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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Recommendations for including surgery on the public health agenda Evan G. Wong, MD, MPH,a,b,* Emmanuel A. Ameh, MD,a,c Sherry M. Wren, MD,a,d Wakisa Mulwafu, MD,a,e Mark A. Hardy, MD,a,f Benedict C. Nwomeh, MD, MPH,a,g Adam L. Kushner, MD, MPH,a,f,h and Raymond R. Price, MDa,i,j a
Surgeons OverSeas (SOS), New York, New York Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada c Division of Paediatric Surgery, Department of Surgery, Ahmadu Bello University & Ahmadu Bello University Teaching Hospital, Zaria, Nigeria d Department of Surgery, Stanford University, Palo Alto, California e Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi f Department of Surgery, Columbia University, New York, New York g Department of Pediatric Surgery, Nationwide Children’s, Hospital, Columbus, Ohio h Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland i Department of Surgery, Intermountain Health Care, Salt Lake City, Utah j Department of Surgery, University of Utah, Salt Lake City, Utah b
article info
abstract
Article history:
Background: Surgical care has made limited inroads on the public health and global health
Received 10 February 2015
agendas despite increasing data showing the enormous need. The objective of this study
Received in revised form
was to survey interested members of a global surgery community to identify patterns of
21 March 2015
thought regarding barriers to political priority.
Accepted 3 April 2015
Materials and methods: All active members of the nongovernmental organization Surgeons
Available online xxx
OverSeas were surveyed and asked why surgical care is not receiving recognition and support on the public health and global health agenda. Responses were categorized using
Keywords:
the Shiffman framework on determinants of political priority for global initiatives by two
Health priorities
independent investigators, and the number of responses for each of the 11 factors was
Politics
calculated.
Public health
Results: Seventy-five Surgeons OverSeas members replied (75 of 176; 42.6% response rate). A
Surgery
total of 248 individual reasons were collected. The most common responses were related to external frame, defined as public portrayals of the issue (60 of 248; 24.2%), and lack of effective interventions (48 of 248; 19.4%). Least cited reasons related to global governance structure (4 of 248; 2.4%) and policy window (4 of 248; 1.6%). Conclusions: This survey of a global surgery community identified a number of barriers to the recognition of surgical care on the global health agenda. Recommendations include improving the public portrayal of the problem; developing effective interventions and seeking strong and charismatic leadership. ª 2015 Elsevier Inc. All rights reserved.
* Corresponding author. Centre for Global Surgery, McGill University Health Centre, 1650 Cedar Avenue, L9 411, Montreal, QC, Canada H3G 1A4. Tel.: þ1 514 934 1934; fax: þ1 514 843 1503. E-mail address: [email protected] (E.G. Wong). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.04.020
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1.
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e6
Introduction
Globally, an estimated 2 billion people lack access to an operating room [1], and between 5 and 25% of populations in sub-Saharan Africa are estimated to need surgical evaluation [2,3]. In addition, surgical care is recognized as a vital component of a functioning health system and necessary to provide truly universal health care [4,5]. However, despite the documented need, surgery has made limited inroads onto the public health and global health agendas. A number of organizations and initiatives have developed specific programs, documented the substantial burden of surgical disease, and advocated for surgical care. In addition, efforts are underway to further evaluate the problem [6,7]. In 2007, Shiffman and Smith [8] described a framework on determinants of political priority for global initiatives and looked specifically at maternal mortality. Preliminary investigations have begun to focus on the reasons why surgical care and anesthesia are not more prominent on the global health agenda [9,10]. One global surgery community, Surgeons OverSeas (SOS), is a United States-based nonprofit organization with a mission to save lives in developing countries by improving surgical care. Founded in 2007, this society comprises members representing over 15 subspecialties and with experience in over 31 different countries [11]. In this context, we sought to survey the SOS membership and apply the Shiffman framework to identify potential barriers to political priority and to plan for broader inclusion of surgical care by the public health and global health communities. These data should lead to a more consistent, systematic, and focused effort by those involved in providing surgical care.
2.
Materials and methods
2.1.
Data collection
dent investigators (A.L.K. and E.G.W.) and categorized into one of the 11 Shiffman factors for shaping political priority, which have been previously described in detail [8]. Briefly, these 11 factors used as categories included 1. Policy community cohesion: level of coalescence among those involved 2. Leadership: commitment of strong champions for the cause 3. Guiding institutions: leadership provided by coordinating organizations 4. Civil society mobilization: recruitment of grassroots organizations 5. Internal frame: degree of agreement of the policy community on root causes and solutions 6. External frame: portrayal of the problem to the external audience 7. Policy windows: capacity to capitalize on favorable global political opportunities 8. Global governance structure: extent to which current institutions are conducive to collective action 9. Credible indicators: availability of effective measures 10. Severity: extent of the problem 11. Effective interventions: availability of solutions to the problem Any discrepancies were discussed between the two investigators until consensus was achieved. Equal weights were attributed to each response, and total responses for each factor were summed. Responses were also divided based on SOS member location, grouped as either high-income countries (HICs) or low- and middle-income countries (LMICs) according to the World Bank definitions.
3.
Similar methods have previously been used to document the benefits of international rotations for United States surgical trainees [11]. Briefly, to elucidate potential barriers to the inclusion of surgical care on the global health agenda, over a 3-wk period in December 2013, all active members of SOS were contacted via e-mail and queried: “Please reply with 3 (or more) brief reasons why surgery is still not receiving recognition and support on the public health and global health agendas.” The answers provided were free-text and not limited by space or scope. Respondents were allowed to provide more than three answers if desired, so as to not limit potential contributions. The respondents’ country of origin was also noted. This study was approved by the SOS Research Committee.
