Emergency and essential surgery (EES), in the context of developing countries, is surgical and anesthesia care that reduces disabilities or saves lives. The WHO’s manual, Surgical Care at the District Hospital (SCDH), defines the surgical and anesthetic interventions that are necessary to deliver EES [1]. Even this basic type of surgical care has traditionally been dismissed as too expensive and technologically advanced for developing countries. However, surgical treatment of injuries, abdominal conditions, and obstetrical complications, which comprise the majority of EES needs, are now recognized as being among the most cost-effective public health interventions [2, 3]. Economists consider improving surgical capacity at the district hospital among the world’s top priorities, yet two to three billion people lack basic surgical care [4, 5]. EES deficiencies in resource-poor countries are expected to worsen as noncommunicable surgical diseases increase along with economic development [6]. This contributes to a phenomenon known as the double burden of disease, where noncommunicable conditions merge with malnutrition and tropical diseases, resulting in complex patient care that further strains already limited EES resources.

Despite the demand for EES and its cost-effectiveness in developing countries, it remains the “neglected stepchild” of global public health [7]. Politicized and popular diseases are frequently prioritized ahead of more urgent and cost-effective EES interventions, demonstrating that evidence alone is insufficient for setting public health agendas [8]. Isolated surgical and anesthesia efforts are lacking sustainability and scalability, features represented in other successful global health projects. Political inroads are necessary to grow EES capacity but are generally lacking. In this article we offer possibilities for political action capable of moving EES higher on global health agendas and thereby increasing access to these much needed services. Other public health problems have benefited from examining organizational, symbolic, economic, research, and politician political streams [9]. This type of analysis has yet to be applied to EES and offers opportunities for improving its political priority. The ideas proposed here are by no means exhaustive but merit further examination in the literature. While this framework encompasses many ideas, we have condensed our recommendations into a table of priority actions that we believe should be pursued by individuals and groups as a broad front (Table 1).

Table 1 Priority actions to increase the political priority of Emergency and Essential Surgery (EES)
Full size table

First, global health resources are organizationally monopolized by communicable disease agendas despite the increasing need for EES services in impoverished countries that are inheriting the health consequences of development, which commonly require surgical care [7]. The previously necessary but narrow focus on communicable disease must be reconsidered, and the mobilization of EES advocates will be critical in achieving this change [6]. Organizational fragmentation within global surgery efforts impedes large-scale action. A unified movement is needed to attract attention from broader audiences, expand agenda-setting power, and improve visibility [10]. As an example, the WHO’s Global Initiative for Emergency and Essential Surgical Care (GIEESC) coordinates stakeholders globally, regionally, and at the country level in order to expand anesthesia and surgical services to the district and subdistrict level health-care facilities [11]. Furthermore, intentional strategies are needed to increase organizational advocacy by equipping surgeons and anesthetists to influence global health policy. This could be accomplished by creating opportunities for individuals to gain formal expertise in global health and public policy.

Organizational momentum could also be augmented by bridge-building with politically powerful cause-specific campaigns such as male circumcision, which could prevent six million new HIV infections and save three million lives in Africa alone over the next 20 years [12]. Merging EES with priority programs allows a synergistic approach by which well-funded disease-specific (vertical) campaigns provide (horizontal) spill-over of infrastructure, supplies, and human and financial resources.

Second, symbolic politics are meant to use language and images to create, shift, and control definitions and power within global health [9]. EES advocates must be intentional about using key symbols. For example, reframing EES as an essential component of primary health care (PHC) is an overdue symbolic political move. The Alma-Ata Declaration of 1978 originally established the role of EES by calling for treatment of injuries, common pathologies, and locally endemic diseases, but applying surgical care to these health issues in the context of developing countries has been overlooked for three decades [13]. The family bread winner must be able to obtain care for a debilitating injury or life-saving surgery for an acute abdomen from appendicitis. Women and mothers should be able to access life-saving surgical care for obstructed labor or unsafe abortion, and a baby born with congenital anomalies should receive definitive surgical care. Prevention remains foundational to PHC; however, curative interventions are also essential for population well-being. As a step in the right direction, the 2008 World Health Report emphasized support of comprehensive health services, which includes surgical care not only for emergencies and maternal health, but also for common nonurgent surgical conditions [6]. Acknowledging EES as a core component of PHC will increase its influence, funding, and role in improving global health and will strengthen the weak health systems in developing countries.

