World J Surg (2010) 34:381 385 DOI 10.1007/s00268-009-0263-4 Developing Priorities for Addressing Surgical Conditions Globally: Furthering the Link Between Surgery and Public Health Policy Charles Mock Meena Cherian Catherine Juillard Peter Donkor Stephen Bickler Dean Jamison Kelly McQueen Published online: 30 October 2009 Ó Société Internationale de Chirurgie 2009 Abstract Background Efforts to promote wider access to surgical services globally would be aided by developing consensus among clinicians, the public health policy community, and other stakeholders as to which surgical conditions warrant the most focused attention and investment. This would add value to other, ongoing efforts, especially in helping to define unmet need and effective coverage. Methods In this concept paper, we introduce preliminary ideas on how priorities for surgical care could be better defined, especially as regards the interface between the surgical and public health worlds. Factors that would come into play in this process include the public health burden of the condition and the successfulness and feasibility of the procedures to treat those conditions. Two of the authors are staff members of the World Health Organization. They and the other authors alone are responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the World Health Organization. C. Mock (&) Department of Violence and Injury Prevention and Disability, World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland e-mail: mockc@who.int M. Cherian Emergency and Essential Surgical Care, Clinical Procedures Unit, Department of Essential Health Technologies, World Health Organization, 20 Avenue Appia, Geneva, Switzerland C. Juillard Department of Surgery, University of California at Los Angeles, 10833 LeConte, Los Angeles, CA 90095, USA Results and conclusions The implications of the prioritization process are that those conditions with the highest public health burden and that have procedures that are highly successful and feasible to promote globally, including in the most resource-constrained environments, should be the main focus of national and international efforts. Introduction When confronting the burden of surgical disease there is a major role to be played by many actors from different backgrounds, including both clinicians and the public health community. These two groups have, until recently, had little to do with each other. Efforts to promote wider access and availability of surgical services (including trauma, obstetrics, and anesthesia) globally would be better aided by further definition of the priorities for addressing surgical care. This would include developing consensus as S. Bickler Division of Pediatric Surgery, University of California at San Diego, 9500 Gilman Drive #0739, La Jolla, CA 92093-0739, USA D. Jamison Department of Global Health, University of Washington, 2301 5th Avenue, Suite 600, Seattle, WA 98121, USA K. McQueen Harvard Humanitarian Initiative, Boston, MA, USA K. McQueen 4134 N 49th Place, Phoenix, AZ 85018, USA P. Donkor College of Health Sciences, Kwame Nkrumah University of Science and Technology, University Post Office, Kumasi, Ghana
382 World J Surg (2010) 34:381 385 to the surgical conditions that warrant the most focused attention and investment. This process would add value to the ongoing efforts of groups such as the World Health Organization s (WHO) Global Initiative for Emergency and Essential Surgical Care (GIEESC) [1], the Global Burden of Surgical Disease working group [2], and others. This added value would include better definition of what to focus attention on in terms of the specific conditions to address and the procedures, resources, and ancillary services to promote. It would be especially useful for defining unmet need and effective coverage [3]. It would also allow better definition of the common ground with the public health world that is, those conditions on which both clinicians and the public health world should collaborate most closely. In this concept paper, we introduce preliminary ideas on how priorities for surgical care could be better defined, especially as regards the interface between the surgical and public health worlds. Before proceeding, an important caveat should be stated. Most who care for surgical patients realize the importance of a well functioning facility (including staff and equipment) that can handle a broad array of surgical conditions. Thus, efforts to better define and focus on priority conditions should by no means be viewed as efforts to implement vertical programs by narrowly focusing on only selected conditions but, rather, to identify the capacities required of facilities at different levels. Terminology We have developed preliminary definitions and examples of how a prioritization process might work for surgical conditions. They are meant to be preliminary and to serve as a starting point for discussion; they are not meant to be hard and fast rules as yet. The definition of surgical procedure and surgical condition have been well laid out by the Disease Control Priorities Project [4] and are addressed by the other articles in this series. Another concept that needs to come into play in terms of defining global priorities is that of feasible to promote globally. Factors that influence feasibility include the complexity of the procedure, the length of time needed for training before being able to perform the procedure, the possible need for expensive equipment, and the likelihood that the procedure can be carried out safely with a low complication rate. Other factors include the need for ancillary services (e.g., blood supply, pathology investigation, intensive care unit support for postoperative recovery) and the need for additional treatment services (e.g., irradiation, chemotherapy). In many situations, this implies a procedure that can be done at the district hospital (first referral level), especially for emergencies, so universal access can be ensured. Globally also implies that Table 1 Preliminary definitions for levels of priority of surgical conditions * Priority 1 surgical conditions are those: That have a large public health burden, and For which there is a surgical procedure that is highly successful at treating the condition, and treatments) is cost-effective and feasible to promote globally Priority 2 surgical conditions are those: That have a moderate public health burden, or For which there is a surgical procedure that is moderately successful at treating the condition, or treatments) is moderately cost-effective and feasible to promote globally Priority 3 surgical conditions are those: That have a low public health burden, or For which there is a surgical procedure that is neither highly nor moderately successful at treating the condition, or treatments) is low in cost-effectiveness and feasibility to promote globally. * The presented material is meant for preliminary discussion and is not meant to be comprehensive or final the capabilities must be feasible in the most resourceconstrained environments. However, the fact that even many high-income countries likely still have unmet needs for access to surgical services indicates that the global priorities should apply to all countries. Thus, several levels of priority could be defined. We have herein suggested three such levels (Table 1), although more could be considered with finer degrees of distinction between them. It can be seen that the three levels vary depending on their public health burden, whether there are surgical procedures that are highly (or moderately) effective at treating the condition, and how cost-effective and how feasible it is to promote those procedures globally, especially as regards the most resource-constrained environments. Priority 1 implies that all three conditions must be met. If any of the three conditions fall to the moderate or low level, the priority of the procedure or condition should be shifted to priority 2 or 3. More precise definitions will need to be worked out as regards what constitutes (1) the different levels of public health burden; (2) highly versus moderately successful procedures; and (3) feasibility. Implications Equally important as to how we define the priorities are the implications. Conditions that would be deemed priority 1 are those that would be the highest priority for publicly financed health systems to address and that should also be
World J Surg (2010) 34:381 385 383 the major emphasis for international programs. By virtue of the fact that the treatment for these conditions are in part defined by their feasibility and cost-effectiveness, the treatments could likely be ensured to almost everyone globally at little additional cost primarily through improved organization and planning within health systems. In most situations, procedures to treat these conditions could be done at district, or first referral level, facilities. For some conditions the treatments might reasonably be provided mainly at second or higher level or specialized facilities if reliable mechanisms for referral could be ensured. Part of the response to priority 1 conditions must encompass capabilities outside of the surgical realm. This would include, among other factors, better screening capability for detecting diseases at an early stage, which might also include efforts to increase public awareness of the conditions. Finally, priority 1 conditions are those for which there should be concerted international efforts to measure and monitor the burden of mortality and disability as well as the level of coverage of the procedure. The latter points emphasize again the close connection between the surgical and public health worlds for the definition of, and reaction to, priority 1 conditions. Priority 2 conditions are those for which there are still likely to be major gains made to increase access to treatments primarily by improved organization and planning. The potential gains here are less than for priority 1. There may, nonetheless, be ways to increase access to priority 2 conditions in an affordable and sustainable fashion. There will, in all likelihood, be a secondary gain in efforts to improve access to priority 1 conditions that would improve access to treatment for priority 2 conditions. We should be aware of such potential synergies when approaching and promoting priority 1 conditions. Priority 3 conditions are those for which current efforts to improve access to surgical care are likely not feasible or cost-effective. Most of these conditions would be those with low public health burden and/or for which treatment is costly and complex and primarily restricted to tertiary care facilities with good ancillary services in place. Although these treatments are life-saving, they are procedures for which major infrastructural investments or specialized skills and equipment are required. Unless priority 1 and 2 conditions are being addressed well, it may not be reasonable to focus major national and international efforts entirely on priority 3 conditions. Anesthesia (whether local, regional, or general) is an integral part of access to any surgical procedure. It cuts across as a key component in all the priorities and is therefore not listed separately in Table 1. The definitions and implications of the levels are, once again, preliminary ideas offered for discussion. There could be fewer or more levels of priority defined. Potential Examples of Conditions and Related Procedures for Different Priority Levels Table 2 contains preliminary examples of conditions and related procedures that might reasonably fall into the different levels of priorities. As with the preceding definitions, these examples are meant to be starting points for discussion and not yet hard and fast subjects. It is important to note that the public health burden of many of the surgical conditions have not yet been well defined, making ultimate decisions on the burden tentative at this time. In addition to the brief lists of procedures and conditions in Table 2, many of the procedures (including those for trauma, obstetrics, pediatric surgery, other types of surgery, and anesthesia) that would likely be the highest priority and that are eminently applicable at the first referral level facilities include those addressed in the WHO Surgical Care at the District Hospital and the Integrated Management of Emergency and Essential Surgical Care (IMEESC) Toolkit (including the supplies and anesthesia infrastructure) [5, 6]. Many of the traumatic conditions and related trauma care procedures have been addressed in WHO s Guidelines for Essential Care [7]. Finally, the obstetric procedures and their feasibility and global applicability have been well addressed by many who work to make pregnancy safer globally. Even with the suggestion of these few preliminary potential examples, however, controversial points arise. For example, treatment of breast malignancy particularly presents some difficulties of categorization. Much of the surgery itself fits well within the definition of priority 1, especially in terms of being feasible to promote globally. In addition, breast cancer s high public health burden might mean that it really should be addressed extensively in national health policy, as with