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: [email protected]
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
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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
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World J Surg (2010) 34:381–385
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
For which the surgical procedure (and related ancillary services 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
For which the surgical procedure (and related ancillary services and
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
For which the surgical procedure (and related ancillary services and
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
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.
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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 Trauma 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
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Table 2 Preliminary categorization of surgical conditions and
related procedures by priority categories
World J Surg (2010) 34:381–385
Table 2 continued
Priority 3a
Priority 1
Trauma
Trauma
Surgical airway (threatened or obstructed airway)
Repair of major vascular injuries with prosthetic graft
Other surgical problems
Thoracostomy tube placement (hemothorax, pneumothorax)
Parathyroid surgery
Exploratory laparotomy (hemoperitoneum, pneumoperitoneum,
bowel injury)
Esophageal malignancies and benign esophageal disease
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
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
Hysterectomy for postpartum bleeding and uterine rupture
D&C
Other surgical procedures
Hernia repair (umbilical, inguinal, femoral hernias)
conditions, and procedures that are common to treating
many conditions need to be considered together.
Hydrocelectomy
Appendectomy
Exploratory laparotomy (acute abdominal condition)
Final Caveats
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
Trauma
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
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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
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.
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References
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