event only strengthened their interest, shown by the large amount of attendees willing to contribute to InciSioN Rwanda (over 60 people signed up for active membership in the NWG). We would like to congratulate InciSioN Rwanda for their great work and start, and are excited to see the promising future they have ahead!

Global Surgical Frontiers 2017

7th Global Surgical Frontiers Conference – Royal College of Surgeons, London, United Kingdom – April, 21st-22nd 2017
<Zineb Bentounsi>

Last week, InciSioN was present at the 7th edition of the Global Surgical Frontiers Conference, which took place at the Royal College of Surgeons in London (UK) on April 21st and 22nd. This year’s focus was on paediatric surgery as many surgical specialities deal with children and because most Lower- and Middle-Income Countries (LMICs) have a very young population. The speakers came from various backgrounds: surgeons and physicians from UK, Zimbabwe and Kenya, public health leaders, NGOs and charity representatives, researchers, trainees, etc. The attendance was an interesting mixture of medical students, trainees, surgeons and public health professionals. This variety of competencies brought many interesting experiences, questions and interactions.

InciSioN’s delegation was represented by its two coordinators (Zineb Bentounsi and Dominique Vervoort), two members of the Board of Trustees (Dr. Isobel Marks and Dr. Waruguru Wanjau), and Sara Venturini, member of the InciSioN international team (Research) and lead of the Medsin National Small Working Group on Global Surgery.

Zineb and Dominique facilitated a workshop themed “Healthcare Workers: Brain-Drain and Task-Shifting”, which was a great opportunity to interact with the participants and jointly brainstorm about potential solutions for a better distribution of healthcare workers worldwide, and were pleased to meet the CEO of Lifebox Foundation, Ms. Kris Torgeson, reinforcing the Lifebox-InciSioN collaboration.

Global Surgery from Boston to Sudan

Don’t underestimate what you have done and what you will accomplish in the future… You are the future.” – Dr. John Meara

March 4th, 2017 was definitely an important day for the International Student Surgical Network. On this day, two of our National Working Groups gathered students to discuss the future of global surgery, and to empower them to be involved in this rapidly growing field within global health.

The Global Surgery Students Alliance (GSSA), our recently affiliated US NWG, hosted a symposium at Harvard Medical School in Boston. About 17 speakers and 200 attendees from all over the USA were joined by 18.000 online viewers from approximately 50 countries. The main session of the Boston Global Surgery Symposium (BGSS17) was the introductory keynote address by Dr. John Meara, Co-Chair of the Lancet Commission on Global Surgery (LCoGS). After his inspiring speech, students were able to choose between different panel sessions, being Global Surgery Innovation, Education and Capacity Building, Subspecialties within Global Surgery, and Crisis and Humanitarian Aid.

If you are interested in what was discussed, but were not able to attend, follow the following link to have access to all recordings: https://www.globalsurgerystudents.org/live-streaming-recording. We would like to congratulate the national board of the GSSA for their amazing work and thank them for streaming and recording the event so that the whole network and beyond could and can have access to these treasures of information.

At the exact same moment, our Sudanese branch was also gathering students for a workshop about Global Surgery. Here, students discussed different topics, including Barriers to Surgical Care, Surgical Education and Sustainability in Global Surgery. Students left empowered and motivated to get involved in improving access to surgical care in their country.

The magic of our network is the ability to connect students from different parts of the world to raise awareness about Global Surgery and to educate them so that they can be involved in improving access to surgery early on in their medical careers.

Our next important event will be the Global Surgical Frontiers Conference 2017, taking place at the Royal College of Surgeons in London from the 21st to the 22nd of April. This time, our UK branch, the Medsin National Small Working Group on Global Surgery, is involved in the organization, and Dominique and Zineb will be running a session on behalf of InciSioN to discuss the migration of healthcare workers in global surgery. We hope to see you there!

