ABSTRACT

On September 29, 2023, the Republic of Ecuador convened a meeting to address surgical system strengthening and urge political leaders to invest in surgical infrastructure. The meeting included experts in health diplomacy, innovative financing, implementation strategy and national surgical plans. The event occurred in parallel with the Sixtieth Directing Council of the Pan American Health Organization, Seventy-fifth session of the World Health Organization Regional Committee for the Americas. The meeting centered around four major areas: (i) building surgical capacity as a means to develop universal health care and emergency preparedness; (ii) developing policies and strategies for strengthening surgical systems; (iii) developing models for financing, sustaining, and improving surgical systems in low- and middle-income countries; and (iv) evaluating implementation strategies for funding these endeavors. National surgical plans represent a critical opportunity to build resilient health care systems by establishing comprehensive and sustainable policies. This article highlights the key messages from the event, which focused on Latin America, to inform the broader global health community.

Keywords
Surgery; national health programs; health system resilience; Pan American Health Organization; Latin America

RESUMEN

El 29 de septiembre del 2023, República de Ecuador convocó una reunión para abordar el fortalecimiento del sistema quirúrgico e instar a las autoridades políticas a realizar inversiones en infraestructura quirúrgica. En la reunión participaron expertos en diplomacia de la salud, financiamiento innovador, estrategias de implementación y planes quirúrgicos nacionales. El evento se celebró en paralelo con el 60.^o Consejo Directivo de la Organización Panamericana de la Salud y la 75.^a Sesión del Comité Regional de la Organización Mundial de la Salud para las Américas La reunión se centró en cuatro áreas principales: i) el aumento de la capacidad quirúrgica como medio para avanzar en la atención universal de salud y la preparación para emergencias; ii) la formulación de políticas y estrategias para fortalecer los sistemas quirúrgicos; iii) la elaboración de modelos para financiar, sostener y mejorar los sistemas quirúrgicos en países de ingresos bajos y medianos; y iv) la evaluación de las estrategias de implementación para el financiamiento de estas iniciativas. Los planes quirúrgicos nacionales brindan una oportunidad crucial para la creación de sistemas de atención de salud resilientes mediante el establecimiento de políticas integrales y sostenibles. En este artículo se resaltan los mensajes más destacados del evento, que estuvo centrado en América Latina, a fin de proporcionar información a la comunidad de la salud más amplia a nivel mundial.

Palabras clave
Cirugía general; programas nacionales de salud; resiliencia de los sistemas de la salud; Organización Panamericana de la Salud; América Latina

RESUMO

Em 29 de setembro de 2023, a República do Equador convocou uma reunião para tratar do fortalecimento do sistema de atenção cirúrgica e exortar as lideranças políticas a investir em infraestrutura. Participaram da reunião especialistas em diplomacia da saúde, financiamento inovador, estratégia de implementação e planos nacionais de atenção cirúrgica. O evento ocorreu em paralelo ao 60º Conselho Diretor da Organização Pan-Americana da Saúde, 75^a Sessão do Comitê Regional da Organização Mundial da Saúde para as Américas. A reunião abordou quatro áreas centrais: (i) capacitação cirúrgica como forma de fazer avançar a atenção universal à saúde e a preparação para emergências; (ii) elaboração de políticas e estratégias para fortalecer os sistemas de atenção cirúrgica; (iii) criação de modelos para financiar, sustentar e melhorar os sistemas de atenção cirúrgica nos países de baixa e média renda; e (iv) avaliação de estratégias de implementação para financiar esses esforços. Ao estabelecer políticas integrais e sustentáveis, os planos nacionais de atenção cirúrgica representam uma oportunidade fundamental para criar sistemas de saúde resilientes. Este artigo destaca as principais mensagens desse evento voltado à América Latina, a fim de informar a comunidade mundial de saúde.