2.2.
Data analysis
All responses were noted verbatim and collected in an electronic spreadsheet (Microsoft Excel; Microsoft, Redmond, WA). To use the Shiffman framework to organize the responses, all free-text answers were analyzed by two indepen-
Results
From 176 active SOS members who were contacted for their opinion, a total of 75 responses were received for a response rate of 42.6% (75 of 176). Of the respondents, 61 were from HICs and 14 were from LMICs. Most respondents included three reasons, although the number ranged from 1e9. Therefore, a total of 248 individual reasons were collected. Examples of verbatim responses collected according to their classifications in the Shiffman framework is provided in Table 1. The number of responses categorized by factor for HICs, LMICs, and overall is displayed in Table 2. Respondent answers were most commonly (60 of 248; 24.2%) related to external frame, defined as public portrayals of the issue in ways that resonate with external audiences, especially the political leaders who control resources. The second most cited reason was a lack of effective interventions, defined as the extent to which proposed means of addressing the problems are clearly explained, cost effective, backed by scientific evidence, simple to implement, and inexpensive (48 of 248; 19.4%). The least cited reasons were categorized as global governance structure (4 of 248; 1.6%), policy window (6 of 248; 2.4%), and civil society mobilization (6 of 248; 2.4%).
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Table 1 e Shiffman framework and examples of verbatim answers provided by SOS members. Main categories Actor power
Factors shaping political priority
Examples
“I see a fractured effort as the leading impediment toward moving the surgical capacity building effort forward. [.] The lack of a unified Global Surgery governance, just like in global health efforts, stymies our agenda from moving forward.” “Perception that surgeons do not play well with others.” Leadership “Lack of champions who have access to funding.” “Too few surgeons involved in global and public health.” “Most public health authorities are not surgeons.” “Most surgeons spend most time in the OR rather than advocacy.” Guiding institutions “We need international high level groups that can coordinate surgical activities.” “Surgery isn’t given a caucus or public forum for discussion at public health meetings.” “Lack of vision and insight from local Ministries of Health to make it a priority.” Civil society mobilization “No grassroots/patient initiatives or involvement.” “Lack of awareness among common man that many surgical problems are preventable.” “If we ought to change the place that surgery has on the public and global health agendas we need to make people think of surgery as a every day need and not a “last resource”.” Ideas Internal frame “Surgery has very indistinct borders.” “Single diseases can have strong patient/family support groups but with surgery there are thousands of different conditions that will each have their own small communities but those communities never galvanize around surgical care provision.” “It is not a disease per se, it is a resource or tool for treating a wide array of diseases.” External frame “Misconception about surgery’s cost-effectiveness ($/DALY averted) compared to others.” “Historically ignored - I think we underemphasize the role that inertia plays in this.” “Surgery is still thought to be a specialty service and not primary care.” Political contexts Policy windows “Surgery is not in line with public health efforts. This is where training a cadre of “Public health surgeons” who practice surgery while addressing population health will help.” “Often surgery is felt separated from ob/gyn surgery. While the second is more considered, not a great relevance is given to the first one.” Global governance structure “People don’t think about surgery and access to surgery as a public health problem. They assume surgeons are just there.” Issue characteristics Credible indicators “Lack of thorough, scientifically sound, published evidence.” “Good and accurate data demonstrating the effectiveness of surgery in reducing death and disability and prolonging life has not been available for a long time.” “Lack of reliable research with solid, reproducible methodology (historical)– we can’t argue for NIH money, etc., with poor research methods.” Severity “Lack of recognition as a main contributor to mortality.” “Impact harder to easily quantify e bang for the buck.” Effective interventions “Surgery is considered to be too high-tech for low resource settings.” “A pill is easier to deliver than an OR.” “Lack of ideas how to solve surgical problems.”
4.
Policy community cohesion
4.1.
Discussion
Access to surgical care is vitally important for health care and integral to achieving a functioning health system [4,5]. However, to the frustration of many stakeholders, surgical care has been relatively absent on the public health and global health agendas. This survey of a self-identified global surgery community highlights a number of potential barriers. The analysis of items that were not frequently noted by the respondents, however, may be even more important in the overall analysis as they may represent issues that the global surgery community has ignored. Therefore, there appears to be benefit in studying what is being achieved and what has so far been relatively ignored to guide future efforts.
External frame
The lack of sufficient and/or successful portrayal of the problem to the public and political leaders was most commonly cited. However, there have been some recent successes in overcoming this obstacle. Most importantly, a draft World Health Assembly resolution on surgical care and anesthesia was circulated to Ministries of Health and policymakers of various countries, many of whom now support the issue. Furthermore, several political leaders in the United States have sent letters to the Secretary of Health and Human Services asking specifically for greater emphasis on surgical care and for resources to support it [12]. Recently, the heads of the President’s Emergency Program for Aid Relief and the
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Table 2 e Number of responses and percentages for each factor shaping political priority by SOS members from HICs, LMICs, and total. Factor shaping political priority
HICs (%)
External frame Effective interventions Leadership Severity Credible indicators Internal frame Guiding institutions Policy community cohesion Civil society mobilization Policy window Global governance structure Total
47 36 25 20 18 18 14 10 2 4 3 197
(23.9) (18.3) (12.7) (10.2) (9.1) (9.1) (7.1) (5.1) (1.0) (2.0) (1.5) (100)
LMICs (%) 13 12 5 4 5 3 1 1 4 2 1 51
(25.5) (23.5) (9.8) (7.8) (9.8) (5.9) (2.0) (2.0) (7.8) (3.9) (2.0) (100)
Total (%) 60 48 30 24 23 21 15 11 6 6 4 248
(24.2) (19.4) (12.1) (9.7) (9.3) (8.5) (6.0) (4.4) (2.4) (2.4) (1.6) (100)
World Health Organization were made aware of the surgical needs of global populations.