African youth raises their voice for Universal Health Coverage

On Monday, December, 12th, over 800 organizations and many more individuals raised their voices to establish universal health coverage (UHC) for all. InciSioN (The International Student Surgical Network), one of the partners of the UHC Coalition, encouraged its national small working groups to organize local events for Universal Health Coverage Day with a special focus on Global Surgery. (1)
<Zineb Bentounsi>

Four national small working groups (being Egypt, Morocco, Rwanda and Tanzania) organized local events, being countries where “health for all” is an urgent need, and not just a concept.
In Egypt, Morocco and Tanzania, medical students gathered and brainstormed trying to answer the questions “how can we achieve UHC in our country?” and “how do we avoid that anybody is pushed (further) into poverty for needing surgical care?”. At the end of their meeting, each group wrote a statement with their suggestions. Each group had different suggestions based on their own context, but some suggestions were common.

These three groups urged their government to increase the budget allocated to health and Tanzanian students further highlighted that “there must be a well-defined amount of money” dedicated only to surgical care. Another cornerstone was taxes, with Moroccans and Egyptians both suggesting to lower taxes on medications and health care equipments (especially surgical equipment) and push their governments to start manufacturing that equipment locally, instead of importing them (thus investing in technology and engineering as well).

Egypt and Tanzania also believe that everyone should have access to emergency surgeries regardless of their ability to pay. To achieve this goal, Egypt suggested to establish a fund (financed by taxes proportionally deducted from incomes) to cover those surgeries, while Tanzania thinks that missionaries should focus on settling in low-income areas, providing emergency surgeries to those populations.

Furthermore, some suggestions were adapted to the country’s context. For Moroccan medical students, a health insurance policy to cover every Moroccan should be a priority [Note: there are several public and private health insurance policies in Morocco depending on income, but no standard registration]. For Tanzania, it seems important to include basic surgical care in primary health care in order to “lower the workload” in referral hospitals. Lastly, Egypt mentions the health workforce in their declaration, asking for improvement of the status of healthcare professionals.

On the other hand, the students from Rwanda did something completely different, by choosing to tell the story of a patient who needs surgery because of a road accident, yet can’t afford to pay for it. Reading the story gives you an insight into Rwanda’s health care system and its efforts to reach UHC. To read the story, please find the link as follows: https://m.facebook.com/story.php?story_fbid=1808107899404362&substory_index=0&id=1737737036441449

InciSioN would like to thank each group for organizing and sharing their activity. Special thanks to Nermin Badwi from Egypt, Godfrey Sama and Faith V. from Tanzania, François Xavier Rutayisire, Theogene Sengarambe and Iraguha Bandora Yves from Rwanda, the executive boards of Medec’IN-Casa in Morocco and ZMSSA in Egypt. (2,3)

Further reading:

Nobody should be pushed into poverty for needing surgical care

Imagine the following situation. You’re walking home from work on a day like any other, until you suddenly become part of a road traffic accident. Urgently needing transportation to the nearest emergency care center to receive life-saving surgery, your nation’s health care system requires you to pay out-of-pocket, ultimately leading to catastrophic expenditure and the loss of the few assets you possessed. Your life has been saved, yet you are left without life as you knew it.
<Dominique Vervoort>
Depending on where you come from and what your experiences are, the story above may seem either doubtfully unlikely or the sad truth. Even today, during times of relative global wealth, technological advances and medical heights, such situations continue to happen, both in high- (HICs) and lower- and middle-income countries (LMICs).  
Many countries already provide(d) some sort of health coverage for their population, yet often unequally, with some people receiving deeper coverage than others, regardless of their actual needs. Inequity not only exists between regions and countries, but also within, with many countries providing (more and better) care only for those able to pay, thus negatively affecting the people who need it most, being the poorest part of a population.

Health coverage should not only be extended to those “uncovered”, but also in a way (how deep and what should be covered) that prevents the creation or sustainment of health system gaps. It is therefore important to consider Universal Health Coverage (UHC) as a concept that provides everyone -rich and poor- with the health services they need (i.e., correct and adequate care), and makes sure that nobody suffers undue financial hardship as a result of getting the care they need.

The Case for UHC & Access to Surgery

Health financing mechanisms that offer financial risk protection are needed to protect people from impoverishing and catastrophic expenditure due to out-of-pocket payments. In many countries, these costs are often high, especially when access to surgical care is needed. LMICs have to move away from out-of-pocket user fees to indirect financing methods, including general taxation or insurance models. The latter could then lead to UHC packages, aiming to promote equity and equality, hand-in-hand with financial risk protection within national health systems. These packages should cover, at minimum, a basic package of essential surgical, anaesthesia and obstetric care, based on the needs of the respective country.

