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Improving global emergency and essential surgical care in Latin America and the Caribbean: A collaborative approach

Regional collaborative partnerships—focused on enhancing access to surgical care in Latin America and Caribbean countries—are described.

Gregory Peck, DO, FACS, Lina Roa, MD, Ernest J. Barthélemy, MD, MA, Sammy South, MD, Jorge Esteban Foianini, MD, FACS, Rodrigo Vaz Ferreira, MD, FACS, Nivaldo Alonso, MD, PhD, Andrés M. Rubiano, MD, PhD(c), Gabriel Herrera, MD, FACS, Martha P. Vega, MD, MMSc, Edgar Rodas, MD, FACS, Pierre Marie Woolley, MD, Antonio Ramos-De la Medina, MD, FACS, Laura Martinez-Perez Maldonado, MD, Jordan W. Swanson, MD, MSc, Neema Kaseje, MD

March 1, 2019

In an era of sustainable development goals (SDGs), members of the global surgery, obstetric, and anesthesia (SOA) workforce have grown increasingly aware of its collective role in achieving universal health coverage (UHC). The combined results of Disease Control Priorities Number Three, The Lancet Commission on Global Surgery (LCoGS), and the World Health Assembly (WHA) Resolutions 68.15 and 70.35—which strengthen emergency and essential surgical care and anesthesia as a component of UHC and contribute to the progress of the implementation of the 2030 Agenda for Sustainable Development—jointly contribute to a paradigm shift in global surgery. We are moving away from vertical initiatives focused on a single disease and toward transdisciplinary and cross-sectoral collaborations aimed at strengthening health care systems in a horizontal fashion without disease-specific silos.

Key contributions of LCoGS to the global health paradigm include six core surgical indicators and targets within the surgical system-strengthening framework of preparedness, service delivery, and financial impact.1 Furthermore, LCoGS recommends that each country develop and implement a strategic national surgical, obstetrical, and anesthetic plan (NSOAP) informed by the collection, monitoring, and evaluation of the six core surgical indicators.1 The value of consolidated efforts is progressively appreciated and realized in nascent national and regional efforts across low- and middle-income countries (LMICs), specifically in sub-Saharan Africa, Asia, and Oceania.2,3 Such progress is crucial to extend efforts to all LMICs where as much as 90 percent of the population may lack access to emergency and essential surgical care, and mortality rates of noncommunicable disease are disproportionately high.1

Latin American and Caribbean (LAC) nations are in various stages of national health strategy and SOA systems development in order to address the inequities in access to timely, high-quality, affordable surgical care.1 To address the challenges specifically in LAC nations, Latin American stakeholders met in December 2016 in São Paulo, Brazil, to identify barriers to surgical care and propose strategies for regional cooperation and development of surgical indicators measurement in order to create, improve, or enact policies and processes centered on strengthening surgical systems.4

Subsequently, Rutgers Global Surgery of Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ; the Program in Global Surgery at Virginia Commonwealth University, Richmond, VA; and the Program in Global Surgery and Social Change at Harvard Medical School, Boston, MA, formed a coalition committed to aligning goals with LAC partners that promote regional equity in surgical care through the collection, analysis, and interpretation of high-quality data based on the six core surgical indicators. Once the six indicators are collected and interpreted, a national situational analysis is performed that quantifies an aggregate of system preparedness, service delivery, and financial risk protection.

This analysis provides the evidence base for the multi-sectoral priorities set within formal process objectives of NSOAP development and implementation. The coalition’s activities culminated in formal regional recognition by the executive committee of the Panamerican Trauma Society (PTS) at its 29th Annual Congress in Brazil. The formation of a Global Surgery Sub-Committee at the 30th PTS Annual Congress in Mexico City marked a further milestone in interregional global surgery stakeholder evolution.