4.2.
Effective interventions
The lack of proposed means that are clear, simple and inexpensive to implement, and backed by sound evidence was also commonly mentioned. These interventions should cover all levels of political, humanitarian, and financial interest. High on this list was the absence of funding but also a dearth of cost effective and easy-to-implement programs. However, there have also been a number of recent encouraging developments in this direction. The United States National Institutes of Health have funded a Medical Education and Partnership Initiative grant for surgical care; [13] Fulbright and Fogarty Fellows have included surgeons and surgical trainees; [14] and the National Cancer Institute has created a Center for Global Health that is funding programs in LMICs including surgical research [15]. Funding also exists for many of the nongovernmental organizations providing specialty surgical care, for example: Mercy Ships, Operation Smile, and ReSurge.
4.3.
Leadership
Leadership must come from institutions, policymakers, governments, and most importantly from the public. Ideally, strong and charismatic leaders can help propel an issue onto the global agenda. Currently, there is also a lack of strong leadership for surgical care within the institutions that oversee the global health agenda and dictate funding priorities. On the national level in the United States, leadership is improving with recent emphasis on global surgery by past and current presidents of the American College of Surgeons and by other national and international societies.
4.4.
Underrecognized reasons
Reasons that were identified by fewer than 10% of respondents merit further scrutiny and include: internal frame; guiding institutions; policy community cohesion; civil society mobilization; policy window; and global governance struc-
ture. When examining these factors, it is important to distinguish whether these responses were not included because they are either sufficiently addressed, which is unlikely, or because they are not recognized by the community as important. If it is because of the latter, it will be necessary to educate the global surgery community about the importance of all 11 factors. HICs respondents tended to cite “policy community cohesion” more frequently than LMICs respondents; only one LMICs respondent cited this as a reason. This may reflect the growing sense of fragmentation of the global surgery community in the United States. The reality may be, however, that as the global surgery community grows, there is more involvement by an ever-increasing group with highly varied backgrounds and motivations. Interestingly, both factors in the framework category of political context were minimally cited. The first was “policy windows,” which seek to promote an issue when global conditions align favorably. A possible reason this fact was rarely cited may reflect on the surgical community’s capability of promoting the need for surgical care during opportune times. For example, surgeons were quite effective and vocal in the aftermath of the earthquake in Haiti where, especially in the United States, there was a greater recognition of the vast improvements needed for access to surgical care in LMICs [16]. Q2 The factor of “global governance structure” was also not frequently cited, which may also reflect work that has already been achieved. Surgical care advocates are increasingly tying surgical care to other programs, including millennium development goals [17], human immunodeficiency virus [18,19], noncommunicable diseases [20], and oncology [21]. “Guiding institutions” were not frequently mentioned and that may reflect the dearth of leadership and few organizations to champion surgical care issues. There is also limited support at national and international organizations such as USAID, the Q3 World Health Organization, and the World Bank. This factor may also not have been mentioned because it may be outside the knowledge and experience of many in the global surgery community. The most concerning result of this survey was the lack of responses focused on the issue of “civil society mobilization.” Most SOS members are surgeons and although some have public health training, many do not. In an era when the importance of patient-focused care is increasingly recognized, a major reason why surgical care has not become more visible as a major health care need may be that patients themselves have not been given a voice or the opportunity to express or form a desire for enhancement of surgical services. This preliminary study has a number of limitations. It was limited to a single organization, already interested in global surgery. A broader study might include a larger population of surgeons, nonsurgeons, physicians, nonphysician health workers, and even patients to provide insights, which a global surgery community might not consider important. Moreover, more than half of the respondents were from HICs, most of whom were from the United States. More respondents from LMICs might provide a broader overview of the problems and potential solutions. Ideally, this type of study could include surgical patients and the stakeholders who would directly benefit from enhanced resources and providers who have to
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contribute to such resources. The relatively low-response rate also may limit the number of opinions; however, the insights collected are a useful starting point for guiding interventions to improve the recognition that surgical care must be improved worldwide. Additionally, the survey only asked for 3 responses; it is possible that if 5 or even 10 responses were requested, more of the factors would have potentially been covered. Nevertheless, this survey provides valuable insight into political barriers as perceived by the global surgery community.
4.5.
