Suchergebnisse

Where is the funding? In April 2015, the Lancet Commission on Global Surgery set out a vision for universal access to safe, affordable surgical and anaesthesia care when needed1. Despite policy progress and a global surge of interest in perioperative public health, the Commission blueprint remains an unfinished agenda. This welcome special BJS supplement on global surgery presents an opportunity to reflect on the lessons learned as a surgical community – with a focus on research, engagement, funding and realized vision. The Commission articulated a broad array of research themes, seven of which are found within the breadth of papers in this supplement including: policy2, quality and safety3, 4, training and education5-8, partnership6, 7, 9, information management10-12, care delivery innovation13 and burden14. However, there are four important themes that are not covered, including cost and finance, determinants and barriers, impact of disease and prevention. An even broader interdisciplinary research focus is urgently required to address questions related to the whole health system as well as political, social and economic determinants of health for patients with surgical conditions. The startling evidence that five billion people lack access to safe and affordable surgery and anaesthesia care is perhaps the most quoted of the Commission's key messages1. The healthcare delivery and management group explored patient barriers to surgical care, and promoted three bellwether procedures as signals of a functional surgical ecosystem at the level of district hospitals (caesarean section, emergency laparotomy and open fracture care). The workforce, training and education group proposed a density of at least 20 specialist providers per 100 000 population, and illustrated the dearth and global maldistribution of human resources. The economics and finance group described how surgical patients worldwide are trapped in iatrogenic poverty while needle and thread are as cost‐effective as immunizations, and that return on investments for surgery and anaesthesia would translate into considerable Gross Domestic Product losses averted. The metrics group drew up the six Lancet Commission indicators, designed to capture preparedness, delivery, and the effect of surgical and anaesthesia care with clear time‐bound targets for scale up to 2030. The Commission report concluded with a call for national surgical plans and an appraisal of global surgery research. Overall, the report aligned with health system strengthening and embedded surgery within universal health coverage. Building on the work of many individuals and organizations, the Commission facilitated global surgery progress with multiple partners across more than 100 countries. The escalating emergence of leaders, new networks and changing focus of organizations is encouraging. Key events to highlight include: Denis Mukwege winning the Nobel Prize for humanitarian surgery; Emmanuel Makasa spearheading the unanimously passed World Health Assembly resolution 68.15 on the crucial role of surgery and anaesthesia for universal health coverage15; and John Meara championing national surgical plans through intelligent, collaborative partnership. In addition, media and civil society are maintaining pressure on global surgical issues; guiding institutions such as the World Federation of Societies of Anaesthesiologists and the College of Surgeons in East, Central and Southern Africa have made significant contributions to workforce data; new collaborations, including the Global Initiative for Children's Surgery and InciSioN (the International Student Surgical Network), have been launched; research funders have awarded grants for global surgical research; and regional colleges and specialist associations have supported the Commission's report. The World Health Organization (WHO) has endorsed the Commission indicators and their surgical lead (Walt Johnson) has brought fresh strategic thinking to the organization, and powerful support to the national planning processes16. Despite the 2030 Agenda for Sustainable Development and a reorientation towards health system strengthening, the surgical community has yet to capitalize on global development assistance for health17. Decision‐makers do not necessarily allocate funds proportional to avertable mortality and morbidity, but demand well defined, effective interventions and credible metrics to measure success18. However, the fact that the surgical community now defines better the burden of surgical disease, and has cost‐effective interventions19 and key performance indicators, bodes well for political priority ascendance. In addition, the call for an independent accountability mechanism to track progress from Holmer and colleagues10 in this supplement is also timely and relevant. Sufficient funding from national health budgets as well as international funders should follow the imperatives that, without urgent and accelerated investment in surgical scale‐up, low‐ and middle‐income countries (LMICs) will continue to have immense losses in economic productivity. In comparison, modest scale‐up of costs (1–8 per cent of total annual health expenditure in LMICs) would be sufficient to see returns. Strong advocacy for global surgery funding is required20, and an appropriately funded WHO should be an important starting point. The global surgery community should continue to engage with both humanitarian aid and the wider development sector to disseminate the final Commission messages: that investing in surgical services in LMICs is affordable, saves lives and promotes economic development; and that surgery is part of the health system solution for many disparate health agendas – from maternal health, to trauma, cancer and neonatal mortality. This upstream activity, as is happening in Ethiopia, Zambia, Tanzania and other countries through national surgical planning, should lead to downstream implementation for real change16. However, we must not be fooled: without funding there will be no meaningful implementation of emerging national plans and no access to safe, affordable surgical and anaesthesia care for five billion people.

Background The perception of surgery as expensive and complex might be a barrier to its widespread acceptance in global health efforts. We did a systematic review and analysis of cost-effectiveness studies that assess surgical interventions in low-income and middle-income countries to help quantify the potential value of surgery. Methods We searched Medline for all relevant articles published between Jan 1, 1996 and Jan 31, 2013, and searched the reference lists of retrieved articles. We converted all results to 2012 US$. We extracted cost-effectiveness ratios (CERs) and appraised economic assessments for their methodological quality using the 10-point Drummond checklist. Findings Of the 584 identified studies, 26 met full inclusion criteria. Together, these studies gave 121 independent CERs in seven categories of surgical interventions. The median CER of circumcision ($13.78 per disability-adjusted life year [DALY]) was similar to that of standard vaccinations ($12.96-25.93 per DALY) and bednets for malaria prevention ($6.48-22.04 per DALY). Median CERs of cleft lip or palate repair ($47.74 per DALY), general surgery ($82.32 per DALY), hydrocephalus surgery ($108.74 per DALY), and ophthalmic surgery ($136 per DALY) were similar to that of the BCG vaccine ($51.86-220.39 per DALY). Median CERs of caesarean sections ($315.12 per DALY) and orthopaedic surgery ($381.15 per DALY) are more favourable than those of medical treatment for ischaemic heart disease ($500.41-706.54 per DALY) and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20 per DALY). Interpretation Our findings suggest that many essential surgical interventions are cost-effective or very cost-effective in resource-poor countries. Quantification of the economic value of surgery provides a strong argument for the expansion of global surgery's role in the global health movement. However, economic value should not be the only argument for resource allocation-other organisational, ethical, and political arguments can also be made for its inclusion. Funding Massachusetts General Hospital Department of Surgery, Boston Children's Hospital, and Stanford University Department of Surgery. Copyright (C) Chao et al. Open Access article distributed under the terms of CC BY.