The injury epidemic and maternal health disparities are influential issues, and their symbolism can be used to increase awareness and action. EES in general, and care for injury and maternal health in particular, will be critical for achieving the Millennium Development Goals, especially goals 1 - Eradicating Extreme Poverty, 4 - Reducing Child Mortality, 5 - Improving Maternal Health, and 6 - Combating HIV/AIDS, Malaria and Other Diseases. As an example, injury accounts for more disability adjusted life years (DALYs) lost in Africa than diarrheal illness and tuberculosis combined and more deaths among children over 5 than HIV, TB, and malaria collectively [3]. Deficient EES systems lead to avoidable deaths and chronic disabilities that lock people in poverty, burden developing economies by depleting the workforce, and leave victims dependent on society [3]. The magnitude of the injury epidemic and its consequences are symbols powerful enough to create additional EES priority.

Maternal health issues have similar potential to capture political interest through the evidence that one woman dies each minute from pregnancy-related causes [14]. For each woman who dies, 20-50 more incur birth-injuries, leading to disability such as obstetric fistula, a profoundly stigmatizing condition [14]. Surgical prevention via cesarean section is possible and operative repair is transformational as depicted by a recent documentary film [15]. Consideration should be given to broad media campaigns such as this, which have rarely been applied. In this manner, the symbolic epidemics of injury and maternal health are capable of transforming public interest into tangibles such as equipped hospitals and appropriately skilled health personnel for functioning health systems.

Thirdly, EES economic politics and current funding systems are inadequate. Out-of-pocket fees at the point of service continue to be a barrier to EES access, especially for the poorest billion people. A range of solutions are necessary, from promoting national health insurance (NHI) plans to novel approaches such as public-private partnerships (PPPs). A successful NHI program has been established in Ghana and should be a model for other developing countries [16]. Consideration of how PPPs could augment EES effectiveness, especially if used strategically in conjunction with NHI programs, should be encouraged. Partnerships with surgical equipment suppliers are an underutilized opportunity given the global surgical burden of disease and potential market demand. EES advocates need to actively promote diverse funding mechanisms in order to expand the scope and scalability of deliverable services.

Strong evidence exists to further lobby global health funders to invest in EES. After channeling scarce resources into disease prevention, nutrition, and education, tremendous losses are incurred by death and disability from surgically treatable injuries, which primarily affect the most economically productive [17]. The Disease Control Priorities Project second edition (DCP2) established that EES in Africa is economically on par with childhood vaccinations and that at the district hospital level is among the most cost-effective public health interventions at $33 per DALY averted [2, 3]. The financial incentives to invest in EES are even more obvious when compared to other popular public health interventions such as HIV/AIDS treatment, which is estimated to be $300-500 per DALY averted and requires life-long treatment [3]. As research continues to document the cost-effectiveness of and need for EES, those involved in global health should promote its priority across agendas.

Fourth, expanding research production through scientific politics is crucial as publishing evidence shapes the global health agenda. Currently, there are insufficient data to propose a roadmap for EES development in developing countries [3]. Inequitable allocation of research funding perpetuates this deficiency; for example, injury research is allocated only a fraction of what is spent on HIV/AIDS [18]. In addition to resource limitations, the overwhelming clinical duties for surgery and anesthesia providers in resource-poor settings further limits productive research [19]. Policy efforts must be aimed at overcoming these monetary and human resource obstacles. An important objective globally will be restructuring research priorities to overcome the 10:90 issue whereby 90% of the total funds devoted to health research and development are spent addressing the issues of rich countries while only 10% is devoted to diseases unique to poor countries [20]. Besides policy changes to address these deficiencies on broad levels, focused interventions could apply the use of collaborative programs in which academic programs in different parts of the world partner with each other. This paradigm enables mutually beneficial research and addresses funding and human resource deficiencies [21].

The four political streams discussed thus far can combine to inform the final stream, politician’s politics, or the calculus used to establish agendas. This final product should appeal to agenda-setters by creating political incentives and minimizing political risk [8]. Coupled with statistics on the need for EES, appeals for equity could tip the scales for political elites to promote EES across global health agendas. There are roughly 234 million major surgical procedures worldwide each year, twice the number of annual childbirths and seven times the number of people infected with HIV [22]. However, 30% of the world’s population is receiving three-quarters of these procedures, with the poorest third of the globe receiving less than 4% [22]. Such severe global disparities should drive political agenda setters to support EES. The greatest potential to leverage policy-makers exists when priority actions across all of the political streams are advanced simultaneously.

EES remains a low global health priority despite evidence of massive untreated surgical conditions and the cost-effectiveness of intervention. The sustainability and scalability of EES will depend largely on insightful political strategy. Priority actions include increasing political presence within global health, reframing primary health-care policies to include EES, applying key symbols to create political power, expanding research endeavors, and advocacy for equitable surgical care aimed at political figures. With intentional and broad political tactics used by individuals and groups, life-saving EES can become a reality for the poor.