Recommendations
In light of the findings of this study, several recommendations can be made, which are not dissimilar to those put forward by Shawar et al. [10]. The need for a unifying voice with strong leadership and good representation from all stakeholders is urgently needed. The recently created Lancet Commission on Global Surgery shows promise in coordinating efforts, both in terms of defining the problem and integrating potential solutions. One key to success will be the development of easily understood and executable proposals that can be successfully funded. The public portrayal of global surgery also appears to be a priority. One option to achieve this is to obtain assistance from experts in the fields of advertising and public relations to assist in crafting messages that strongly resonate with policymakers and clearly highlight the political implications for them. Celebrities such as Bono and Elton John have helped raise awareness of the need for resources for human immunodeficiency virus. No such spokesperson represents patients needing surgical care, and this could represent an important medium to gain the public’s attention. To convey the severity of the problem, however, ongoing population- and hospitalbased assessments of the unmet surgical need will be essential. Surgical care should also be integrated into other public health efforts. As previously mentioned, the passage of a World Health Assembly resolution is one approach whereby surgical care can be better incorporated into other ongoing issues at the World Health Organization such as health system strengthening, disabilities, and noncommunicable diseases. The surgical response during Haiti’s earthquake, for instance, is an example of capitalizing on windows of opportunity to stress the lack of access to surgical care and to highlight the utility of surgery in other health sectors. Ideally, more international nongovernmental organizations such as Medecins Sans Frontieres, International Medical Corps, and Save the Children can integrate surgical care in their efforts. Finally, more representation from grassroots organizations and patient advocates should be sought. One option could be to reach out for assistance by experienced advocates such as the International Campaigns to Ban Landmines or groups that advocate for the rights of the disabled or the more recent, noncommunicable disease alliance. Ultimately, patients in LMICs should be given a voice to express their need for surgical care.
5.
5
Conclusions
Although the recognition of the enormous surgical needs of populations around the world is increasing, much remains to be studied. Using the Shiffman framework for global initiatives, this survey of a global surgery community identified a number of important barriers to political priority on the global health agendas, including the public portrayal of the problem, the lack of effective interventions, and lack of cohesive leadership. Of note were the limited recommendations to mobilize civil society, develop guiding institutions, and enhance the political context. Future efforts should focus on gaining political priority for surgical care on the global health agenda.
Acknowledgment The authors thank all respondents for taking the time to share their expertise. Authors’ contributions: E.G.W., A.L.K., and R.R.P. designed and implemented the study. All authors contributed to the analysis and interpretation of the data, critically revised the article for intellectual content, and read and approved the final article. E.G.W. and A.L.K. drafted the article.
Disclosure All authors are members of Surgeons OverSeas (SOS). There are no conflicts of interest to declare and no funding was received for this study.
references
[1] Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet 2010;376:1055. [2] Groen RS, Samai M, Stewart KA, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, crosssectional, countrywide survey. Lancet 2012;380:1082. [3] Petroze RT, Groen RS, Niyonkuru F, et al. Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda. Surgery 2013;153:457. [4] Bae JY, Groen RS, Kushner AL. Surgery as a public health intervention: common misconceptions versus the truth. Bull World Health Organ 2011;89:394. [5] Kushner AL, Kingham TP, Nwomeh BC. Medicine and surgery: the yin and yang of health systems. Lancet 2012; 379:1488. [6] Global surgerydthe final frontier? Lancet 2012;379:194. [7] Meara JG, Hagander L, Leather AJ. Surgery and global health: a Lancet Commission. Lancet 2014;383:12. [8] Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 2007;370:1370. [9] Shawar Y, Shiffman J, Spiegel D, Can “essential” surgical care become a political priority on the global health agenda? an application of a policy framework, APPAM Annual Fall Research Conference, Washington, DC, November 8, 2013. Q4
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[10] Shawar Y, Shiffman J, Spiegel D, Generating political priority for global surgical care, World Congress of Surgery, Obstet Trauma Anesth Port Spain, Trinidad, 2013. [11] Henry JA, Groen RS, Price RR, et al. The benefits of international rotations to resource-limited settings for U.S. surgery residents. Surgery 2013;153:445. [12] Leckman SA, Global need for surgery, Salt Lake Tribune, March 23, 2013, http://www.sltrib.com/sltrib/opinion/ 56035708-82/surgery-health-child-anesthesia.html.csp Accessed December 22, 2013. [13] Directory of awards and collaborating partners for the Medical Education Partnership Initiative (MEPI), http://www. fic.nih.gov/Grants/Search/Pages/Awards-Program-MEPI. aspx, Accessed December 22, 2013. [14] Profile: Fogarty Fellow Dr Robin Petroze studies Rwanda’s surgical capacity, http://www.fic.nih.gov/News/ GlobalHealthMatters/september-october-2013/Pages/robinpetroze-rwanda-surgery.aspx Accessed December 22, 2013. [15] National Cancer Institute, Center for Global Health, http:// www.cancer.gov/aboutnci/globalhealth Accessed December 22, 2013.
