Running head: BARRIERS TO ACCESSING GLOBAL SURGICAL CARE 1

Barriers in Accessing Global Surgical Care

Kristine Krumdiack

Western Washington University

NURS 452 Global Health Inequities and Interventions

Hilary Schwandt, PhD MHS

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Barriers to Accessing Global Surgical Care

Surgery is something that is thought of by some people as a basic accessible resource that

is usually available should one ever need it. It is often depicted on the large screen for its quick

order and fix ability but what if this wasnt the case. What if the nearest hospital was 100 miles

away or the conditions at the facility were so bad that you were at risk for developing an

infection worse than the issue at hand? The truth is, this is all too much a reality for most of the

developing world. The disease burden of these countries is heavy with a vast majority considered

to be easily treatable with surgical intervention if treated early and assuming that resources are

available. The disease burden is the effect of a health condition and is measured by financial

cost, mortality, morbidity, or other health indicators. Disease burden is often measured in terms

of disability-adjusted life years (DALYs) and quality-adjusted life years (QALYs). Together

these values equal the number of years lost due to disease (YLDs). One DALY is to be thought of

as one year of healthy life lost, and the overall disease burden can be thought of as a measure of

the gap between current health status and the ideal health status. (Ozgediz & Riviello, 2008;

Gosselin, 2011)

Currently, there is no conclusive evidence placing a numerical value regarding the exact

burden of surgical disease on developing countries but it is suggested to be of extremely high

volume. In a report released in 2008 from the World Health Organization, it was stated that

around 11% of the global burden of disease could be reduced with surgery. It is known, however,

that this burden demonstrated the increasing gap between need for services and the care that is

available. Key barriers that have been identified in accessing surgical services are poor road

conditions, distance, lack of reliable transportation; lack of surgical professionals, resources, cost

and fear, the most prevalent being facility access and availability of surgical experts.
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Access to Surgical Facility

The first barrier to surgical access in most developing countries is the structural barrier of

distance. Too often, it has been found that there is often a significant distance for patients to

travel to the nearest facility (Grimes 2011). Far too frequently hospitals are receiving surgical

patients too late with critical consequences such as death. It was suggested by Roy and

Khajanchi in 2015 regarding access to surgical facilities in India, there is a larger problem of the

invisible deaths in the community of those who never reached the hospital or died on the way to

the hospital.

In India where there is no formal or designated transportation to a health care facility

there is a growing mortality rate from acute abdominal emergencies such as peptic ulcer disease,

appendicitis, and hernia. If surgical intervention was performed earlier, this could be prevented.

It was said by Ozgediz and Riviello in 2008 while discussing surgical conditions in Sub

Saharan Africa, that Currently in sub-Saharan Africa, most patients with surgical problems that

are routinely treatable in high income countries never reach a health facility, or are treated at a

facility with inadequate human or physical resources. (p. 852)

These conditions lead to premature death or physical disability with a significant

economic burden. Some attempts have been made in Ghana by training truck drivers to respond

to motor vehicle accidents and transport individuals to the nearest hospital, or training local

villagers basic First Aid and CPR. Thus far neither of these initiatives has been very successful in

lifting the time burden. Hospitals in these countries are generally built in wealthier locations with

a high rate of paying patients. Smaller rural facilities generally lack the resources and funding to

accommodate major or sometimes even basic surgeries. The most recent effort to reduce this
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burden has been presented in an announcement from the Lancet Commission on Global Surgery

2030 with a shared vision and strategy for global equity in essential surgical care. The

Commission has a target of 80% coverage of essential surgical and anesthesia services per

country by 2030 as a measure of progress towards timely access to surgery. Reaching this target

will require integration of surgical services across all levels of care (from community referral

networks to first-level and higher-level hospitals), and a commitment to address factors that

result in delays in seeking, reaching, and receiving safe and affordable surgical and medical

care.

Cost of Surgery

According to many articles the most prevalent barrier in preventing surgical access is the

financial barrier to health care. The financial barriers that are addressed are not only the financial

cost of the surgery to the patient but also the cost that is accrued by the operating facility.