Early actions of the LAIRC

  • Facilitating coordination between LAC and North American stakeholders that is formalized through a global surgery system research protocol
  • Simplifying research education and training pathways that focus primarily on establishing leadership of surgical systems strengthening in Latin America and the Caribbean
  • Establishing a home to large-scale process lessons learned by working within a newly formed multinational and transdisciplinary hands-on learner-driven surgical systems research collaborative
  • Unifying efforts that primarily focus on WDI collection, analysis, and interpretation as a means to inform the tactical development, implementation, and evaluation of NSOAP and its respective science

Goals from this academic global surgery coalition shaped what is now known as the Latin American Indicator Research Collaboratory (LAIRC) (see sidebar, this page).5 The LAIRC, formally launched March 2017 at Rutgers University, serves as a foundation for applying core surgical world development indicator (WDI) data collection, analysis, and interpretation in a systems-based surgical education and training research model. The LAIRC contends that academic global surgery program strategic planning for these purposes should target the development, implementation, and evaluation of NSOAP and respective components, which are SOA system workforce, service delivery, information management, infrastructure, governance, and finance.

In the second quarter of 2018, the LAIRC proposed that transnational global surgery learners (students, residents, and fellows) and principal investigators at North America and LAC institutions partner and organize within learning networks called global surgery research units (GSRUs) for strategic planning. The GSRUs optimally provide an interconnected immediate prioritization and expansion of surgical systems research, and work in harmony using collaborative LAC WDI data collection, analysis, and interpretation, guided by a commitment to ultimately achieve NSOAPs.5

Building upon key goals that include organizing high-income country (HIC) and LMIC reciprocal teams in the LAC region, each LAC regionally specific GSRU and its members actively engender collaboration, with each specific nation’s researchers performing their surgical systems data collection, interpretation, and analysis. These researchers work on-the-ground, alongside multinational partners, without experiencing an isolation from the evidence base because of nascent systems research infrastructure or geographical location.6

This article highlights perspectives on the global surgery movement from seven LAC countries as a broad foundation for understanding barriers and successes to making population-level impact through these and other types of surgical system strengthening efforts. The achievements described in policy and practice guidelines development, research, and advocacy around the global surgery indicator and NSOAP framework, however, are only an introduction to this issue. By summarizing key aspects of LACs’ 2018 point of departure, the authors endeavor to optimize and scale discourse around indicator collection and NSOAP development, implementation, and evaluation; to disseminate surgical system science throughout LACs in 2019; and to build reproducibility through the early wins described in this article.

Report from the Bolivia collaborative

Since 2015, a collaborative effort between local stakeholders in Santa Cruz de la Sierra, Bolivia, and HIC academic surgeons have had a significant impact on nationwide health policy. This collaborative has used a bottom-up approach wherein partnerships—notably between five of the largest hospitals in the city of Santa Cruz de la Sierra—have facilitated access to regional data, identification of salient factors affecting public health, and a path to address these issues.

Local stakeholders and their academic collaborators from North America recognized the importance of an evidence-based approach to improve health care and generate better patient outcomes. To that end, prehospital data from the city’s morgue and inhospital all-cause mortality data were made more widely available to collaborating institutions. Importantly, local and statewide government officials, including the Minister of Health (MOH), identified the value of these efforts and supported a complete surgical needs assessment beginning in 2016.

This data-driven design to effect policy is exemplified in trauma care. The data showed that the greatest overall contributor to prehospital death is trauma, and 84 percent of all prehospital mortality events were conditions interpreted to be sensitive to a prehospital system improvement. Because Santa Cruz de la Sierra did not have a formal prehospital system, these data provided the impetus for legislation to establish the components of a prehospital emergency trauma and medical system in 2017.

The Bolivian team realized the value of the LCoGS indicators and framework for assessing surgical systems planning nationally; however, it also quickly realized that the existing data collection and information management tools were insufficient. To overcome this challenge, the team has since used a specific modification of the LCoGS indicators that was first applied to framing a trauma system data collection and analysis in Colombia (see Table 1). This modification provided a starting point in Bolivia for the value proposition of LCoGS indicators when specifically applied to regional injury care goals and legislation creation.7

Table 1. LCoGS core indicators and associated trauma program/system elements

Table 1. LCoGS core indicators and associated trauma program/system elements
Table 1. LCoGS core indicators and associated trauma program/system elements