Palavras-chave
Cirurgia geral; programas nacionais de saúde; resiliência de sistemas de saúde; Organização Pan-Americana da Saúde; América Latina

On September 29, 2023, in parallel with the Sixtieth Directing Council of the Pan American Health Organization (PAHO), Seventy-fifth Session of the World Health Organization (WHO) Regional Committee for the Americas, the Republic of Ecuador convened a meeting, jointly hosted by its Embassy in the United States and its Permanent Mission to the Organization of American States, at its Washington, D.C., headquarters, to develop scalable solutions to improve disparate access to and provision of surgical care in the WHO Region of the Americas. This meeting supported the pursuit of universal health coverage (UHC), a central theme of the Seventy-eighth United Nations General Assembly in 2023 (¹1. World Health Organization. UN High-level Meetings on Universal Health Coverage [Internet]. Geneva: World Health Organization; 2024 [cited 2024 Apr 12]. Available from: https://www.who.int/activities/preparing-for-the-un-high-level-meeting-2023-and-achieving-health-for-all
https://www.who.int/activities/preparing... ). The meeting convened international stakeholders and representatives from PAHO Member States, catalyzing a collaborative effort to address the critical yet neglected global health priority of providing safe, timely and affordable surgical and anesthesia care for all. In 2015, the Lancet Commission on Global Surgery, the third edition of the World Bank’s Disease control priorities (known as DCP3), and World Health Assembly Resolution 68.15, focusing on strengthening emergency and essential surgical and anesthesia care, brought the burden of surgical disease onto the global health stage (²2. World Health Assembly. Resolution WHA68.15. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. In: Sixty-eighth World Health Assembly, 26 May 2015. Geneva: World Health Organization; 2015. https://iris.who.int/handle/10665/253244
https://iris.who.int/handle/10665/253244... , ³3. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors. Disease control priorities. 3rd ed. Volume 1: essential surgery. Washington (DC): World Bank; 2015.). Still, little progress has been made in the Region of the Americas. Thus, Ecuador and its partners sought to address these issues by convening experts in health diplomacy, innovative financing, policy implementation, and the development of national surgical plans (NSPs), prioritizing surgical development within Latin America. With a hybrid and bilingual format, the meeting’s primary goal was to galvanize regional actors to fortify surgical health systems in the Americas and explore innovative, sustainable and collaborative models for the implementation of NSPs on a regional scale. This article reflects the authors’ perspectives on critical points raised throughout the meeting and the role of surgical care in advancing the regional health agenda as it moves towards universal access.

In the Americas, the urgency of this initiative comes as a result of emerging health challenges (⁴4. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1204–22.). The rising incidence of trauma, injury and noncommunicable diseases; the health care challenges exacerbated by the COVID-19 pandemic; and the pressures of climate change, all reinforce the need to strengthen surgical service capacity (⁵5. Mosadeghrad AM, Isfahani P, Eslambolchi L, Zahmatkesh M, Afshari M. Strategies to strengthen a climate-resilient health system: a scoping review. Global Health. 2023;19:62.). Substantial disparities in surgical systems lead to inequities and restrict access for much of the population. In fact, surgical conditions are a leading cause of morbidity and mortality worldwide (⁴4. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1204–22.). In 2015, at the time of the Lancet Commission on Global Surgery, an estimated 365 million people in the Region lacked access to essential surgical treatment (⁶6. Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316–23., ⁷7. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.). Without a concerted effort to scale up services, the economic burden incurred through this lack of surgical care is projected to exceed 1.5% of their annual gross domestic product between 2015 and 2030 (⁸8. Shrime MG, Dare AJ, Alkire BC, O’Neill K, Meara JG. Catastrophic expenditure to pay for surgery worldwide: a modelling study. Lancet Glob Health. 2015;3 Suppl 2:S38–44.). In light of these projections, this meeting emphasized the urgent need to expand and strengthen the Region’s emergency, surgical and critical care services, incorporating lessons from previous and shared experiences.

Ecuador has taken a leading role in the Region through the development and recent launch of its National Surgical Strengthening Plan (NSSP) (⁹9. Hyman GY, Salamea JC, Gerk A, Kumar N, Wurdeman T, Park KB, et al. Ecuador’s national surgical strengthening plan: first in Latin America, provides hope for surgical care agenda. Rev Panam Salud Publica. 2024;48:e22. doi:10.26633/RPSP.2024.22
https://doi.org/10.26633/RPSP.2024.22... ). The policy supports the health system mandate to provide UHC. The NSSP, which aligns strategically with Ecuador’s recently announced 10-year Plan for Health 2022–2031, aims to enhance access to safe, high-quality surgical care (¹⁰10. República del Ecuador, Ministerio de Salud Pública. Plan decenal de salud 2022–2031: resumen ejecutivo [Ten-year plan for health: executive summary]. Quito: Ministerio de Salud Pública; 2022.). In Ecuador, with a population of 18 million, the annual surgical procedure rate is approximately 2 400/100 000 people, significantly below the recommended global benchmark of 5 000/100 000 (⁷7. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.). High-quality health systems capable of providing essential surgical care directly support efforts to meet the targets of the Sustainable Development Goals (SDGs). From advancing maternal and child health (SDG Targets 3.1, 3.2 and 3.3) to reducing death and disability from trauma and injury (SDG Target 3.6), surgical care is essential for health system strengthening and meeting the population’s needs (¹¹11. United Nations. The Sustainable Development Agenda [Internet]. New York: United Nations; 2024 [cited 2024 Oct 8]. Available from: https://www.un.org/sustainabledevelopment/development-agenda/
https://www.un.org/sustainabledevelopmen... ).