One could say that some nations don’t have the needed funds to allocate to investments in their health care systems, yet the WHO published their WHO Health Systems Financing Report in 2010, which indicates that every country is able to mobilize the funds to move toward UHC. (1)

In 2013, the Lancet Commission on Investing in Health found that better health status drove 24% of full-income growth over a decade, with every $1 invested able to return 9-20 times the benefits. (2) Thus, UHC has proven to be cost-effective, resulting in social and economic dividends for nations as a whole, and as a result, the question that arises is not “if”, but “when” more governments will start investing in UHC. Nevertheless, today, still far too many governments fail to invest enough in their health care systems.

UHC Day

December, 12th 2016 will mark the 3rd consecutive UHC Day, a day on which several hundreds of organizations from over 100 countries across the globe join forces as part of the UHC Coalition to spread awareness and organize activities regarding UHC. Even today, hundreds of millions of people’s lives and finances are jeopardized by the existence of health system gaps.

Even though there is still a long way to go, many steps forward have been taken in 2015 and 2016, partially due to the success of the first two UHC Days. In June 2015, a few months after the costly Ebola crisis -which would have cost less to prevent- the first UHC Global Monitoring Report was published by the WHO and World Bank Group. It was the first report measuring health coverage and financial protections in countries, in order to assess their progress towards UHC. The report showed that 400 million people do not have access to one or more essential health services, 17% of people are impoverished by health costs and 6% of people in LMICs are tipped or pushed further into extreme poverty. (3) As a result, in September 2015, the goal of achieving UHC became part of the Sustainable Development Goals (SDG 3.8). (4)

After the G7 endorsed UHC in May 2016, African leaders united in August 2016 to launch a framework to work towards UHC, driven by the investment of $24 billion by the World Bank and Global Fund. One month later, WHO Director-General Dr. Margaret Chan announced the International Health Partnership for UHC 2030. (5)

African countries can become more competitive in the global economy by making several strategic investments, including investing more in their people, their most prized resource. A critical part of this commitment is to accelerate progress on universal health coverage—ensuring that everyone, everywhere has the opportunity to live a healthy and productive life.” – Jim Yong Kim, President of the World Bank Group

This year, the UHC Coalition aims to “act with ambition”, saying that:

  • Countries making the greatest strides toward UHC put the poorest and most marginalized populations first, not last;
  • Leaders can and must invest in policies and health systems that reach every person and community based on need, not ability to pay, with services that are free at the point of use;
  • People have diverse health needs over a lifetime and valid concerns about cost and quality of care. Health care systems should ensure high-performing primary care in every community, supported by well-trained, well-paid health care workers;
  • Proactively safeguarding everyone, everywhere, will prevent the next pandemic, expand economic opportunities and promote shared prosperity;
  • Data should measure what matters, i.e., whether systems, services and medicines are accessible, high-quality and affordable for all.

Establishing universal health coverage in nations is imperative for reaching the health-related Sustainable Development Goals by 2030. International and nations’ leaders should be held accountable for current health system gaps, in order to promote more and smarter investments in health systems. To achieve these goals, we can all help by spreading awareness and further pushing UHC on the global health agenda as, after all, everyone, everywhere should inherently be safeguarded from health expenditure.

References

  1. World Health Organization. Health Systems Financing: The Path To Universal Coverage. Geneva: World Health Organization; 2010.
  2. Jamison DT, Summers LH, Alleyne G, Arrow KJ, Berkley S, Binagwaho A, et al. Global health 2035: a world converging within a generation. Lancet. 2013;382:1898–955. doi: 10.1016/S0140-6736(13)62105-4.
  3. World Health Organization, World Bank Group. Tracking Universal Health Coverage: First Global Monitoring Report. Geneva: World Health Organization; 2015.
  4. United Nations. Transforming Our World: The 2030 Agenda For Sustainable Development. United Nations; 2015.
  5. World Bank. Partners Launch Framework To Accelerate Universal Health Coverage In Africa; World Bank And Global Fund Commit $24 Billion.; 2016.