Report from the Brazil collaborative

Brazil has pioneered surgical indicator collection in Latin America using national, open-access databases. As a world leader in UHC, Brazil has a comprehensive single-payor and provider system, as well as a private care system, which has covered 27.9 percent of the population.8 Brazil’s public surgical system has met several key benchmarks (see Table 2).9 However, geographic disparities in the provision of surgical care remain.9

Table 2. Indicators 2–6 in the year 2014 for Brazil and for each region

Table 2. Indicators 2–6 in the year 2014 for Brazil and for each region
Table 2. Indicators 2–6 in the year 2014 for Brazil and for each region

Measurement of the surgical indicators raised questions about data quality and the need for more granular information about the workforce. This finding led to follow-up studies in the Amazonas region, with a qualitative and quantitative assessment of surgical capacity at a randomized cross-section of 20 sites to compare national database statistics with on-the-ground realities. Additional studies to assess disparities revealed a maldistribution of health care professionals, with 75.2 percent of the surgical workforce located where only 40.4 percent of the population lives.10 As the issues faced by the Brazilian surgical systems are further characterized, specifically workforce issues, these research studies may be used to leverage policy change and advocate for the development of NSOAP components.11,12

Many of Brazil’s global surgery efforts have focused on education and research capacity building. In the Amazonas, The Universidade do Estado do Amazonas (UEA) has accredited global surgery as a discipline. The program affords students and faculty recognized and protected time for global surgery—a crucial step in building sustainable academic global surgery competencies and careers.

Along with the work being done on access to surgical care, reports of variations in quality of care have created a new focus. Harvard University, São Paulo University, and UEA, alongside The Lancet Global Health Commission on High Quality Health Systems in the SDG Era, have worked to develop a set of indicators to measure quality of surgical care.13,14 The evidence-based indicators, worked into easy-to-use tools, are designed to be applicable to a range of hospital levels in the low-resource setting. The global surgery team at UEA has piloted the feasibility of these tools to collect a baseline of surgical quality data at Hospital Pronto-Socorro 28 de Agosto in Manaus.

As the world’s fifth most populous country, organized into 26 states and a federal district, one of Brazil’s main challenges will be the coordination of efforts and priorities, and a regional or state-specific approach led by each state’s health secretariat may be more effective than a national effort. Nevertheless, in 2019, the focus is on coordinated collaboration between the Brazilian College of Surgeons, the Brazilian Society of Anesthesiology, and the Brazilian Federation of Gynecology and Obstetrics with an eye toward developing regional and national surgical plans. Ultimately, the progress presented herein, along with the anticipated improvements, will be evaluated at subsequent SOA Latin America meetings.

Report from the Colombia collaborative

Since 1993, the Colombia national health care system has depended on a mixed model of private and public organizations that deliver health care services financed primarily by payroll taxes.15 This universal health insurance system has resulted in a decline in the population’s out-of-pocket expenses from 40 percent of payment for health care services in 1995 to 9.6 percent in 2014.16 However, over the last two decades, many private insurance companies have declared bankruptcy, and the financial sustainability of this framework has become the subject of increased scrutiny by the health and economic sectors.

Colombia: National Clinical Practice Guideline in Severe TBI

  • Delineates more than 15 evidence-based recommendations to minimize national variability in the diagnosis and management of severe TBI
  • Demonstrates that the detrimental impact of ineffective or unsuccessful intubation of TBI patients in the prehospital setting is related to insufficient material resources and training in a majority of cities
  • Represents an example of a national cost-effectiveness study for severe TBI management
  • Reveals investment in improved ambulance resources and training is more cost-effective than paying for the complications of inaction; that is, not intervening or providing time-sensitive care in the emergency setting
  • Promotes indicators that evaluate TBI service delivery quality and timeliness; that is, four-hour access metric for neurosurgical intervention

In 2002, the MOH developed professional working groups to strengthen national policy resolutions regarding emergency and essential health care services to treat the prevalent and high incidence of intentional injury associated with a multiregional civil war.17 Several years later, the National Resolution for Emergency Care Regulatory Centers (Resolution #1220 of 2010) defined local and regional administration to organize emergency care dispatch for initial emergency response and interfacility transfers.18 Resolution #2003, finalized in 2014, established a minimum standard for surgery and emergency services, which include a MOH committee’s periodic review and an update process on all aspects related to national equipment, infrastructure, and human resources. In addition, health care facilities and health care professionals are required to uphold minimum standards to acquire national-level authorization for providing surgery and emergency patient care services.