priority 1 conditions. However, the need for ancillary services such as mammography, pathology, radiation therapy, and chemotherapy make this more of a priority 2 condition in terms of feasibility. As another example, surgical procedures for benign gynecologic conditions such as fibroids could perhaps go either way (priority 1 or 2). Difficulties with the prioritization process also arise when considering whether the process should focus on conditions or procedures. In many instances they are synonymous in that addressing a specific condition implies a defined procedure or set of procedures. In some instances, there are some procedures that pertain to several or more conditions. For example, venous access (e.g., with a cutdown) should certainly be a procedure that is widely available, as with any other procedure that would be listed in category 1. A strictly condition-oriented approach would not address a procedure such as a cut-down. Clearly, conditions themselves, procedures for treating these
384 World J Surg (2010) 34:381 385 Table 2 Preliminary categorization of surgical conditions and related procedures by priority categories Priority 1 Surgical airway (threatened or obstructed airway) Thoracostomy tube placement (hemothorax, pneumothorax) Exploratory laparotomy (hemoperitoneum, pneumoperitoneum, bowel injury) Splenectomy, splenic repair, packing of hepatic injury, repair of small bowel perforation Split-thickness skin grafting External fixation Toileting of open fracture Closed management of most fractures Pregnancy-related Cesarean section Management of ectopic pregnancy Hysterectomy for postpartum bleeding and uterine rupture D&C Other surgical procedures Hernia repair (umbilical, inguinal, femoral hernias) Hydrocelectomy Appendectomy Exploratory laparotomy (acute abdominal condition) Bowel obstruction Perforation Cholecystectomy (acute cholecystitis) Male circumcision Incision and drainage (infection) Drainage of septic arthritis Repair of isolated cleft lip Repair of club foot Priority 2 Repair of major vascular injuries primarily or with vein Open reduction and internal fixation Evacuation of intracranial hematoma Pregnancy-related Vesicovaginal, rectovaginal fistula repair Other surgical Hysterectomy (fibroid, other benign causes, cervical or uterine carcinoma) Gastric/duodenal ulcers (other than for perforation, as noted above) Thyroid surgery Breast malignancy Colon cancer Repair of cleft palate Table 2 continued Priority 3 a Repair of major vascular injuries with prosthetic graft Other surgical problems Parathyroid surgery Esophageal malignancies and benign esophageal disease Lung cancer Cardiac surgery Pancreatic cancer Transplantation This material is meant for preliminary discussion and is not meant to be comprehensive or final. Anesthesia (local, regional, general) cuts across fields as a key component in all the priorities and is therefore not listed separately in the table a There will be a long list of conditions and procedures in this category. Those listed are just a few preliminary examples conditions, and procedures that are common to treating many conditions need to be considered together. Final Caveats As mentioned earlier, we should be careful to avoid vertical approaches for specific surgical conditions. Defining priorities for surgical care is really is more about building comprehensive surgical capabilities, ensuring wide access, and monitoring and making sure that high priority conditions are, in reality, adequately addressed. Prioritization of conditions may change with national patterns of diseases. For example, esophageal cancer would likely fall into priority 3, given the complexity of the procedures needed to treat it and the need for ancillary services. In locations where the disease prevalence is high and where sufficient surgical capacity already exists, it might be reasonable to change it to priority 2. Many conditions with a moderate to low public health burden might very well be treated by low-cost, feasible procedures. By our definitions, these would not fall under priority 1. This does not mean they should be neglected. For example, hernia and hydrocele fall under priority 1. Sebaceous cysts and other benign cutaneous lesions do not, mainly because of their lower public health burden. However, any facility that treats hernia and hydrocele would also reasonably be able to treat these benign cutaneous lesions. Thus, in training programs for clinicians providing surgical care, treatment of such lesions should
World J Surg (2010) 34:381 385 385 indeed be addressed, even if such lesions are not part of national or international programs to increase access to care for priority 1 conditions. Conclusion Eventual goals of such a prioritization process would include wide political buy-in by stakeholders, including decision-makers, clinicians, and the public health community. For now, one first small step might be think tank -type work on defining the terms and concepts. The concepts on feasibility could be approached more by consensus, using some of the existing data on the cost-effectiveness of various surgical procedures. However, it would obviously be best to be able to define as accurately as possible the burden of at least the priority 1 conditions, which might require further data gathering and analysis. Such further definition of the high burden conditions (and figuring out ways by which to monitor them) will require close interactions with the Global Burden of Disease Study, Disease Control Priorities Project, and other public health actors. References 1. World Health Organization (2009) Global Initiative for Emergency and Essential Surgical Care. http://www.who.int/surgery/en/. Accessed 15 June 2009 2. Anonymous (2009) Global burden of surgical disease. http://www.gsd2008.org/. Accessed 15 June 2009 3. Ozgediz D, Hsia R, Weiser T et al (2009) Population health metrics for surgery: effective coverage of surgical services in lowincome and middle-income countries. World J Surg 33:1 5 4. Debas HT, Gosselin R, Colin McCord C et al (2006) Surgery. In: Disease control priorities in developing countries, 2nd edn. Oxford University Press, New York, pp 1245 1260 5. World Health Organization (2009) Integrated Management of Emergency and Essential Surgical Care (IMEESC) tool kit. http://www.who.int/surgery/publications/imeesc/en/index.html. Accessed 15 June 2009. World Health Organization, Geneva 6. World Health Organization (2003) Surgical Care at the District Hospital. World Health Organization, Geneva 7. Mock C, Lormand JD, Goosen J et al (2004) Guidelines for Essential Care. World Health Organization, Geneva