[16] Patel A, Pfaff M, Clune JE, et al. Disseminating surgery effectively and efficiently in Haiti. J Craniofac Surg 2013; 24:1244. [17] Kushner AL, Cherian MN, Noel L, Spiegel DA, Groth S, Etienne C. Addressing the millennium development goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg 2010; 145:154. [18] Kingham TP, Kamara TB, Daoh KS, Kabbia S, Kushner AL. Universal precautions and surgery in Sierra Leone: the unprotected workforce. World J Surg 2009;33:1194. [19] Leow JJ, Groen RS, Bae JY, Adisa CA, Kingham TP, Kushner AL. Scarcity of healthcare worker protection in eight low- and middle-income countries: surgery and the risk of HIV and other bloodborne pathogens. Trop Med Int Health 2012;17:397. [20] Kushner AL, Groen RS. Non-communicable diseases: beyond prevention and screening. Lancet 2011;378:567. [21] Kingham TP, Alatise OI, Vanderpuye V, et al. Treatment of cancer in sub-Saharan Africa. Lancet Oncol 2013; 14:e158.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Recommendations for including surgery on the public health agenda Evan G. Wong, MD, MPH,a,b,* Emmanuel A. Ameh, MD,a,c Sherry M. Wren, MD,a,d Wakisa Mulwafu, MD,a,e Mark A. Hardy, MD,a,f Benedict C. Nwomeh, MD, MPH,a,g Adam L. Kushner, MD, MPH,a,f,h and Raymond R. Price, MDa,i,j a
Surgeons OverSeas (SOS), New York, New York Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada c Division of Paediatric Surgery, Department of Surgery, Ahmadu Bello University & Ahmadu Bello University Teaching Hospital, Zaria, Nigeria d Department of Surgery, Stanford University, Palo Alto, California e Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi f Department of Surgery, Columbia University, New York, New York g Department of Pediatric Surgery, Nationwide Children’s, Hospital, Columbus, Ohio h Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland i Department of Surgery, Intermountain Health Care, Salt Lake City, Utah j Department of Surgery, University of Utah, Salt Lake City, Utah b
article info
abstract
Article history:
Background: Surgical care has made limited inroads on the public health and global health
Received 10 February 2015
agendas despite increasing data showing the enormous need. The objective of this study
Received in revised form
was to survey interested members of a global surgery community to identify patterns of
21 March 2015
thought regarding barriers to political priority.
Accepted 3 April 2015
Materials and methods: All active members of the nongovernmental organization Surgeons
Available online xxx
OverSeas were surveyed and asked why surgical care is not receiving recognition and support on the public health and global health agenda. Responses were categorized using
Keywords:
the Shiffman framework on determinants of political priority for global initiatives by two
Health priorities
independent investigators, and the number of responses for each of the 11 factors was
Politics
calculated.
Public health
Results: Seventy-five Surgeons OverSeas members replied (75 of 176; 42.6% response rate). A
Surgery
total of 248 individual reasons were collected. The most common responses were related to external frame, defined as public portrayals of the issue (60 of 248; 24.2%), and lack of effective interventions (48 of 248; 19.4%). Least cited reasons related to global governance structure (4 of 248; 2.4%) and policy window (4 of 248; 1.6%). Conclusions: This survey of a global surgery community identified a number of barriers to the recognition of surgical care on the global health agenda. Recommendations include improving the public portrayal of the problem; developing effective interventions and seeking strong and charismatic leadership. ª 2015 Elsevier Inc. All rights reserved.
* Corresponding author. Centre for Global Surgery, McGill University Health Centre, 1650 Cedar Avenue, L9 411, Montreal, QC, Canada H3G 1A4. Tel.: þ1 514 934 1934; fax: þ1 514 843 1503. E-mail address: [email protected] (E.G. Wong). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.04.020
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1.
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Introduction
Globally, an estimated 2 billion people lack access to an operating room [1], and between 5 and 25% of populations in sub-Saharan Africa are estimated to need surgical evaluation [2,3]. In addition, surgical care is recognized as a vital component of a functioning health system and necessary to provide truly universal health care [4,5]. However, despite the documented need, surgery has made limited inroads onto the public health and global health agendas. A number of organizations and initiatives have developed specific programs, documented the substantial burden of surgical disease, and advocated for surgical care. In addition, efforts are underway to further evaluate the problem [6,7]. In 2007, Shiffman and Smith [8] described a framework on determinants of political priority for global initiatives and looked specifically at maternal mortality. Preliminary investigations have begun to focus on the reasons why surgical care and anesthesia are not more prominent on the global health agenda [9,10]. One global surgery community, Surgeons OverSeas (SOS), is a United States-based nonprofit organization with a mission to save lives in developing countries by improving surgical care. Founded in 2007, this society comprises members representing over 15 subspecialties and with experience in over 31 different countries [11]. In this context, we sought to survey the SOS membership and apply the Shiffman framework to identify potential barriers to political priority and to plan for broader inclusion of surgical care by the public health and global health communities. These data should lead to a more consistent, systematic, and focused effort by those involved in providing surgical care.
2.
Materials and methods
2.1.
Data collection
dent investigators (A.L.K. and E.G.W.) and categorized into one of the 11 Shiffman factors for shaping political priority, which have been previously described in detail [8]. Briefly, these 11 factors used as categories included 1. Policy community cohesion: level of coalescence among those involved 2. Leadership: commitment of strong champions for the cause 3. Guiding institutions: leadership provided by coordinating organizations 4. Civil society mobilization: recruitment of grassroots organizations 5. Internal frame: degree of agreement of the policy community on root causes and solutions 6. External frame: portrayal of the problem to the external audience 7. Policy windows: capacity to capitalize on favorable global political opportunities 8. Global governance structure: extent to which current institutions are conducive to collective action 9. Credible indicators: availability of effective measures 10. Severity: extent of the problem 11. Effective interventions: availability of solutions to the problem Any discrepancies were discussed between the two investigators until consensus was achieved. Equal weights were attributed to each response, and total responses for each factor were summed. Responses were also divided based on SOS member location, grouped as either high-income countries (HICs) or low- and middle-income countries (LMICs) according to the World Bank definitions.
3.
Similar methods have previously been used to document the benefits of international rotations for United States surgical trainees [11]. Briefly, to elucidate potential barriers to the inclusion of surgical care on the global health agenda, over a 3-wk period in December 2013, all active members of SOS were contacted via e-mail and queried: “Please reply with 3 (or more) brief reasons why surgery is still not receiving recognition and support on the public health and global health agendas.” The answers provided were free-text and not limited by space or scope. Respondents were allowed to provide more than three answers if desired, so as to not limit potential contributions. The respondents’ country of origin was also noted. This study was approved by the SOS Research Committee.