Further progress occurred when an open call was issued to fund the development of national guidelines related to emergency surgery in 2013. Colombia’s Clinical Practice Guideline in Severe Traumatic Brain Injury (TBI) charted national history with an inaugural funding effort to develop evidence-based technical documents for trauma care. In 2013 to 2014, the Colombian government, along with the IberoAmerican Cochrane Center in Spain and the Brain Trauma Foundation in the U.S., facilitated the development of a national guideline document for traumatic brain injury (see sidebar, page 30).19

The Colombia Statutory Health Law #1751 of 2015, which health care professionals, health care unions, and academic organizations supported, was promulgated as a new social contract between the nation’s citizens and the government. This legislation reprioritized the Colombian national government and the MOH’s health care sector law and policy formation.18,20 As a result, the Integral Policy for Health Care was initiated to identify the most prevalent health determinants of all-cause, national mortality in the separate states.18,21

For each health condition identified, a strategy called Integral Route for Health Care was created to engage policymakers for the purposes of integrating national health promotion, prevention, and rehabilitation through health service systems of medical and surgical providers. The Integral Route for Health Care showed that the low number of specialists, high rate of interfacility transfer, and regional economic deficits contributed to the unaffordable type of primary and preventive medicine that was provided primarily in emergency rooms rather than at the community level. As a result, two main objectives were established: enhance promotion and prevention strategies for the most prevalent diseases at basic-level facilities, and enhance access to the specialized care needed in the various states and regions.

Because the four most prevalent health conditions are all noncommunicable, academic global surgery teams extended across Cali, Medellin, and Bogotá from 2016 to 2018. The experiential lessons learned helped to craft a LAIRC tool kit and identify the value of student research partnerships between university-specific chapters of the Global Surgery Student Alliance and InciSioN Colombia.22 The tool kit provided publicly shareable global surgery student checklists, a research protocol, an interinstitutional memorandum of understanding (MOU) template, and a call for a transparent indicator data collection, analytic and interpretative team formation, and completion of situational analyses for first steps in process mapping of NSOAP development and implementation. A strategic meeting was then convened in Bogotá, May 10, 2018—the Global Surgery in Latin America: Findings, Recommendations and Implementation of The Lancet Commission on Global Surgery Indicators Data Collection, Analysis, and Interpretation. As a result of this meeting, indicator collection was scaled up nationally and a Colombian surgical, obstetrics, anesthesia, orthopaedics, and neurosurgical intersocietal formal commitment to global surgery was achieved, with a series of 2019 global surgery meetings planned to organize stakeholders in Colombia around specific SOA system study and priority. At a meeting December 5, 2018, in Bogotá, hosted by the Colombian MOH and Vice-MOH, LAIRC stakeholders and Colombian GSRUs presented a completed process that achieved Colombia’s six core surgical indicators collection, analysis, and interpretation. These process activities have resulted in an ongoing government-academia discourse with respect to Colombian National SOA system strategy and development in 2019.

Report from the Ecuador collaborative

In 2008, Ecuador instituted a universal health care system, integrating various health care networks including the Ministry of Public Health, the Social Security Institute, military forces, national police, and nongovernmental and private health care facilities. Together, these organizations serve 16.39 million Ecuadorians; nevertheless, 36 percent of the population who live in rural settings often lack timely access to health care.23,24

To gain an in-depth understanding of the factors that obstruct the rural population’s access to surgical care in a country where universal health care is the standard model, the Program in Global Surgery and Social Change and the Master of Medical Sciences in Global Health Delivery Program at Harvard Medical School partnered with a diverse group of local collaborators at the forefront of rural surgical care delivery, as well as recipients of surgical services. Participants included the following:

  • Nationally renowned Andean Hospital Homero Castanier Crespo and its leaders Renan M. Ulloa, MD (hospital director), Francisco Bravo, MD (associate director, general surgeon), and Juan F. Castanier, MD (general surgeon)
  • Community health care workers and surgical patients from rural Andean, Coastal, and Amazon regions
  • Community leaders, such as Angelina Chumpi, president, Coordination for Equity, Development and Social Action in the Amazon region
  • The Cinterandes, a mobile surgery program under the leadership of Anita Vicuña, MD (executive director, anesthesiologist), and Blasco Guzhñay, MD (chief physician)

These partnerships stimulated the development of a pragmatic research approach that allowed the collaborative to collect not only surgical indicators, but also in-depth qualitative data from local informants who can best describe their experience navigating the country’s UHC model. Results revealed complex biosocial barriers and facilitators that shape the interface between the health care system’s ability to deliver surgical care and the patient’s ability to access care. The group encourages other LAC nations to harness diversity among research collaborators and to supplement indicator data collection with qualitative local data to understand and address hindrances to surgical care access.

Ecuador is unique in that it is the only Latin American country with an established mobile surgical program—the Cinterandes Foundation, a nongovernmental organization (NGO) founded in 1990 by the late Edgar Rodas Andrade, MD, FACS.25 Through implementation of a fully functioning mobile surgical unit assembled on a 24-foot truck, Cinterandes offers free or low-cost surgical care to vulnerable populations, conducting more than 8,000 operations in remote, rural, and urban areas.26-28 This underused resource could be expanded to meet some of the country’s needs with cost-effectiveness measures to inform evaluation. It is a feasible surgical delivery model that other LAC nations could adopt to develop innovative methods to address the unmet burden of surgical disease, especially in rural and remote settings.

Substantial developments in trauma and emergency services have occurred in Ecuador since the 1990s. The government improved prehospital and emergency care and created a robust 9-1-1 call system.29 However, along with other LAC nations, Ecuador needs robust surgical indicator data collection, and development and implementation of a NSOAP to achieve global surgery 2030 targets.

Report from the Haiti collaborative

Haiti is the only low-income country in the Americas. The 2010 earthquake that claimed more than 200,000 casualties further crippled Haiti’s fragile economy, while highlighting significant disparities in access to surgical care.30-32 Indeed, with a workforce of only 5.9 SOA providers per 100,000 population, most of whom practice in urban Port-au-Prince, Haiti’s SOA workforce amounts to less than one-third the recommended density.30,33 Consequently, Haiti’s surgical disease burden, which includes obstetric, traumatic, infectious, and noncommunicable conditions, remains largely unmet.34,35 Moreover, the nation’s fragmented health care system includes many NGOs that either initiated or expanded their operations with funding received after the earthquake. Their involvement has had a complex yet decisive impact on Haitian medicine.36-38

National survey data indicate that up to 20 percent of seriously ill patients in Haiti are unable to receive care at a health care center because of excessive financial hardship (58 percent), prohibitive travel distance (12 percent), or excessive wait time (4 percent).39,40 These access barriers are compounded by the virtual absence of surgery from Ministère de la Santé Publique et de la Population (MSPP) policies prior to 2016 and systematic challenges, such as a dismal health care budget and a chronic workforce shortage aggravated by human capital flight.41 The Haitian Surgical Association has advocated for initiatives to address these concerns, calling for a modest increase in SOA financing and innovative education/training programs.42

Of great concern is the fact that it is difficult to retain trained SOA professionals. According to MSPP data, for the last five years, Haiti’s teaching hospitals have trained approximately 20 new surgeons annually.43-46 Similar figures are noted for other SOA specialists. These physicians ideally should enter the workforce immediately upon completing their training; however, the expatriation of newly trained SOA providers into HICs continues to diminish local SOA labor density. Improved workplace conditions and higher salaries in HICs are among the causes of this brain drain. So, ironically, Haiti has become an LIC producing SOA providers for HICs.

