Take Home Messages from WHO-Lancet Commission on Global Surgery National Surgical Forum, Delhi, March 2016

Presented at the WHO-Lancet Commission Meeting on March 11, 2016

INTRODUCTION

who-lancet global surgery mtg pic 2The National Surgical Forum meeting arranged by the Lancet commission on global health and World Health Organization at Delhi was a unique one. It is probably the first time all the stake holders in rural surgical care were brought together under one roof to discuss about what could done to take surgical care to the poor and the marginalized in India. In addition to the two organizers WHO and Lancet there were representations from the Academia, from the Government of India, from the Medical Council of India, from the National Board of Examinations, from the Professional associations, from the rural and general surgery associations, from the Industry and the corporate hospitals.

The agenda was based on the needs of the rural surgeons that were documented after a workshop at Karad along with the Association of Rural Surgeons of India and International Federation of Rural Surgeons. Earlier a consensus statement was made known as the Karad consensus [1].

THE CURRENT INDIAN STATUS

India, a nation of more than 1/7th of the world’s population, claims the dubious honor of the highest number of individuals without access to safe, affordable and timely surgical and anesthesia care. “This issue couldn’t be more pressing,” says Dr Nobhojit Roy, Commissioner and Chair, Health Delivery & Management Working Group, The Lancet Commission on Global Surgery.

India especially in the rural areas lags behind in the indicators that the Lancet commission has developed for indicating the adequacy of surgical care like the 2 hour access, the number of surgical procedures carried out per 100,000 populations, the number of surgical care providers per 100,000 populations and so on. Only 57% of hospitals in India provide comprehensive surgical care [2].

Until recently surgery was not considered a public health problem although 32% of the global disease burden is surgical.

There are gross inequalities in the number of undergraduate and postgraduate training programs and the completion for postgraduate training makes the doctors spend time in preparing for the entrance exams rather than utilizing what they have learnt in helping patients. Ninety percent of the undergraduate training programs are tertiary level hospital based and they do not train the students to take care of the needs in rural areas. The number of true general surgeons would dramatically decrease with the current trend in surgical training in India. The DNB program has successfully tried district hospital based DNB training in anesthesia and general surgery.
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While 70% of the population in India lives in rural areas less than 20% of the surgical workforce is available to them and while the estimated need is about 150,000 surgical procedures in the district only about 1,500 are actually carried out.

There are no accreditation facilities for rural hospitals and rural surgeons although called upon to do a variety of surgical procedures do not have proper credentialing. For instance no one would appreciate the 1,000 urological procedures a rural surgeon does to help the poor and the needy but everyone would jump to question him when a problem arises with these urological surgeries. There is no one way yet of recognition of surgeons working in rural or remote areas in India.

The urban slums face the same challenges of rural India and the private sector meeting 90% of the surgical needs of India. There is 60% impoverishment/catastrophic expenditure due to surgical treatment.

SUGGESTIONS FOR THE WAY FORWARD

There is a great need for innovative shorter training programs to rapidly alleviate the severe workforce shortage. The consensus is for developing a Task or Competency based credentialing system where an International organization gives the credentialing. There is need for online and on-site specific training programs for all categories of surgical workforce. CMC Vellore, Karunya University, etc are already involved in a small way in this venture.

Possible incentives for rural surgeons were discussed. WHO/Lancet commission could give recognition or awards to rural surgeons. Possibilities of financial incentives for rural surgeons were considered.

Sharing of equipment and its maintenance, low cost innovation, rural accreditation, etc are very important to improve the quality of services in rural areas. Standardization and accreditation of rural surgical facilities could be a way forward.

Revamp of surgical volunteers is a priority as there are many volunteers and their services are not fully utilized. Sometimes they cause more harm than good. Collection of rural surgical data on patients needing surgical procedures and facilities could help in optimizing and providing efficient services through the volunteers.

There is need for using the entire delivery chain for training. Plenty of teaching material is available in rural hospitals and they could be used for effective training [3, 4, and 5].

UDBT is the consensus for the way forward in meeting the blood needs in rural areas.

The World Health Organization has been a key partner in the process and is potentially looking to use the model for surgical system strengthening in India as an example for other nations. “Thus far, there has been broad interest across sectors to advance this critical, long overdue issue,” said Dr. Walt Johnson, who heads the Global Initiative for Emergency and Essential Surgical Care at the WHO [6].

According to Dr. Roy, there are some very simple fixes that cost little to no money, highlighted in the Karad Consensus Statement, that can really optimize the system while we implement longer-term solutions. “We need to act on these things now,” he said [6].

Task or Competency based credentialing is the first thing that the NSF India has already started working. Funding for rural surgery specific research and establishing an innovation center is another such project the NSF can start working.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

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