The event underscored the role of surgical care in delivering immediate health gains and long-term improvements in health outcomes. Surgical care was framed as a catalyst for human development and equity, and several entry points for strengthening surgical systems to advance UHC were highlighted: (i) improving primary health care and addressing noncommunicable diseases, (ii) adopting comprehensive approaches to build systems that are adaptable and responsive to climate change, (iii) developing policies that prioritize equity, and (iv) creating ownership and autonomy at the local hospital level to encourage a culture of sustainable strengthening. Surgical care is essential for broader social and economic well-being, particularly in low- and middle-income countries, where barriers to access exacerbate health and socioeconomic disparities that limit health service use. In many areas throughout Latin America, health systems struggle to maintain sufficient resources and personnel to provide care. Prioritizing surgical care through NSPs can expand a health system’s capacity through investment in the main pillars of health system strengthening: workforce training, equipment, service delivery, information technology, financing and governance. Ecuador’s NSSP framework aligns closely with these pillars (⁹9. Hyman GY, Salamea JC, Gerk A, Kumar N, Wurdeman T, Park KB, et al. Ecuador’s national surgical strengthening plan: first in Latin America, provides hope for surgical care agenda. Rev Panam Salud Publica. 2024;48:e22. doi:10.26633/RPSP.2024.22
https://doi.org/10.26633/RPSP.2024.22... ).

HEALTH SYSTEM RESILIENCE IN THE POST-PANDEMIC ERA

The strategic importance of surgical capacity for national security in a world increasingly at risk of catastrophic health emergencies is more apparent than ever (¹²12. Metelmann IB, Flessa S, Busemann A. Does health securitization affect the role of global surgery? Z Gesundh Wiss. 2022;30:925–30.). Climate change, natural disasters, political instability, pandemics and forced migration all threaten local and regional, and social and economic stability. Resolutions focusing on strengthening pandemic preparedness and response are critical for creating resilient health systems and are achievable only with safe surgical care (¹³13. United Nations General Assembly. Political declaration of the United Nations General Assembly High-level Meeting on Pandemic Prevention, Preparedness and Response [Internet]. New York: United Nations; 2023 [cited 2024 Oct 8]. Available from: https://www.un.org/pga/77/wp-content/uploads/sites/105/2023/08/Final-text-for-silence-procedure-PPPR-Political-Declaration.pdf
https://www.un.org/pga/77/wp-content/upl... ). The adoption of World Health Assembly Resolution 76.2 (Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies) at the Seventy-sixth World Health Assembly in 2023 represented a firm dedication to improving emergency preparedness and response (¹⁴14. World Health Assembly. Resolution WHA76.2. Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies. In: Seventy-sixth World Health Assembly, Geneva, 21–30 May 2023. Resolutions and decisions, annexes. Geneva: World Health Organization; 2023:6-11. https://iris.who.int/handle/10665/376760
https://iris.who.int/handle/10665/376760... ). The Resolution built on the momentum of WHA 68.15 that supported “strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage” (²2. World Health Assembly. Resolution WHA68.15. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. In: Sixty-eighth World Health Assembly, 26 May 2015. Geneva: World Health Organization; 2015. https://iris.who.int/handle/10665/253244
https://iris.who.int/handle/10665/253244... ).