The clinical isolation of private practice surgeons who remain in Haiti presents another dilemma. These surgeons, operating alone or with an assistant, see both their caseloads and revenue steadily decline as they lose patients to NGOs. The disguised joblessness of these professionals and a population with immense needs have created an enormous health care gap. This circumstance does, however, provide an opportunity to develop and implement a Haitian NSOAP that efficiently organizes and mobilizes all available resources toward durable solutions to these problems.

Although Haiti has yet to prioritize NSOAP creation, regional advocacy efforts in the LAC region offer potentially replicable models for NSOAP-driven health system strengthening. Against the backdrop of an evolving global surgery movement, the leaders of Haitian surgery are at a crossroads. On the one hand, they are challenged to address the country’s indisputable lack of access to essential, timely, and affordable SOA care; on the other hand, they are tasked with managing new and existing relationships with NGOs and academic partners from HICs that have invariably altruistic intentions, but variable cultural competence and often inadequate appreciation of the challenges facing this nation.

The specter of surgical colonialism is of particular concern in Haiti given its history.47,48 The realization of universal equity in access to surgical care for the people of Haiti will therefore require bold and visionary leadership from Haiti’s SOA community and larger health care sector. First, these leaders will need to make an inwardly focused commitment to using fundamental democratic structures to create innovative policies that facilitate the strengthening of SOA systems. Second, they will need to demonstrate an outwardly focused commitment to comprehensive surveillance of, and prudent engagement with, foreign partners in SOA capacity building so that their participation in Haiti’s surgical landscape empowers the country’s sustainable development, enables its national sovereignty, and promotes social justice for all Haitian patients and physicians.

Report from the Mexico collaborative

With a population of 119.9 million people,49 it is important that Mexico has made, and will continue to make, significant strides toward achieving UHC and combating inequality. However, the Mexican health care system has a balkanized structure that leads to inefficiency, regional maldistribution of resources, limited access in geographically isolated areas, and high administrative costs. Health care expenditures as a percentage of the gross domestic product in 2016 were 6.5 percent, and the share of out-of-pocket spending was 45 percent—the highest among Organization for Economic Co-operation and Development countries.50 Founded in 1943, the Mexican Social Security Institute is the nation’s largest social welfare agency. Multiple parallel subsystems coexist for other employed workers, the uninsured, and the unemployed, and private sector providers paid by private insurers or out-of-pocket by patients who decide not to use the densely crowded, suboptimally staffed, and underequipped facilities run by the government.

Mexico has a successful vaccination program that has dramatically reduced morbidity and mortality from childhood disease and also has made significant advances in maternal mortality.51,52 Life expectancy increased significantly during the 20th century, mainly because of improvements in public health and living standards.53 However, this trend has reversed recently because of an increase in homicides secondary to the violence unleashed in response to the government’s war on drugs. Life expectancy for men fell by 0.6 years between 2005 and 2010.54 The National Sectorial Health Plan issued in 2013 established the main goals of prevention and improved access to care. Still, other than programs directed toward surgical safety and descriptive statistics of surgical disease, there is no specific focus on analytical study that informs the development or implementation of plans that integrate surgical preparedness, service delivery, and affordability. Mexico’s new government, which took office at the end of 2018, has announced plans to abolish the country’s largest public insurance program, federalize state health subsystems, and gradually create a single health system to achieve UHC, but it is still uncertain whether the 2019–2024 National Health Plan will specifically address surgical needs.

Surgical workforce density is estimated at 40.6 per 100,000 population, well above the target set by the LCoGS; however, surgical volume has been reported to be significantly lower than the minimum of 5,000 procedures per 100,000 population set as a target for 2030 and established now as a core surgical WDI.55,56 To better understand the status of surgical practice in the country, offer clinical trials, conduct cohort studies, and support research and training, Hospital Español de Veracruz established the Center for Global Surgery Research. The center is supported by the National Institute of Health Research Unit on Global Surgery, a consortium between the Universities of Birmingham, Edinburgh, and Warwick, U.K. Together with GlobalSurg, a U.K.-based research initiative, and its international partners, Mexico is participating in high-quality, prospective, practice-changing international clinical studies.57,58

The Hospital Español de Veracruz’s Center for Global Surgery Research also has started assessing WDIs and conducting situational analyses across 50 hospitals in Veracruz with its own GSRU and LAIRC partnership.22 The group is actively engaging local stakeholders to further advance the goal of making surgery an essential component of the health care system and a public health imperative. Only through academic collaboration with surgeons and organizations in HICs and other LMICs is it possible to achieve meaningful improvements in the delivery of surgical care.

