Opinionista Kathryn Chu 14 January 2020

Surgical care saves lives, but needs political prioritisation and strong health systems

This week a precedent-setting conference in Cape Town aims to improve access to surgery for people in disadvantaged and rural communities across southern Africa. It aims to share common solutions, identify barriers to the provision of surgical care, and create regional recommendations for stronger surgical systems.

From 15 to 17 January 2020, the Centre for Global Surgery at Stellenbosch University will host the AfroSurg networking conference for surgical care stakeholders. It will draw together surgeons, rural doctors, anaesthetists, obstetricians, public health specialists, social scientists, community advocacy representatives and service users.

Delegates from Zimbabwe, Zambia, Malawi, Botswana, Namibia, and South Africa will discuss existing national surgical policies and interventions currently used to improve the quality and access to timely surgical care.

As a result of the conference, AfroSurg will try to create a larger stakeholder pool to lobby for greater political prioritisation for emergency and essential surgical care as a component of Universal Healthcare, thereby helping to achieve several Sustainable Development Goals (SDGs): decrease poverty, improve health and well-being, and reduce inequalities.

To understand why such a conference is necessary, first consider the true story of Mrs M.

Mrs M is a 65-year-old woman living in rural Eastern Cape. She sought care for a breast mass at a traditional healer for several months. When it did not get smaller, she went to a local clinic where the nurse secured her a district hospital outpatient appointment four months later. The district hospital doctor told Mrs M she was worried about possible breast cancer but there was no way to make a diagnosis and no surgeon to treat her at that facility.

The doctor booked Mrs M to see a surgeon six weeks later at the provincial hospital which was located nine hours away by taxi. The surgeon asked her to return several times over the next few weeks for tests which eventually confirmed the cancer diagnosis.

By this time, Mrs M was exhausted and had spent much of her social grant on transport. She needed an operation but the waiting time was another three months.

While waiting, Mrs M started feeling weak and began coughing. She had no way to contact the hospital surgeon. The day before her operation, Mrs M was admitted to the surgical ward but a chest X-ray showed that the breast cancer had spread to her lungs and the operation was no longer going to cure her.

She was discharged without an operation and died nine months later.

There are many similar stories to Mrs M’s in South Africa. Yet, research published in The Lancet shows that with timely surgical care it is possible to cure or improve up to one-third of the world’s diseases. Despite this, five billion people worldwide, more than half the global population, do not have access to surgical care when they need it. Most of these people live in poorer countries, including across southern Africa.

In the past, surgical care was mistakenly considered too expensive to be provided to all persons with surgical needs. However, care for emergency and essential conditions has been shown to be cost-effective and between 18-26 May 2015, the World Health Organisation (WHO) declared surgical care should be an essential component of primary healthcare. The WHO also suggested district hospitals, located closer to more beneficiaries than are tertiary facilities, be the backbone for surgical care.

In November 2018, the Southern African Development Community (SADC) passed an intergovernmental resolution that recognised emergency and essential surgical care as an indispensable component of universal healthcare, affirming the 2015 World Health Assembly resolution.

SADC health ministers, including the former South African Minister of Health, Dr Aaron Motsoaledi, pledged to improve emergency and essential surgical care in the region by developing, implementing, and costing National Surgical Anaesthesia and Obstetric Plans. All SADC countries are meant to report back on progress every two years.

The resolution is an important step forward. However, the SADC region still has a long way to go before safe and timely surgical care for all is achieved. Africans are twice as likely to die after surgery than people living in the rest of the world7. Throughout the SADC region, there are many structural and process barriers such as surgical (including anaesthesia, obstetric, and nursing) provider shortages, lack of political will, and a gap in knowledge about the burden of surgical disease and the solutions needed to improve quality surgical system strengthening.

Only two of the 16 SADC countries, Zambia and Tanzania, have developed National Surgical Anaesthesia and Obstetric Plans and none has implemented them8. South Africa too has failed to make meaningful inroads to include surgical care in universal healthcare.

Surgical care is barely mentioned in the National Department of Health Strategic Plan and the National Department of Health has yet to create a National Surgical Anaesthesia and Obstetric Plans task force. In addition, there is no specific provision for surgical conditions in the proposed National Health Insurance (NHI) Bill.

This makes no sense, particularly when research has shown that failing to invest in an essential and emergency surgical package that is accessible to all South Africans, beginning at first-level (district) facilities, will result in significant gross domestic product workforce-related productivity losses (up to 2% by the year 2030), as a result of premature disability and mortality.

Surgical care can save lives. But we need to ensure there is adequate research into effective solutions on how to strengthen surgical systems in order to garner political will and develop effective policies. Lives are at stake. How many more people, like Mrs M, must die unnecessarily from treatable surgical conditions?

If governments fail to act then – as happened with HIV – civil society and academia must work together to drive this agenda and incite change.

The time to act is now. MC

For further information about the conference contact: [email protected]

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