Surgical care plays an integral role across the health care continuum. The goal of NSPs is to ensure that surgical systems are integrated with and responsive to the health care needs of the population across the entire continuum, from prehospital care through surgical treatment to postoperative outcomes. Substantial progress has already been made to develop prehospital care and improve the quality of care in Latin America. For example, WHO provides a basic emergency care course, and Argentina and Ecuador have implemented prehospital systems that have substantially reduced mortality from traffic accidents and myocardial infarction (¹⁵15. Benzaquén I, Epele N, Marchionni M. Impact of the implementation of an emergency care service on the deaths due to traffic accidents: the case of SAME in the province of Buenos Aires. Estudios Econ. 2023;40(80):43–76., ¹⁶16. Oliveira CCM, Novaes HMD, Alencar AP, Santos IS, Damasceno MCT, Souza HP. Effectiveness of the Mobile Emergency Medical Services (SAMU): use of interrupted time series. Rev Saude Publica. 2019;53:99.). The first point of contact with a health system often involves stabilizing and transporting patients, ensuring that people can obtain access to necessary care, whether surgical or medical. In terms of the quality of care, the WHO Surgical Safety Checklist demonstrates that simple, cost-effective interventions aligned with surgical policy can be scalable solutions for improving the quality of care and patient safety (¹⁷17. Wæhle HV, Haugen AS, Wiig S, Søfteland E, Sevdalis N, Harthug S. How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties. BMC Health Serv Res. 2020;20:111.). Ecuador prioritized the implementation of the WHO Surgical Safety Checklist as a mandatory measure and formulated protocols across various institutions to enhance patient safety and the quality of care. These are examples of how NSPs can strengthen health service delivery. It is necessary for national governments to support regional and local government systems in introducing innovations that are uniquely suited to their communities. In addition to government services, nongovernmental organizations contribute to surgical service delivery by providing essential procedures and training staff. In Latin America, Operation Smile has been providing surgeries since the 1990s and has provided more than 8 000 surgeries in Ecuador alone. Such interventions require significant resource mobilization and coordination; NSPs are a strategic tool to integrate resources and fortify collective responses.

Investing in surgical capacity, with transparent regional coordination strategies, facilitates pragmatic responsiveness to public health problems. The Southern African Development Community (SADC) exemplifies how regional multilateral organizations can create leverage and momentum for developing surgical systems. Preliminary results shared at the meeting emphasized the importance of collaboration between Member States and learning from collaborative groups, such as the Pan-African Surgical Healthcare Forum. SADC highlights how collective insights that are used to advocate for pooled resources to address gaps in surgical care in Africa have contributed to southern Africa’s progress in surgical planning by leveraging regional collaborations to cultivate political will towards developing surgical systems.

To improve surgical care, NSPs focus on multitargeted solutions. This includes prioritizing workforce training, integrating information systems across facilities, building infrastructure, improving service delivery and creating appropriate regulations and governmental oversight. These actions require significant coordination between governmental bodies at all levels, but ultimately lead to more cohesive and robust health care. The SADC area has demonstrated success in surgical strengthening by addressing these priorities. It is also impor-tant to recognize that each of these sectors requires prudent and enduring funding to support NSP implementation. As such, the following section focuses on newer mechanisms that can supplement government spending to build surgical systems.

NEED FOR PRAGMATIC FINANCIAL ALIGNMENT

Sustainable financing mechanisms are key to surgical strengthening. While investing in surgical systems is extremely cost effective, the realization of cost recovery occurs much farther in the future than any political or normal budgetary cycle, hence this investment is viewed as a significant up-front cost (⁷7. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.). Relying solely on grants has proven insufficient for sustainable impact; hence, financing challenges pose the greatest threat to developing surgical systems. This highlights the necessity for political priorities beyond medical care. However, it also provides unique opportunities for financial innovation, as advocated for by organizations such as the Women’s Health and Economic Empowerment Network (WHEN). Using catalytic capital, WHEN’s blended finance instrument aims to stimulate societal impact while engaging both the public and the private sectors to transform health service delivery (¹⁸18. Women’s Health and Economic Empowerment Network. WHEN at UNGA: structuring WHEN financial vehicles [Internet]. Washington (DC): WHEN; 2022 [cited 2024 Oct 8]. Available from: https://when-23.cghd.org/when-unga-press-release/
https://when-23.cghd.org/when-unga-press... ). This blended finance approach seeks to support profitable ventures related to the health ecosystem in different sectors (¹⁹19. The Global Surgery Foundation. SURGfund: the only catalytic fund for surgical care systems [Internet]. Geneva: Global Surgery Foundation; 2024 [cited 2024 May 3]. Available from: https://www.globalsurgeryfoundation.org/surgfund
https://www.globalsurgeryfoundation.org/... ). For example, by aggregating profitable investments in renewable energy with less profitable investments in hospitals that provide affordable care, the lost capital in hospitals is offset by larger gains in renewable energy. This approach mitigates health system losses and also promotes public–private partnerships, which can increase access to affordable care for patients (²⁰20. The Center for Global Health and Development. Public private partnerships [Internet]. CGHD; 2024 [cited 2024 May 3]. Available from: https://cghd.org/index.php/publication/global-health-partnerships-and-solutions/public-private-partnerships
https://cghd.org/index.php/publication/g... ).