2.2.
Data analysis
All responses were noted verbatim and collected in an electronic spreadsheet (Microsoft Excel; Microsoft, Redmond, WA). To use the Shiffman framework to organize the responses, all free-text answers were analyzed by two indepen-
Results
From 176 active SOS members who were contacted for their opinion, a total of 75 responses were received for a response rate of 42.6% (75 of 176). Of the respondents, 61 were from HICs and 14 were from LMICs. Most respondents included three reasons, although the number ranged from 1e9. Therefore, a total of 248 individual reasons were collected. Examples of verbatim responses collected according to their classifications in the Shiffman framework is provided in Table 1. The number of responses categorized by factor for HICs, LMICs, and overall is displayed in Table 2. Respondent answers were most commonly (60 of 248; 24.2%) related to external frame, defined as public portrayals of the issue in ways that resonate with external audiences, especially the political leaders who control resources. The second most cited reason was a lack of effective interventions, defined as the extent to which proposed means of addressing the problems are clearly explained, cost effective, backed by scientific evidence, simple to implement, and inexpensive (48 of 248; 19.4%). The least cited reasons were categorized as global governance structure (4 of 248; 1.6%), policy window (6 of 248; 2.4%), and civil society mobilization (6 of 248; 2.4%).
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Table 1 e Shiffman framework and examples of verbatim answers provided by SOS members. Main categories Actor power
Factors shaping political priority
Examples
“I see a fractured effort as the leading impediment toward moving the surgical capacity building effort forward. [.] The lack of a unified Global Surgery governance, just like in global health efforts, stymies our agenda from moving forward.” “Perception that surgeons do not play well with others.” Leadership “Lack of champions who have access to funding.” “Too few surgeons involved in global and public health.” “Most public health authorities are not surgeons.” “Most surgeons spend most time in the OR rather than advocacy.” Guiding institutions “We need international high level groups that can coordinate surgical activities.” “Surgery isn’t given a caucus or public forum for discussion at public health meetings.” “Lack of vision and insight from local Ministries of Health to make it a priority.” Civil society mobilization “No grassroots/patient initiatives or involvement.” “Lack of awareness among common man that many surgical problems are preventable.” “If we ought to change the place that surgery has on the public and global health agendas we need to make people think of surgery as a every day need and not a “last resource”.” Ideas Internal frame “Surgery has very indistinct borders.” “Single diseases can have strong patient/family support groups but with surgery there are thousands of different conditions that will each have their own small communities but those communities never galvanize around surgical care provision.” “It is not a disease per se, it is a resource or tool for treating a wide array of diseases.” External frame “Misconception about surgery’s cost-effectiveness ($/DALY averted) compared to others.” “Historically ignored - I think we underemphasize the role that inertia plays in this.” “Surgery is still thought to be a specialty service and not primary care.” Political contexts Policy windows “Surgery is not in line with public health efforts. This is where training a cadre of “Public health surgeons” who practice surgery while addressing population health will help.” “Often surgery is felt separated from ob/gyn surgery. While the second is more considered, not a great relevance is given to the first one.” Global governance structure “People don’t think about surgery and access to surgery as a public health problem. They assume surgeons are just there.” Issue characteristics Credible indicators “Lack of thorough, scientifically sound, published evidence.” “Good and accurate data demonstrating the effectiveness of surgery in reducing death and disability and prolonging life has not been available for a long time.” “Lack of reliable research with solid, reproducible methodology (historical)– we can’t argue for NIH money, etc., with poor research methods.” Severity “Lack of recognition as a main contributor to mortality.” “Impact harder to easily quantify e bang for the buck.” Effective interventions “Surgery is considered to be too high-tech for low resource settings.” “A pill is easier to deliver than an OR.” “Lack of ideas how to solve surgical problems.”
4.
Policy community cohesion
4.1.
Discussion
Access to surgical care is vitally important for health care and integral to achieving a functioning health system [4,5]. However, to the frustration of many stakeholders, surgical care has been relatively absent on the public health and global health agendas. This survey of a self-identified global surgery community highlights a number of potential barriers. The analysis of items that were not frequently noted by the respondents, however, may be even more important in the overall analysis as they may represent issues that the global surgery community has ignored. Therefore, there appears to be benefit in studying what is being achieved and what has so far been relatively ignored to guide future efforts.
External frame
The lack of sufficient and/or successful portrayal of the problem to the public and political leaders was most commonly cited. However, there have been some recent successes in overcoming this obstacle. Most importantly, a draft World Health Assembly resolution on surgical care and anesthesia was circulated to Ministries of Health and policymakers of various countries, many of whom now support the issue. Furthermore, several political leaders in the United States have sent letters to the Secretary of Health and Human Services asking specifically for greater emphasis on surgical care and for resources to support it [12]. Recently, the heads of the President’s Emergency Program for Aid Relief and the
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Table 2 e Number of responses and percentages for each factor shaping political priority by SOS members from HICs, LMICs, and total. Factor shaping political priority
HICs (%)
External frame Effective interventions Leadership Severity Credible indicators Internal frame Guiding institutions Policy community cohesion Civil society mobilization Policy window Global governance structure Total
47 36 25 20 18 18 14 10 2 4 3 197
(23.9) (18.3) (12.7) (10.2) (9.1) (9.1) (7.1) (5.1) (1.0) (2.0) (1.5) (100)
LMICs (%) 13 12 5 4 5 3 1 1 4 2 1 51
(25.5) (23.5) (9.8) (7.8) (9.8) (5.9) (2.0) (2.0) (7.8) (3.9) (2.0) (100)
Total (%) 60 48 30 24 23 21 15 11 6 6 4 248
(24.2) (19.4) (12.1) (9.7) (9.3) (8.5) (6.0) (4.4) (2.4) (2.4) (1.6) (100)
World Health Organization were made aware of the surgical needs of global populations.
