A realized vision of access to safe, affordable surgical and anaesthesia care

Where is the funding?In April 2015, the Lancet Commission on Global Surgery set out a vision for universal access to safe, affordable surgical and anaesthesia care when needed1. Despite policy progress and a global surge of interest in perioperative public health, the Commission blueprint remains an unfinished agenda. This welcome special BJS supplement on global surgery presents an opportunity to reflect on the lessons learned as a surgical community – with a focus on research, engagement, funding and realized vision.The Commission articulated a broad array of research themes, seven of which are found within the breadth of papers in this supplement including: policy2, quality and safety3, 4, training and education5-8, partnership6, 7, 9, information management10-12, care delivery innovation13 and burden14. However, there are four important themes that are not covered, including cost and finance, determinants and barriers, impact of disease and prevention. An even broader interdisciplinary research focus is urgently required to address questions related to the whole health system as well as political, social and economic determinants of health for patients with surgical conditions.The startling evidence that five billion people lack access to safe and affordable surgery and anaesthesia care is perhaps the most quoted of the Commission's key messages1. The healthcare delivery and management group explored patient barriers to surgical care, and promoted three bellwether procedures as signals of a functional surgical ecosystem at the level of district hospitals (caesarean section, emergency laparotomy and open fracture care). The workforce, training and education group proposed a density of at least 20 specialist providers per 100 000 population, and illustrated the dearth and global maldistribution of human resources. The economics and finance group described how surgical patients worldwide are trapped in iatrogenic poverty while needle and thread are as cost‐effective as immunizations, and that return on investments for surgery and anaesthesia would translate into considerable Gross Domestic Product losses averted. The metrics group drew up the six Lancet Commission indicators, designed to capture preparedness, delivery, and the effect of surgical and anaesthesia care with clear time‐bound targets for scale up to 2030. The Commission report concluded with a call for national surgical plans and an appraisal of global surgery research. Overall, the report aligned with health system strengthening and embedded surgery within universal health coverage.Building on the work of many individuals and organizations, the Commission facilitated global surgery progress with multiple partners across more than 100 countries. The escalating emergence of leaders, new networks and changing focus of organizations is encouraging. Key events to highlight include: Denis Mukwege winning the Nobel Prize for humanitarian surgery; Emmanuel Makasa spearheading the unanimously passed World Health Assembly resolution 68.15 on the crucial role of surgery and anaesthesia for universal health coverage15; and John Meara championing national surgical plans through intelligent, collaborative partnership. In addition, media and civil society are maintaining pressure on global surgical issues; guiding institutions such as the World Federation of Societies of Anaesthesiologists and the College of Surgeons in East, Central and Southern Africa have made significant contributions to workforce data; new collaborations, including the Global Initiative for Children's Surgery and InciSioN (the International Student Surgical Network), have been launched; research funders have awarded grants for global surgical research; and regional colleges and specialist associations have supported the Commission's report. The World Health Organization (WHO) has endorsed the Commission indicators and their surgical lead (Walt Johnson) has brought fresh strategic thinking to the organization, and powerful support to the national planning processes16.Despite the 2030 Agenda for Sustainable Development and a reorientation towards health system strengthening, the surgical community has yet to capitalize on global development assistance for health17. Decision‐makers do not necessarily allocate funds proportional to avertable mortality and morbidity, but demand well defined, effective interventions and credible metrics to measure success18. However, the fact that the surgical community now defines better the burden of surgical disease, and has cost‐effective interventions19 and key performance indicators, bodes well for political priority ascendance. In addition, the call for an independent accountability mechanism to track progress from Holmer and colleagues10 in this supplement is also timely and relevant. Sufficient funding from national health budgets as well as international funders should follow the imperatives that, without urgent and accelerated investment in surgical scale‐up, low‐ and middle‐income countries (LMICs) will continue to have immense losses in economic productivity. In comparison, modest scale‐up of costs (1–8 per cent of total annual health expenditure in LMICs) would be sufficient to see returns. Strong advocacy for global surgery funding is required20, and an appropriately funded WHO should be an important starting point.The global surgery community should continue to engage with both humanitarian aid and the wider development sector to disseminate the final Commission messages: that investing in surgical services in LMICs is affordable, saves lives and promotes economic development; and that surgery is part of the health system solution for many disparate health agendas – from maternal health, to trauma, cancer and neonatal mortality. This upstream activity, as is happening in Ethiopia, Zambia, Tanzania and other countries through national surgical planning, should lead to downstream implementation for real change16. However, we must not be fooled: without funding there will be no meaningful implementation of emerging national plans and no access to safe, affordable surgical and anaesthesia care for five billion people.