International surgical cooperation: Challenges and future perspectives

Surgery is a critical part of healthcare, and lack of access to safe and affordable surgical services remains a significant problem in many regions of the world. Today, five billion people live without adequate access to surgical care, with low- and middle-income countries bearing the highest burden of untreated diseases. This results in a high population morbidity rate (28–32%) and consequently economic impoverishment. In 2010, an estimated 16.9 million lives (32.9% of deaths worldwide) were lost due to lack of surgical care. Every year, at least 77.2 million disability-adjusted life years lost could be avoided through basic surgical care.¹

In 2015, the WHO Resolution 68.15 recognised the importance of essential surgical care as an integral part of global medical care and its importance for the economic and social development of countries. Until then, most priorities in global health focussed on specific diseases such as HIV, tuberculosis or malaria, without data or information on surgically treatable pathologies, overlooking the fact that surgery is a healthcare necessity that has an impact on the economic and social development of peoples. More than 30 million people become impoverished each year in the process of seeking surgical and anaesthetic care due to direct healthcare costs. In addition, 2% of potential annual economic growth is lost in low- and middle-income countries as a result of inadequate surgical conditions. In this way, this resolution aims to obtain a new model of global health, which would achieve the sustainable development goals by 2030 through the strengthening of health services and systems, which will only be effective if safe, affordable and timely surgical care is guaranteed.

However, despite this recognition, ensuring access to surgery within the current global health framework remains very difficult. In response to these challenges, the Lancet Commission on Global Surgery was founded and then produced the report “Global Surgery 2030: a Roadmap for High-Income Country Actors”. This report highlights the need for a global roadmap that addresses the different scenarios existing in surgical care in different parts of the world, examining surgery as a fundamental component of healthcare. This strategic approach proposes key policy measures and recommendations to guide future progress, recognising the shared responsibility of all countries, including high-income states, in promoting surgical health globally.²

Even knowing that significant progress has been made in global health in recent years, we are still far from achieving the 2030 targets, not least because of the unequal distribution of operating theatres, lack of basic supplies and infrastructure, and a small number of staff with specialised training that still does not ensure that all communities have access to essential surgical services. According to the Lancet Commission report, 2.2 million health workers trained in surgery, gynaecology anaesthesia are needed to provide surgical coverage for the world’s population.^3,4

The interest and concern among healthcare personnel in recent years as regards addressing these disparities has led to the creation of spontaneous groups or ones sponsored by hospitals or international organisations, as well as sections in the different scientific associations and medical colleges, with numerous health professionals interested in international volunteering.

Recognising this inequality has traditionally led volunteers to travel to some remote place for a short period of time, as part of a campaign subsidised or not by an NGO or foundation, to operate on a large number of patients. However, these campaigns, although necessary - as they meet the most acute needs of the population - altruistic and of great human generosity, do not usually produce long-term results on local healthcare systems. In no case should they definitively replace the shortcomings of the local counterpart, as this could reduce the country's investment in infrastructure and Health.⁵

The only way to ensure that international cooperation is sustainable and lasting is through the involvement and commitment of local authorities and healthcare professionals. Strategic plans are needed that address issues such as healthcare, infrastructure, education and research. As described by Bickler et al., in their analysis of the distribution of paediatric surgery in sub-Saharan Africa, specialised training in resource-limited regions is necessary to strengthen the global surgical infrastructure.^6,7

Thus, international surgical cooperation must evolve towards the creation of more complete, multidisciplinary projects, which include protocols for action, support, joint work and the formation of local teams. In addition, it is necessary to strengthen research, since the lack of scientific riguer in the campaigns means that there is a lack of knowledge regarding the work carried out, the objectives obtained, and their quality.^8,9

In 2017, the Humanitarian Collaboration Working Group within the Spanish Association of Surgeons (AEC in its Spanish acronym) was created with the aim of raising awareness and promoting development activities and research, with a defined line of work focussed on global surgery. In addition to offering grants every year from International Cooperation Aid to facilitate stays and projects for Spanish surgeons in hospitals in developing countries, the AEC has reached collaboration agreements with other groups such as the Foundation of Medical Colleges for International Cooperation (FCOMCI in its Spanish acronym) and the Spanish Agency for International Development Cooperation (AECID). Another no less important line of work within the AEC is the training of both Spanish surgeons who would like to collaborate in the field, and surgeons from low-income countries who want to train in what are emerging techniques for them. For instance, since last year we have been offering the basic laparoscopy course translated into and recorded in English for export to any cooperation project. In the same way, the group encourages data collection (RedCoop Project), research and the publication of scientific articles focussed on cooperation.

Today, international cooperation in surgery is necessary and essential to address inequities in the provision of surgical services globally. The term humanitarianism is implicit in the practice of our profession, which is why the commitment of everyone is necessary, so that, through strategic collaboration focussed on the implementation of evidence-based solutions and the strengthening of education and training, we can move towards globally accessible and quality surgical care.

Disclosure

The authors declare no conflict of interest.