1. Traumatic Disparities: Surgical Disease and the Great Divergence June 2014

2. Vision Universal access to safe, affordable surgical and anesthesia care when needed UHC Health Equity

3. LCoGS Mission Raise global surgery within the international agenda Prioritize surgery within national policy Improve surgical care delivery (access/quality/safety) All with a goal of achieving our vision

4. Stakeholders/Audience: For whom are we responsible?

6. Vision Universal access to safe, affordable surgical and anesthesia care when needed UHC Health Equity

7. Stakeholders/Audience

10. Recommendations n = 37 Government/MOH/MOF42 Int organizations – WHO, UN, USAID, WB35 Colleges and Professional Societies21 Foundations (Gates, etc.)/Big Donors16 Patients4 NGO4 Community Health Workers1 President and President’s wife1 Facility Managers, Clinicians1 NIH/Similar HIC Institutes1 Stakeholders:

11. Recommendations Sample Suggestions WHO/International Organizations Include universal access to safe surgery in global health agenda Collect and share data on metrics identified Listen to, support LMICs based on local needs Pressure gov’ts to improve surgery Surgery as key component of UHC Foundations/Big Donors Direct money into research, programmatic support and infrastructure Fund programs that build capacity and focus on health system strengthening Create a global surgical fund to support capability enhancement, system strengthening, and research Government/MOH/MOF Include access to basic life-saving surgical care within national health plans. Invest in human resources necessary for providing surgical/anesthesia services Financial protection for poor patients undergoing surgery Provide funding for surgical services Colleges/Professional Societies Locally based surgical education Train surgeons in a way that meets population needs Advise gov’ts on how to improve existing facilities Support task sharing when requested by LMICs

12. Traumatic Disparities: Surgical Disease and the Great Divergence June 2014

13. Key Messages 1.Surgery is an indivisible, indispensible component of a properly functioning health system, UHC and SDGs, with the ultimate goal of health care equity – Trauma – Cancer 2.Investments in surgery are pro growth, cost effective and have a positive return on investment 3.How can we improve the situation? 4.How can it be paid for?

14. Key Messages n = 46 1. Rights/equity (Farmer resolution): 5 billion people do not have access to safe affordable surgical and anesthesia care when needed 70% 2. Structure/process (Jim Kim resolution): Surgery is an indivisible, indispensible component of a properly functioning health system 85% 3. Governance/management (Eva Hanciles resolution): Huge gains in surgical care provision are possible with already existing health care systems by employing proper governance and management principles and training processes 40% 4. Economic (Yamey/Conteh/Yip resolution): Investments in surgery are pro growth, cost effective, have a positive ROI etc… 63%

15. Key Messages Other Messages: Access to surgical care should be a universal human right. Lack of surgical provision leads to an equity issue. Appropriate training is essential to achieve global surgery. Start with attention in trauma. When you have a good team to this attention, I think the surgical system works alone. Safe and effective surgical care is the foundation of a functioning, strengthened health system.

16. Traumatic Disparities: Surgical Disease and the Great Divergence June 2014

17. Metrics n = 41 1. Proximity: Percent of population within 2 hours to a facility capable of safe emergency surgery 71% 2. Timeliness: Emergency surgery performed within 24 hours73% 3. Workforce: Trained providers per population83% 4. Throughput: Procedure rate per population66% 5. Elective to emergency procedure ratio44% 6. Capacity: Percent of district-level hospitals meeting requirements for safe surgery 78% 7. Outcomes: Peri-Operative Mortality Rate (all procedures or bellwether)83% 8. Financial Protection: Percent of population falling into poverty or incurring catastrophic expenditure due to out-of-pocket healthcare expenditure 73% 9. Mixed: Unmet need for surgical care63% 10. Strategic Planning: Inclusion of surgery within national or regional health plans 83%

18. Metrics Other Metrics: ASA Class Metric on blood and oxygen availability (units of blood collected? availability of blood and oxygen with urban/rural distribution?) Is there any measurement of safe referral system? Coverage (met need/unmet need)

19. Requirements for Safe Surgery n = 31 1. Staff: A trained surgical provider and team100% 2. Staff: A trained anesthesia provider and team97% 3. Staff: Postop nursing care, and physiological observations94% 4. Staff: 24/7 surgical cover to review & assess patients81% 5. Stuff: Equipment, supplies, consumables, antibiotics and pain meds100% 6. Stuff: Equipment maintenance94% 7. Stuff: Sterilization capability100% 8. Stuff: Screened and cross-matched blood78% 9. Stuff/Staff protection: Gloves, and the ability to test for HIV87% 10. Process: Safe surgery checklist *47% 11. Process: Preoperative risk assessment and operation planning59%

20. Requirements for Safe Surgery Other Metrics: Quality and delivery monitoring and feedback mechanism/audit process Basic diagnostics Aspirational: Pathology Morbidity and mortality Minimal lab tests and imagery Diagnostics Hygiene of the hospital setting Ability to refer to a higher level of care via efficient transport system Access to support and mentorship (e.g. more senior surgeon) Performing surgery within established guidelines

21. Future Research Agenda n = 28 Research Areas Implementation15 Workforce14 Quality12 Barriers to access/care8 Cost of care delivery7 Access7 Burden6 Other6 Benchmarking4 Patient experience3 Safety1 28 individual responses 82 research suggestions

22. Future Research Agenda Sample Suggestions Implementation Health system design and operational research What are the optimal methods to deliver surgical care to a broad population quickly and effectively? Private practice model vs. public? Research on how to improve systems for delivery of care and supply chain challenges Workforce Workforce training, distribution and retention Benefits and disadvantages of task shifting What are the key incentives to optimize retention and function of a workforce in a low-income environment? Quality Identify quality issues that cut across all groups of surgery that can be used as a metric and for progress monitoring Quality of surgical services: all three aspects of Donabedian Framework (structure, process, outcomes) Financing Financing: What proportion of GDP (both local and foreign) goes to surgical spending? Capacity development: Impact of integrative capacity development on services

23. Traumatic Disparities: Surgical Disease and the Great Divergence June 2014

24. Items requiring consensus