Performing even basic surgeries is a major financial burden. Not only does it require a surgeon to

perform the procedure but access to a sterilizer, trained surgical team including anesthesiologist,

surgical equipment and soft goods such as suture material and drapes, medications, lights, and

access to laboratory and blood services. (Ozgediz & Riviello 2008)

Currently, most federal funding that is allocated for global health issues is focused on the

efforts in eradication and treatment of communicable diseases such as HIV, malaria and

tuberculosis. While in some circumstances certain surgical diseases may initially be caused by

communicable diseases, they are not all classified as communicable diseases, therefore leaving

the funding out of reach. Some groups such as Partners in Health (PIH) have made efforts in

waiving the fees for surgical care in one of the care centers in Haiti. They believed that unless
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they waived the fee they would be excluding the very people that they began helping in the first

place (Farmer & Kim, 2008, p. 534).

Following this effort, the PIH case load became almost unmanageable. In efforts to

reduce this burden, it became necessary to create partnerships with neighboring district hospitals

to offer similar cost reductions. It is not yet certain how sustainable these efforts have been or

will be without supportive funding. In a systemic review published in the World Journal of

Surgery by Grimes et al, 2011, it was mentioned that not only are there direct financial burdens

to surgery as the ones listed above, but there are also indirect costs that were identified for the

patients such as loss of income and potential need for a caregiver post-surgery.

Availability of Experts and Equipment

There are very few physicians per population in most of the poorest rural regions

(Farmer, 2008). There are even fewer surgeons and the ones they do have are in more urban areas

of these countries and remain out of reach to the ones that are in need. This gap remains as more

and more trained physicians flee to wealthier countries in pursuit of higher salaries and superior

surgical environments. In order to minimize such gaps, many ongoing initiatives such as brief

visits by surgeons from advantaged countries, sending surgical residents to spend time in a

developing country as part of their training, or ships weighing anchor offshore and offering some

limited on-shore or on-board services, have not proven successful (Gosselin, 2011, p. 2 ). It

goes on to suggest that even when qualified providers are available, there are other barriers that

may arise such as difficulty accessing the supplies and materials and lack of funding for adequate

reimbursement or payment to the provider for services.

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Conclusion

Access to surgical care is essential in reducing death and disability from surgical disease.

Research has found that, at this time, over half of the worlds population is unable to access

surgical care should they need it. Reducing these barriers and improving facilities ability to

provide care while also providing accessibility for individuals to this surgical care is an ongoing

effort. With forward progression from Partners in Health, the World Health Organization and

Lancet Commission on Global Surgery there is no doubt that a change for the better is just

beyond the horizon. Like most things, however, they take time and lots of effort. With these

increasing partnerships and expansion within the surgical work force, surgery will hopefully no

longer be considered the forgotten stepchild of global health.

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References

Dare, A. J., Ng-Kamstra, J. S., Patra, J., Fu, S. H., Rodriguez, P. S., Hsiao, M., ... & Million

Death Study Collaborators. (2015). Deaths from acute abdominal conditions and

geographical access to surgical care in India: a nationally representative spatial

analysis. The Lancet Global Health, 3(10), e646-e653.

Farmer, P. E., & Kim, J. Y. (2008). Surgery and global health: A view from beyond the

OR. World journal of surgery, 32(4), 533-536.

Grimes, C. E., Bowman, K. G., Dodgion, C. M., & Lavy, C. B. (2011). Systematic review of

barriers to surgical care in low-income and middle-income countries. World journal of

surgery, 35(5), 941-950.

Gosselin, R. A., Gyamfi, Y.-A., & Contini, S. (2011). Challenges of Meeting Surgical Needs in

the Developing World. World Journal of Surgery, 35(2), 258261.

http://doi.org/10.1007/s00268-010-0863-z

Lancet Commission on Global Surgery. (2016). Global Surgery 2030. Report overview: A

collective call for equity and integration in the provision of surgical and anesthesia care,

Retrieved from http://www.lancetglobalsurgery.org/

Ozgediz, D., & Riviello, R. (2008). The other neglected diseases in global public health:

surgical conditions in sub-Saharan Africa. PLoS medicine, 5(6), e121.

Roy, N., & Khajanchi, M. U. (2015). A hospital too faraccess to surgical facilities in India. The

Lancet Global Health, 3(10), e587-e588.

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