At one point or another, many of us have been asked by relatives and friends to contribute towards surgical treatment, often for a family member who needs to travel abroad for specialised surgical treatment. Millions of families in low-resource settings cave under the astronomical cost of paying for a loved one’s surgery. The Lancet Commission on Global Surgery (LCoGS) estimates that 33 million people are affected by such costs. The economic impact can be devastating, with families forced to sell livelihoods and property to pay for surgical care. However, surgical care requires far less investment than Malaria and Tuberculosis combined. How can this narrative be changed? Political will to institutionalize surgical and anaesthesia care is key.
The LCoGS global estimate of 5 billion people lacking access to safe and timely surgical care is alarming. Of these, 1.7 billion are children with treatable conditions such as cleft lip and palate, club foot, hernia or even broken limbs. Based on the LCoGS’s work, we were driven to take action towards ensuring resilient and functional healthcare systems in Africa with surgical and anaesthesia care as responsive and integral components towards achieving Universal Health Coverage. The Pan-African Surgical Healthcare Forum (PASHeF) was born from the urgency for African countries to collectively address this unacceptable inequity. Early intervention not only save lives but also empowers populations to contribute to the economic development of their countries.
Achieving Global Health Equity requires a united effort to improve the quality of life under the 6 pillars of health systems strengthening, for Universal Health Coverage: health workforce, service delivery, health system financing, leadership and governance, and health information systems, medical products, vaccines and technologies. The United Nation General Assembly Resolution 74.2 encouraged integrating essential surgery capacities, as an essential part of integrated health-care delivery systems.
In 2023, the inaugural PASHeF meeting brought together 40 representatives from the continent to discuss the different stages of surgical healthcare policy development and implementation in member states. The focus was on dialogue and exchanging ideas on how to develop and implement the national surgical healthcare strategies. At the time, only five African countries- Ethiopia, Nigeria, Rwanda, Tanzania and Zambia, had Surgical, Obstetrics, Trauma and Anaesthesia (SOTA) Policies, referred to as SaLTS, NSOANP, NSOAP and NSOAS respectively. While dynamics may vary from country to country, forums like PASHeF provide a platform to exchange ideas and brainstorm on how African nations can move forward together to institutionalize surgical and anaesthesia care. Though not exhaustive, below are some critical priority areas that need to be addressed.
Holding the Line: Managing Brain Drain
Health worker strikes have become more common across the continent, with the primary demands being improved facilities and fair remuneration for their workload. Poor infrastructure, frustrating work environments, and a shortage of skilled personnel often drive healthcare professionals to leave low- and middle-income nations for better-paying jobs in high-income countries. The World Health Organization health workforce support and safeguards list 2023 listed 55 countries globally with dire staffing gaps, 40 of which are African countries. The health workers are leaving the continent for greener pastures, further worsening the healthcare professionals’ shortage. In Nigeria, The Africa Report noted that 9000 healthcare professionals had migrated to work in other countries between 2016-2018.
As a mitigation measure, the WHO proposed the WHO Code of Practice on the International Recruitment of Health Personnel, which recommends measures to address the vulnerabilities of developing countries with low workforce density. Implementing this code of practice would require dialogue between ministries of health and stakeholders to strike a balance on benefits between source and destination countries. Ultimately, however, source countries would need to create their own ways of keeping their workforce within the country by addressing the critical push factors of infrastructure, low wages and security- if they are to retain their healthcare workforce.
Walking the Talk: The Triumph in Implementation
The test of the ship is on the high seas. In implementing the Surgical, Obstetrics and Anaesthesia (SOA) plans, governments can identify gaps and opportunities to strengthen local health systems. Countries that have already implemented their plans have a wealth of experience that they bring to PASHeF discussions. These roundtables offer governments a chance to explore governance and strategic investments that can build resilient health systems that are responsive to surgical healthcare. Inclusivity is key to enhancing knowledge exchange, involving stakeholders at every level—civic and political leaders, healthcare professionals, academia, and industry. Shared ownership is so crucial to successful implementation that all efforts should be made to achieve buy-in from these stakeholders.
Innovation for Policy Development
The rapid adoption of technology during the COVID-19 pandemic has created opportunities for telehealth and telemedicine. Exciting innovations, like those from Smile Train’s Simulare Division, improve surgical outcomes on patients with cleft lip and palate. Additionally, innovative education resources from the University of Global Health Equity in Rwanda are attracting growing interest. The world is rapidly changing to incorporate artificial intelligence, design thinking and systems management as part of enhancing global interconnectedness. The Mobile Economy Sub-Saharan Africa 2024 report shows that significant advancements in mobile technology and connectivity play a crucial role in boosting socioeconomic development in Sub-Saharan Africa. By 2030, the mobile sector is projected to contribute $170 billion to the region’s GDP. However, it requires multi- stakeholder collaboration to address the gaps such as broadband connectivity, where only a third of Africans have access to the internet as stated by GSMA’s 2024 State of Mobile Internet Connectivity report.
These inequities limit access to knowledge and information and rapid transmission of solutions. Africa’s young population—70% under the age of 30—is brimming with creativity. With strategic engagement, this generation can help develop sustainable solutions for healthcare and other sectors.
Monitoring and Evaluation: The Roadmap to Quality Assurance
At the heart of any progressive economy is quality data to support evidence -based policy development. Data collection and management systems should be in place to support successive governments to improve on the service delivery. Africa’s contribution to global research is just 1%, but increased support from governments could motivate academia and future medical professionals to contribute more. Mentorship and training to produce credible research papers would help unlock Africa’s untapped potential, providing policymakers with the data they need to create local solutions.
The above approaches are conversation starters. Critical issues like financing and service delivery must also be addressed. Not all problems can be solved at once, but with a phased approach, progress can be made. Ministries of Health are making positive strides by engaging development partners to develop and implement their SOTA plans, with Ghana being the latest to join. However, governance structures that transcend political regime changes are essential. Africa is at a turning point in redefining how global surgery is perceived. With 15% of the world’s population, it’s time for African governments to rise to the occasion and work together to make surgical and anesthesia care accessible and affordable for all.
By Mrs. Nkeiruka (NK) Obi is the Vice-President and Regional Director for Africa at Smile Train, Dr. Justina Seyi-Olajide is a Consultant Paediatric Surgeon and currently works at the Department of Surgery, Lagos University Teaching Hospital and Prof. Emmanuel Ameh is Professor of Paediatric Surgery, National Hospital, Abuja, Nigeria.