Report from the Nicaraguan collaborative

In 2015, the Nicaraguan ambassador to the United Nations Sustainable Development Summit proposed an International Campaign on Access to Safe Surgery to improve access to and delivery of surgical care. This proposition was issued in recognition of the magnitude of surgery-related deaths compared with fatalities from human immunodeficiency virus/acquired immunodeficiency syndrome, malaria, and tuberculosis combined.59 This proposal coincided with the efforts of the Nicaraguan MOH and Operation Smile—which for 20 years had been leading an increasing array of cleft surgery and education programs—and an MOU that calls for collaborative efforts to improve surgical capacity building specifically in underserved rural areas of Nicaragua.

During the first year of collaboration, life support training programs for all MOH perioperative health providers were offered through a train-the-trainer model, which reached 90 percent of the eligible workforce.60 Subsequently, district hospitals were targeted as the optimal, though often underused, physical location for providing surgical care to the majority of underserved people.

Then, a two-year pilot program called Cirugía Para El Pueblo (CPEP) commenced in 2017.61 This program deployed a comprehensive set of educational, equipment, and programmatic interventions to significantly expand access to and availability of impactful surgical care at rural primary hospitals in the Las Minas region of northern Nicaragua. Strong emphasis was placed on the following:

  • Patient-focused care pathways using evidence-based and human-centered design
  • Targeted field innovation, such as developing a biomedical technician role and curriculum specific to the district hospital context
  • Community engagement, with initiatives such as weekly radio talks to educate the population on the benefits of surgery and  the ability of local institutions to provide safe care
  • Workforce training
  • Investments in infrastructure and equipment, such as purified water delivery to the operating room (OR), surge-protected electrical supply, and building out an additional OR to combat bottlenecks

Existing Nicaraguan MOH management successes included the availability of most essential medicines.62 An aggressive maternal health strategy that provided better access to cesarean sections, which represented more than 50 percent of the surgical volume at the district hospitals assessed in Las Minas, reduced maternal mortality rates significantly.62 Moreover, no out-of-pocket payments were needed for hospital expenses related to accessing this surgical care, protecting patients from financial ruin.62 Along with such successes, however, opportunities for improvement were identified (see Table 3).

Table 3. Nicaragua: successes and opportunities for improvement

table 3. Nicaragua: successes and opportunities for improvement
table 3. Nicaragua: successes and opportunities for improvement

The CPEP program includes monitoring and evaluation of key indicators and results.63 The Global Initiative for Children’s Surgery performed a baseline assessment of surgical care provision at the CPEP district using multiple validated instruments.64-67 The comprehensive assessment included an evaluation of team dynamics and has focused on pediatric surgical care delivery. In the first four months of operation, a 25 percent increase in the average monthly surgical volume was observed (confidence interval [CI] 0.17; 0.33), the WHO safety checklist use went from 0 percent to 77 percent (CI 0.69; 0.85), and 30-day perioperative mortality and complication rates among all surgical patients were 0.4 percent (CI 0; 0.02) and 1.9 percent (CI 0; 0.04), respectively.62 The results observed with CPEP offer preliminary data and early lessons in emergency and essential surgical care at the district level and are now being considered for extension into other regions of the country and beyond.

All together moving forward

An increased network of coordination and collaboration in surgical indicator data collection, analysis, and interpretation will characterize the regional agenda for global surgery in LAC. The efforts described in this article strengthen the early characterization of interdependent NSOAP development, implementation, and evaluation that has been instituted over time. To facilitate a LAC context-specific agenda for equitable surgical care access, a series of global surgery meetings will purposefully expand from these nascent national efforts, to incorporate LAC nations’ 2019 movement forward in the global NSOAP system science agenda. We are welcoming all countries’ transdisciplinary and multi-sectoral stakeholders to join this effort, report their particular national-level barriers and opportunities, and help break down the current silos that hinder SOA workforce assistance of MOH’s progress toward timely, quality, and affordable emergency and essential surgical care.

