Widening the scope: the role of perioperative medicine in developing global healthcare
This article sees Dr Duncan Wagstaff, an academic fellow at the National Institute for Health Research, Dr Oliver Ross, an anaesthetic consultant at University Hospital Southampton NHS Foundation, and Dr Gerald Dubowitz, Associate Professor at the University of California, San Francisco, School of Medicine introduce perioperative medicine in the context of global health.
2015: The Emergence of Global Surgery
Global Health encompasses programs that ‘use the resources, knowledge, and experience of diverse societies to address health challenges throughout the world’. 
Historically its focus has been infectious diseases, but it has now evolved to include a broad range of healthcare issues which have global, political and economic impact. It now includes many of the activities mandated by the WHO, often in the realm of Maternal & Paediatric Health, Public Health campaigns and Non-Communicable Disease. Surgical disease, outside of emergency obstetric care, has become more prominent as a Global Health issue.
Following on from decades of local initiatives all over the world, 2015 saw the publication of two key documents:
- The Lancet Commission for Global Surgery (‘LCGS’), 
- Disease Control Priorities, third edition (‘DCP3’). 
These documents set out the data, problems and possible solutions for Global Surgery, and, in so doing, established surgical disease on the Global Health agenda. Speaking to the inaugural launch of the LCGS, Jim Kim, President of the World Bank, urged the Global Health community to challenge the injustice of global inequity in surgical care, stating that “surgery is an indivisible, indispensable part of health care”.
Key Findings from the LCGS & DCP3
- There is a huge burden of treatable surgical disease remaining unmet, with consequent health, social and economic consequences
- 5 billion people do not have access to safe affordable surgical and anaesthetic care when needed; 94% of these people live in in Low and Middle Income Countries (LMICs)
- Only 6% of 313 million surgical procedures undertaken each year are in LMICs, often with high perioperative mortality rates
- 143 million additional surgical procedures are needed in LMICs each year to save lives and prevent disability; the provision of essential surgical procedures would avert 1.4 million deaths and 77.2 million Disability Adjusted Life Years (DALYs) each year
- ‘Catastrophic health expenditure’ is incurred by 33million families paying for surgery each year, with a further 48 million families paying for non-medical costs associated with accessing surgery.
- The provision of essential surgery is one of the most cost effective methods of healthcare intervention, comparing favourably with large public health interventions. By addressing surgical provision in LMICs, benefits of up to 2% of GDP could be nationally accrued.
The Three Delays Model
The LCGS employs this framework to identify barriers to accessing surgical care:
- The Delay in Seeking Care: due to cultural beliefs, poor education, poverty or lack of awareness of available services
- The Delay in Reaching Care: due to availability/affordability of transportation
- The Delay in Receiving Care: due to inadequate hospital infrastructure, resources or workforce
The Perioperative Workforce
A lack of skilled healthcare professionals can be due to a lack of recruitment, training or retention. The LCGS describes how fewer than 20 surgeons, anaesthetists and obstreticians per 100,00 population correlates with increased maternal mortality. Potential solutions to workforce deficits include task sharing/shifting, although these models remain contentious.
Key Recommendations from the LCGS & DCP3
- Essential emergency surgical services should be provided at ‘first level’ (‘district’) hospitals
- Safety initiatives (such as the WHO Safe Surgery Checklist) should be deployed to reduce disparities in perioperative mortality rates
- Core indicators should be used to track progress, including: Access to surgery; Workforce density; Surgical volume; Perioperative mortality; and Protection against impoverishing/catastrophic expenditure
- Increasing surgical provision will strengthen health systems and enable progress towards achieving Sustainable Development Goals and Universal Health Coverage.
A role for global perioperative medicine?
Perioperative medicine (’POM’) has been defined as ‘coordination of the multidisciplinary team from contemplation of surgery to full recovery to improve patient outcomes’. 
We suggest that this approach should be extended to encompass the geographical, political, social and economic factors which affect the Three Delays to accessing and recovering from surgery.
Marrying the multidisciplinary collaborative approach of POM with existing Global Health approaches will enable advocacy for safe, high quality surgical care for all.
We conclude by agreeing with these comments:
“Surgery can no longer be viewed as too costly and complex to be included within essential health care in LMICs. There is both a moral imperative and an economic case for addressing surgical inequity in the world’s poorest regions.”
Do you have experience of providing perioperative care in Low or Middle Income Countries? If so, did you encounter any barriers to providing high quality care, or evidence of the ‘three delays’ model in practice? (Please do remember to keep all patient information confidential in discussions)
- Koplan, J., Bond, C., Meron, M., Reddy, S., Rodriguez, M., Sewnkambo, N., Wasserheit, J. Towards a common definition of global health. The Lancet 2009; 373: 1993–95
- Meara, J., Leather, A., Hagander, L. et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Published April 2015 in the Lancet online
- Essential Surgery. Disease Control Priorities, third edition, volume 1
- Perioperative Medicine: The Pathway to Better Surgical Care. Royal College of Anaesthetists
- Dare, A., Grimes, C., Gillies, R., Greenberg, S., Hagander, L., Meara J., Leather, A. Global surgery: defining an emerging global health field. The Lancet 2014; 384:2245-2247
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