4.2.
Effective interventions
The lack of proposed means that are clear, simple and inexpensive to implement, and backed by sound evidence was also commonly mentioned. These interventions should cover all levels of political, humanitarian, and financial interest. High on this list was the absence of funding but also a dearth of cost effective and easy-to-implement programs. However, there have also been a number of recent encouraging developments in this direction. The United States National Institutes of Health have funded a Medical Education and Partnership Initiative grant for surgical care; [13] Fulbright and Fogarty Fellows have included surgeons and surgical trainees; [14] and the National Cancer Institute has created a Center for Global Health that is funding programs in LMICs including surgical research [15]. Funding also exists for many of the nongovernmental organizations providing specialty surgical care, for example: Mercy Ships, Operation Smile, and ReSurge.
4.3.
Leadership
Leadership must come from institutions, policymakers, governments, and most importantly from the public. Ideally, strong and charismatic leaders can help propel an issue onto the global agenda. Currently, there is also a lack of strong leadership for surgical care within the institutions that oversee the global health agenda and dictate funding priorities. On the national level in the United States, leadership is improving with recent emphasis on global surgery by past and current presidents of the American College of Surgeons and by other national and international societies.
4.4.
Underrecognized reasons
Reasons that were identified by fewer than 10% of respondents merit further scrutiny and include: internal frame; guiding institutions; policy community cohesion; civil society mobilization; policy window; and global governance struc-
ture. When examining these factors, it is important to distinguish whether these responses were not included because they are either sufficiently addressed, which is unlikely, or because they are not recognized by the community as important. If it is because of the latter, it will be necessary to educate the global surgery community about the importance of all 11 factors. HICs respondents tended to cite “policy community cohesion” more frequently than LMICs respondents; only one LMICs respondent cited this as a reason. This may reflect the growing sense of fragmentation of the global surgery community in the United States. The reality may be, however, that as the global surgery community grows, there is more involvement by an ever-increasing group with highly varied backgrounds and motivations. Interestingly, both factors in the framework category of political context were minimally cited. The first was “policy windows,” which seek to promote an issue when global conditions align favorably. A possible reason this fact was rarely cited may reflect on the surgical community’s capability of promoting the need for surgical care during opportune times. For example, surgeons were quite effective and vocal in the aftermath of the earthquake in Haiti where, especially in the United States, there was a greater recognition of the vast improvements needed for access to surgical care in LMICs [16]. Q2 The factor of “global governance structure” was also not frequently cited, which may also reflect work that has already been achieved. Surgical care advocates are increasingly tying surgical care to other programs, including millennium development goals [17], human immunodeficiency virus [18,19], noncommunicable diseases [20], and oncology [21]. “Guiding institutions” were not frequently mentioned and that may reflect the dearth of leadership and few organizations to champion surgical care issues. There is also limited support at national and international organizations such as USAID, the Q3 World Health Organization, and the World Bank. This factor may also not have been mentioned because it may be outside the knowledge and experience of many in the global surgery community. The most concerning result of this survey was the lack of responses focused on the issue of “civil society mobilization.” Most SOS members are surgeons and although some have public health training, many do not. In an era when the importance of patient-focused care is increasingly recognized, a major reason why surgical care has not become more visible as a major health care need may be that patients themselves have not been given a voice or the opportunity to express or form a desire for enhancement of surgical services. This preliminary study has a number of limitations. It was limited to a single organization, already interested in global surgery. A broader study might include a larger population of surgeons, nonsurgeons, physicians, nonphysician health workers, and even patients to provide insights, which a global surgery community might not consider important. Moreover, more than half of the respondents were from HICs, most of whom were from the United States. More respondents from LMICs might provide a broader overview of the problems and potential solutions. Ideally, this type of study could include surgical patients and the stakeholders who would directly benefit from enhanced resources and providers who have to
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contribute to such resources. The relatively low-response rate also may limit the number of opinions; however, the insights collected are a useful starting point for guiding interventions to improve the recognition that surgical care must be improved worldwide. Additionally, the survey only asked for 3 responses; it is possible that if 5 or even 10 responses were requested, more of the factors would have potentially been covered. Nevertheless, this survey provides valuable insight into political barriers as perceived by the global surgery community.
4.5.