Concessional catalytic capital has proven particularly effective in drawing additional investments. The United States Agency for International Development transformed a relatively small $ 22 million investment into a $ 260 million fund by encouraging investors to back the initial investment (²¹21. United States Agency for International Development. Using blended finance to generate additionality and human impact: guidance note. Washington (DC): USAID; 2021.). This nontraditional strategy combines the strengths of both the private and public sectors to extend comprehensive care to patients. Moreover, innovative financing mechanisms, such as holding funds, as demonstrated by Rwanda’s investment in national health insurance holdings in the New York Stock Exchange, seek dollar-stabilized returns, make investments significantly less risky, and allow funds dedicated to building a medical system to grow.

Exploring other financial instruments, such as recoverable grants, convertible debts and supportable equity, introduces a new frontier for financing models. However, these blended financing models are complex and limited in their application, underscoring the need for broader understanding and adoption to capitalize on their potential for societal impact. The SURGfund is a multilateral fund that facilitates investments in surgical services in low-resource settings; the fund is supported by a coalition of government, philanthropic and financial organizations, and private industry (¹⁹19. The Global Surgery Foundation. SURGfund: the only catalytic fund for surgical care systems [Internet]. Geneva: Global Surgery Foundation; 2024 [cited 2024 May 3]. Available from: https://www.globalsurgeryfoundation.org/surgfund
https://www.globalsurgeryfoundation.org/... ). Ultimately, strengthening surgical systems requires a sense of ownership and a focus on patient-centered care, but the potential for possible synergies between public and private entities is vast.

These newer funding solutions are exciting and offer the potential to renew support for surgical systems. At the same time, it is important to consider the breadth of impact that these solutions may have. Certainly, public–private partnerships have the potential to lead to worsening inequalities in the communities they intend to assist. Private interests focus on increasing their revenue and often make decisions based on market fluctuations. If governments work alongside the surgical community to embrace public–private partnerships, it is imperative to build safeguards to ensure that already underprivileged communities are not harmed. As Latin America begins to expand its surgical capacity, NSPs are an example of where such regulations can be outlined, implemented, monitored and evaluated to protect citizens.

Conclusions

This event, led by Ecuador amid the recent development of its NSSP, united influential stakeholders worldwide who are dedicated to improving surgical care, building partnerships and strengthening political will. Their goal was to kickstart a process for PAHO Member States to undertake similar efforts in developing policies and NSPs that will improve surgical care. PAHO’s Executive Committee has already taken some inspiring steps, adding a discussion around developing strategies for integrated emergency, critical and operative care to their next agenda (²²22. Pan American Health Organization. CE174/19. Strategy on integrated emergency, critical and operative care 2025–2030. Provisional agenda item 4.8, 13 May 2024. Washington (DC): PAHO; 2024. https://www.paho.org/en/documents/ce17419-strategy-integrated-emergency-critical-and-operative-care-2025-2030
https://www.paho.org/en/documents/ce1741... ). In October 2024, PAHO voted to prioritize surgical care in the years to come (²³23. Pan American Health Organization. Agenda: CD61/1, Rev. 1, 3 October 2024. Washington (DC): PAHO; 2024. https://www.paho.org/en/documents/cd611-rev-1-agenda
https://www.paho.org/en/documents/cd611-... ). Nevertheless, more than political will is required to meet the surgical needs of Latin America. Assembling leaders who champion the development of sophisticated, collaborative and contextually adapted approaches is essential for building international partnerships and providing universal access to surgical care.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública/Pan American Journal of Public Health or the Pan American Health Organization.

REFERENCES

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