Background: Little is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs. Methods and Findings: We undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery. Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable. Conclusions: National health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.

Although 5 billion people lack access to surgery and anaesthesia care, little systems-level data exist to address this health inequity and social injustice.1 Data drive quality improvement processes in business and health systems in high-resource settings, but clinicians and policymakers in low-resource environments have been metaphorically—and often literally—operating in the dark. The challenges to obtaining accurate health systems data involve nearly all clinical delivery platforms in global health and have been well documented and are also relevant to surgery and anaesthesia.2 They include insufficient national-level investment in analytics, insufficient donor investment in data collection, little analysis of global health funding streams, limited tools and resources for data collection at the local level, and limited accessibility of collected data to those best positioned to implement data-driven solutions. Such gaps undermine advocacy, as the problems remain invisible and thus fail to inspire political will.In January 2014, at the inception of a global surgical movement designed to realign stakeholders into a structured approach to surgical systems strengthening, Dr Jim Kim, President of the World Bank Group, challenged The Lancet Commission on Global Surgery (LCoGS) to develop consensus-based indicators and time-bound targets to track progress. Sixteen months later, in April 2015, after thorough consultation with clinicians, researchers, hospital administrators and policymakers, the Commission recommended six core indicators to assess surgical and anaesthesia systems strength.3 When these indicators (summarised in table 1) are considered together, they serve as basic proxies of surgical health system functioning.View this table:In this windowIn a new windowTable 1 Data obtained per indicator including totalThe LCoGS indicators assess multiple aspects of surgical and anaesthesia care delivery within a country. Where are the facilities capable of providing surgical care and how close are they to the populations that need them? How many surgical and anaesthesia providers are present? What quantity of surgical care is provided to a population? …

Global Health has not featured as prominently in the European Union (EU) research agenda in recent years as it did in the first decade of the new millennium, and participation of low-income and middle-income countries (LMICs) in EU health research has declined substantially. The Horizon Europe Research and Innovation Framework adopted by the European Parliament in April 2019 for the period 2021–2027 will serve as an important funding instrument for health research, yet the proposed health research budget to be finalised towards the end of 2019 was reduced from 10% in the current framework, Horizon 2020, to 8% in Horizon Europe. Our analysis takes the evolvement of Horizon Europe from the initial framework of June 2018 to the framework agreed on in April 2019 into account. It shows that despite some improvements in terms of Global Health and reference to the Sustainable Development Goals, European industrial competitiveness continues to play a paramount role, with Global Health research needs and relevant health research for LMICs being only partially addressed. We argue that the globally interconnected nature of health and the transdisciplinary nature of health research need to be fully taken into account and acted on in the new European Research and Innovation Framework. A facilitated global research collaboration through Horizon Europe could ensure that Global Health innovations and solutions benefit all parts of the world including EU countries.

Global Health has not featured as prominently in the European Union (EU) research agenda in recent years as it did in the first decade of the new millennium, and participation of low-income and middle-income countries (LMICs) in EU health research has declined substantially. The Horizon Europe Research and Innovation Framework adopted by the European Parliament in April 2019 for the period 2021-2027 will serve as an important funding instrument for health research, yet the proposed health research budget to be finalised towards the end of 2019 was reduced from 10% in the current framework, Horizon 2020, to 8% in Horizon Europe. Our analysis takes the evolvement of Horizon Europe from the initial framework of June 2018 to the framework agreed on in April 2019 into account. It shows that despite some improvements in terms of Global Health and reference to the Sustainable Development Goals, European industrial competitiveness continues to play a paramount role, with Global Health research needs and relevant health research for LMICs being only partially addressed. We argue that the globally interconnected nature of health and the transdisciplinary nature of health research need to be fully taken into account and acted on in the new European Research and Innovation Framework. A facilitated global research collaboration through Horizon Europe could ensure that Global Health innovations and solutions benefit all parts of the world including EU countries.

Global Health has not featured as prominently in the European Union (EU) research agenda in recent years as it did in the first decade of the new millennium, and participation of low-income and middle-income countries (LMICs) in EU health research has declined substantially. The Horizon Europe Research and Innovation Framework adopted by the European Parliament in April 2019 for the period 2021–2027 will serve as an important funding instrument for health research, yet the proposed health research budget to be finalised towards the end of 2019 was reduced from 10% in the current framework, Horizon 2020, to 8% in Horizon Europe. Our analysis takes the evolvement of Horizon Europe from the initial framework of June 2018 to the framework agreed on in April 2019 into account. It shows that despite some improvements in terms of Global Health and reference to the Sustainable Development Goals, European industrial competitiveness continues to play a paramount role, with Global Health research needs and relevant health research for LMICs being only partially addressed. We argue that the globally interconnected nature of health and the transdisciplinary nature of health research need to be fully taken into account and acted on in the new European Research and Innovation Framework. A facilitated global research collaboration through Horizon Europe could ensure that Global Health innovations and solutions benefit all parts of the world including EU countries.