Recommendations
In light of the findings of this study, several recommendations can be made, which are not dissimilar to those put forward by Shawar et al. [10]. The need for a unifying voice with strong leadership and good representation from all stakeholders is urgently needed. The recently created Lancet Commission on Global Surgery shows promise in coordinating efforts, both in terms of defining the problem and integrating potential solutions. One key to success will be the development of easily understood and executable proposals that can be successfully funded. The public portrayal of global surgery also appears to be a priority. One option to achieve this is to obtain assistance from experts in the fields of advertising and public relations to assist in crafting messages that strongly resonate with policymakers and clearly highlight the political implications for them. Celebrities such as Bono and Elton John have helped raise awareness of the need for resources for human immunodeficiency virus. No such spokesperson represents patients needing surgical care, and this could represent an important medium to gain the public’s attention. To convey the severity of the problem, however, ongoing population- and hospitalbased assessments of the unmet surgical need will be essential. Surgical care should also be integrated into other public health efforts. As previously mentioned, the passage of a World Health Assembly resolution is one approach whereby surgical care can be better incorporated into other ongoing issues at the World Health Organization such as health system strengthening, disabilities, and noncommunicable diseases. The surgical response during Haiti’s earthquake, for instance, is an example of capitalizing on windows of opportunity to stress the lack of access to surgical care and to highlight the utility of surgery in other health sectors. Ideally, more international nongovernmental organizations such as Medecins Sans Frontieres, International Medical Corps, and Save the Children can integrate surgical care in their efforts. Finally, more representation from grassroots organizations and patient advocates should be sought. One option could be to reach out for assistance by experienced advocates such as the International Campaigns to Ban Landmines or groups that advocate for the rights of the disabled or the more recent, noncommunicable disease alliance. Ultimately, patients in LMICs should be given a voice to express their need for surgical care.
5.
5
Conclusions
Although the recognition of the enormous surgical needs of populations around the world is increasing, much remains to be studied. Using the Shiffman framework for global initiatives, this survey of a global surgery community identified a number of important barriers to political priority on the global health agendas, including the public portrayal of the problem, the lack of effective interventions, and lack of cohesive leadership. Of note were the limited recommendations to mobilize civil society, develop guiding institutions, and enhance the political context. Future efforts should focus on gaining political priority for surgical care on the global health agenda.
Acknowledgment The authors thank all respondents for taking the time to share their expertise. Authors’ contributions: E.G.W., A.L.K., and R.R.P. designed and implemented the study. All authors contributed to the analysis and interpretation of the data, critically revised the article for intellectual content, and read and approved the final article. E.G.W. and A.L.K. drafted the article.
Disclosure All authors are members of Surgeons OverSeas (SOS). There are no conflicts of interest to declare and no funding was received for this study.
references
[1] Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet 2010;376:1055. [2] Groen RS, Samai M, Stewart KA, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, crosssectional, countrywide survey. Lancet 2012;380:1082. [3] Petroze RT, Groen RS, Niyonkuru F, et al. Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda. Surgery 2013;153:457. [4] Bae JY, Groen RS, Kushner AL. Surgery as a public health intervention: common misconceptions versus the truth. Bull World Health Organ 2011;89:394. [5] Kushner AL, Kingham TP, Nwomeh BC. Medicine and surgery: the yin and yang of health systems. Lancet 2012; 379:1488. [6] Global surgerydthe final frontier? Lancet 2012;379:194. [7] Meara JG, Hagander L, Leather AJ. Surgery and global health: a Lancet Commission. Lancet 2014;383:12. [8] Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 2007;370:1370. [9] Shawar Y, Shiffman J, Spiegel D, Can “essential” surgical care become a political priority on the global health agenda? an application of a policy framework, APPAM Annual Fall Research Conference, Washington, DC, November 8, 2013. Q4
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[10] Shawar Y, Shiffman J, Spiegel D, Generating political priority for global surgical care, World Congress of Surgery, Obstet Trauma Anesth Port Spain, Trinidad, 2013. [11] Henry JA, Groen RS, Price RR, et al. The benefits of international rotations to resource-limited settings for U.S. surgery residents. Surgery 2013;153:445. [12] Leckman SA, Global need for surgery, Salt Lake Tribune, March 23, 2013, http://www.sltrib.com/sltrib/opinion/ 56035708-82/surgery-health-child-anesthesia.html.csp Accessed December 22, 2013. [13] Directory of awards and collaborating partners for the Medical Education Partnership Initiative (MEPI), http://www. fic.nih.gov/Grants/Search/Pages/Awards-Program-MEPI. aspx, Accessed December 22, 2013. [14] Profile: Fogarty Fellow Dr Robin Petroze studies Rwanda’s surgical capacity, http://www.fic.nih.gov/News/ GlobalHealthMatters/september-october-2013/Pages/robinpetroze-rwanda-surgery.aspx Accessed December 22, 2013. [15] National Cancer Institute, Center for Global Health, http:// www.cancer.gov/aboutnci/globalhealth Accessed December 22, 2013.
[16] Patel A, Pfaff M, Clune JE, et al. Disseminating surgery effectively and efficiently in Haiti. J Craniofac Surg 2013; 24:1244. [17] Kushner AL, Cherian MN, Noel L, Spiegel DA, Groth S, Etienne C. Addressing the millennium development goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg 2010; 145:154. [18] Kingham TP, Kamara TB, Daoh KS, Kabbia S, Kushner AL. Universal precautions and surgery in Sierra Leone: the unprotected workforce. World J Surg 2009;33:1194. [19] Leow JJ, Groen RS, Bae JY, Adisa CA, Kingham TP, Kushner AL. Scarcity of healthcare worker protection in eight low- and middle-income countries: surgery and the risk of HIV and other bloodborne pathogens. Trop Med Int Health 2012;17:397. [20] Kushner AL, Groen RS. Non-communicable diseases: beyond prevention and screening. Lancet 2011;378:567. [21] Kingham TP, Alatise OI, Vanderpuye V, et al. Treatment of cancer in sub-Saharan Africa. Lancet Oncol 2013; 14:e158.
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