Links between research and partnerships such as the LAIRC, and the promotion and development of most national surgical societies across LAC, can generate the collaborative capacity to name, define, measure, reproduce, and strengthen NSOAP development, implementation, and evaluation more broadly. If we are able to standardize and disseminate a global health systems agenda for nationwide baseline surgical indicator collection and NSOAP in LAC, it ideally facilitates SOA-system advocacy for national-level governance and leadership in the provocative surgical and anesthesia policymaking and legislation urgently needed in the treatment of global noncommunicable disease.

The integration of national SOA indicator data into health care system strengthening platforms enables stakeholder, situational, and predictive analytics in the growing evidence and innovation basis of NSOAP and respective components; that is, workforce, service delivery, information management, infrastructure, governance, and finance. Most importantly, the evidence and innovation base vital to doing so is actively occurring within a newly defined collaboratory that aligns the global academic surgery community in an “experimental and empirical research environment in which scientists work and communicate with each other to design systems, participate in collaborative science, and conduct experiments to evaluate and improve systems.”68 Wulf and colleagues affirm with their statement that a collaboratory is in fact “a center without walls, in which the nation’s researchers can perform without regard to physical location, interacting with colleagues, assessing instrumentation, and sharing data.”6

The global surgery indicator and NSOAP framework prioritizes this system-level thinking toward SOA preparedness, service delivery, and affordability, and offers a growing research context that aligns bottom-up with top-down processes in global surgery systems science.69 Given the growing recognition of global health and SOA system priorities in other parts of the world, activation of students, trainees, providers, institutions, and the public health, financial, and governmental sectors in the LAC region is crucial. The generation of transnational behavior consistent with value-based care structures, processes, and outcomes will engender social and financial responsibility through LACs’ emergency and essential surgical and anesthesia care.


Members of the Bolivia collaborative who contributed to this article include Sammy South, MD; Esteban Foianini, MD, FACS; Joaquin Monasterio, MD; and Mamta Swaroop, MD, FACS.

Members of the Brazil collaborative who contributed to this article include Rodrigo Vaz Ferreira, MD; Nivaldo Alonso, MD, PhD; Lina Roa, MD; Isabel Citron, BmBCh, MPH; and Fabio Mendes Botelho Filho, MD.

Members of the Colombia collaborative who contributed to this article include Andrés M. Rubiano MD, PhD(c), FACS; Gabriel Herrera, MD, FACS; Luis F. Correa-Serna, MD; Juan C. Puyana, MD, FACS; Gregory L. Peck, DO, FACS; and Joseph S. Hanna, MD, PhD.

Members of the Ecuador collaborative who contributed to this article include Martha P. Vega, MD, MMSc; Edgar B. Rodas, MD, FACS; Hannah N. Gilbert, PhD; Robert Riviello, MD, MPH, FACS; Renan M. Ulloa, MD, MS; Francisco Bravo, MD; Anita L. Vicuña, MD; Juan F. Castanier, MD; and Blasco Guzhñay, MD.

Members of the Haiti collaborative who contributed to this article include Ernest J. Barthélemy, MD, MA; Pierre Marie Woolley, MD; Eunice Dérivois-Mérisier, MD; Myriam Gousse Larsen, MD; Marie Yvrose J. Chrysostome, MD; and Louis-Franck Télémaque, MD, MSc.

Members of the Mexico collaborative who contributed to this article include Antonio Ramos-De la Medina, MD, FACS, and Laura Martinez-Perez Maldonado, MD.

Members of the Nicaraguan collaborative who contributed to this article include Neema Kaseje, MD; Jordan W. Swanson, MD, MSc; Ruben Ayala, MD, MSc; Nydia Betanco, BSN; Armando Siu, MD; and the Nicaraguan MOH.


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