A surgical approach to strengthening our health systems 

“Do we provide the right care, the right way, at the right time, every time?” asked Dr. Atul Gawande, who was confirmed this month as assistant administrator of the Bureau of Global Health for the US Agency for International Development (USAID). He responded to his own question on the complexities of healthcare delivery in the U.S. with a resounding “No.” 

With his new role, we propose extending Dr. Gawande’s assertion, because the answer to his question is meaningless unless we can deliver that care everywhere.   

Many know Dr. Gawande as a surgeon, and from the surgical perspective alone, the problems facing global healthcare delivery are daunting.  

Seventy percent of the world’s population lack timely access to safe, affordable surgical care (including 1.7 billion children and adolescents).  

Trauma, the leading cause of disability and death from ages 5-14, is predicted to cause the death of 9.8 million children by 2030.

Under current healthcare financing schemes, 81 million people face financial catastrophe every year merely seeking surgical care. 

These crushing statistics are expressed in surgical terms, not only because a surgeon will lead global health efforts at USAID but because we believe that the capacity to perform surgery represents the strength of a healthcare system.  

The announcement of USAID’s campaign Vision for Health System Strengthening 2030 asserts the organization’s position “that integrated, systems-based approaches for strengthening health systems are now more critical than ever.” With his confirmation, Dr. Gawande will seek to turn that vision into reality.  

Nearly one-third of the disease burden in the world is surgical — if health systems are to be strengthened completely, then USAID’s vision must include safe, timely and affordable surgical care.  

The task of “health systems strengthening” is complex, with multiple components requiring improvements in concert with one another. Broadening the scope of primary care can lead to a wider capability of providers and earlier detection of disease, and potentially offer basic surgical services without the need for an operating room.  

Revitalized community-based clinics in Cuba have brought additional access to primary care and an improved range of specialty services. Investments in technology transfers between clinics and specialized hospitals allow providers in rural clinics to offer basic trauma care, obstetrics and gynecology services, and even minor surgery.  

Malawi faces a critical shortage of orthopedic surgeons and offers care by providers with different levels of training. Orthopedic clinical officers, who receive some training but have not gone to medical school, showed no difference in outcomes after major amputations and open reductions when compared to fully trained surgeons.  

These findings suggest some conditions can be treated safely by providers with a shorter duration of training leading to a more rapid expansion of the surgical workforce. Although not a perfect solution, it will help low-income countries come closer to the twenty-fold increase in workforce density necessary to meet minimum recommendations.  

An investment in surgical systems will not just improve outcomes for surgical patients. The staff, space and supplies needed to perform surgery is necessary across multiple areas of medicine. 

The COVID-19 pandemic demonstrates the cross-cutting ability of surgical resources to extend the capabilities and resilience of healthcare systems in times of immense crisis.   

Hospitals overwhelmed with COVID-19 patients display incredible flexibility by converting operating rooms into intensive care units and anesthesia machines into ICU ventilators. Faced with widespread case cancellations, surgeons, anesthesiologists and staff continue to offer themselves as a highly trained workforce ready to help with the deluge of COVID-19 patients.  

Stronger health systems bring with them improved access to surgical care, and improvements in access to surgical care strengthens health systems. This synergistic relationship works to optimize resources and deliver care across the full spectrum of disease.  

If the vision of Dr. Gawande and USAID is truly health systems strengthening, surgical care must be an indivisible, indispensable part of the systems we hope to build. This hope rests in the fact that every day we are presented the opportunity to make life better for billions of people. This is the true vision; to make the world better. 

John Meara, MD, DMD, MBA, is the plastic surgeon-in-chief at Boston Children’s Hospital and is the Kletjian Professor of Global Surgery at Harvard Medical School, where he serves as the director for the Program in Global Surgery and Social Change. @johnmeara 

Geoffrey A. Anderson, MD, MPH, is an associate surgeon at Brigham and Women’s Hospital, a member of the faculty at Harvard Medical School, and part of the core faculty at the Program in Global Surgery and Social Change. @GeoffAndersonMD  

Matthew T. Hey is a research associate for the Program in Global Surgery and Social Change at Harvard Medical School. @Mattt_Hey