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R. M. Kaumann and C. E. Haisch
training, and to ensure that strong health care
systems exist everywhere” [5]. Very few states
provide a pathway for a foreign medical graduate (FMG) to spend time participating in patient
care for any amount of time. VUMC is located
in Tennessee where no licensure category
existed to facilitate an FMG partner from Kenya
to come to VUMC for anything other than an
observership. While each state’s licensing rules
and categories differ, in Tennessee the power to
create a new licensure category rests with the
state legislature. After identifying this imbalance in the partnership, VUMC sponsored a bill
to propose a new temporary licensure category
for FMGs to spend time at an institution within
the state of Tennessee, for purposes of clinical
care, research training, and surgical education in
a supervised setting, with the goal of expanding
surgical capacity in LMICs. This bill was signed
into law in May 2022 [12]. This form of advocacy on behalf of our global surgical LMIC
partners, replicated in all states, is needed to
move academic global surgery toward true bidirectional, equitable, sustainable collaborations.
References
1. Merson MH.University engagement in global health.
N Engl J Med. 2014;370:1676–8.
2. Meara JG, Leather AJ, Hagandar L, et al. Global
Surgery 2030: evidence and solutions for achieving
health, welfare, and economic development. Lancet.
2015;386:569–624.
3. Debas HT, Donkor P, Gawande A, et al. Essential
surgery; disease control priorities, vol. Vol 1. 3rd ed.
Washington, DC: The World Bank; 2015.
4. Abraham PJ, Abraham MN, Corey BL, etal. Crosssectional analysis of global surgery opportunities
among general surgery residency programs. J Surg
Educ. 2020;77(5):1179–85.
5. Hudspeth JC, Rabin TL, Dreifuss BA, et al.
Reconguring a one-way street: a position paper on
why and how to improve equity in global physician
training. Acad Med. 2019;94:482–9.
6. Taylor-Robinson SD, Spearman CW, Suliman
AAA. Why is there a paucity of clinical trials in
Africa? QJM. 2021;114(6):357–8.
7. Thompson, D, Steffes, B.God’s surgeons for Africa.
Personal communication.
8. Tarpley M, Hansen E, Tarpley JL. Early experience
in establishing and evaluating an ACGME-approved
international general surgery rotation. J Surg Educ.
2013;70(6):709–13.
9. https://www.vumc.org/global- surgical- atlas/.
Accessed 3 June 2022.
10. Scheiner A, Rickard JL, Nwomeh B, etal. Global surgery pro/con debate: a pathway to bilateral academic
success or the bold new face of colonialism? J Surg
Res. 2020;252:272–e280.
11. Debas H, Olusegun A, Balch CM, etal. Academic
partnerships in global surgery: an overview of
the American Surgical Association Working
Group on Academic Global Surgery. Ann Surg.
2020;271(3):460–9.
12. https://wapp.capitol.tn.gov/apps/BillInfo/Default.
aspx?BillNumber=SB1902. Accessed 3 June 2022.
How toStrengthen Surgical
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Systems inLowandMiddle- Income Countries
RennieX.Qin, BelainEyob, EmmanuelMakasa,
andKeeB.Park
Perhaps no sin so easily besets us as a sense of self-satised superiority to others.
– William Osler
5
Abbreviations
HICs high-income countries
HPSR health policy and systems research
LCoGS the Lancet Commission on Global
Surgery
LMICs low- and middle-income countries
NSOAP National Surgical, Obstetric, and
Anesthesia Plan
PGSSC Program in Global Surgery and Social
Change
SAT surgical assessment tool
SDG Sustainable Development Goal
R. X. Qin (*) · B. Eyob
Program in Global Surgery and Social Change, The
Department of Global Health and Social Medicine,
Harvard Medical School, Boston, MA, USA
e-mail: be2256@cumc.columbia.edu;
belain_eyob@hsph.harvard.edu
E. Makasa
Orthopedics, Witwatersand University, SADC
Regional Collaboration Center for Surgical
Healthcare, University of Witwatersrand,
Johannesburg, South Africa
K. B. Park
Program in Global Surgery and Social Change, The
Department of Global Health and Social Medicine,
Harvard Medical School, Boston, MA, USA
Program in Global Surgery and Social Change,
Harvard Medical School, Boston, MA, USA
SOA surgical, obstetric, and anesthesia
UHC universal health coverage
WHA World Health Assembly
WHO World Health Organization
Introduction
Surgical system strengthening is an increasingly
used term in global surgery. Surgical system
strengthening looks beyond clinical service provision and teaching by individual surgeons
toward improving the broader health system
around surgical, obstetric, and anesthesia (SOA)
care. Improving outcomes from surgically treated
diseases requires much more than the performance of surgery inside the operating theatre. For
example, the survival of a patient with abdominal
hemorrhage following a road trafc accident
requires not only a surgeon and an operating theatre but also roads, a functioning emergency
transport system, a referral system, blood bank,
sterilization services, radiology, physiotherapy,
rehabilitation, and health information system,
among other components.
The publication of the Lancet Commission on
Global Surgery (LCoGS) in 2015 redened the
eld of global surgery and shifted its focus from
merely supporting health systems to strengthen-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_5
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R. X. Qin et al.
ing them [1]. Beyond the delivery of clinical care
and teaching to ll health system gaps in low- and
middle-income countries (LMICs), global surgery must improve the system’s capacity to
deliver surgical services in the long term. Although
surgical system strengthening is not traditionally
within the purview of the academic surgeon or
textbooks on Global Surgery, it is the next necessary step to improve the outcome of surgical care.
Surgical system strengthening also has implications for other services far beyond surgical care
that require similar health system elements, such
as emergency care, and critical care.
Surgical system strengthening requires an
understanding of health systems, the development of policy and advocacy skills, and the
knowledge of disciplines beyond medicine and
epidemiology, such as economics, political science, sociology, and anthropology.
In this chapter, we dene surgical system
strengthening, explore its history, and discuss
how to conduct surgical system strengthening
and acquire the necessary knowledge and skills
to do it. In doing so, we are targeting practitioners
from both HICs and LMICs, as surgical system
strengthening efforts must ultimately be driven
by and led from within countries.
What Is Surgical System
Strengthening?
The concept of surgical system strengthening
arose from that of health system strengthening. In
order to understand surgical system strengthening,
we must start by exploring the concept of health
system strengthening and delving into the eld of
health policy and systems research (HPSR).
What Are Health Systems?
The World Health Organization (WHO) denes
health systems as the ensemble of “all organizations, institutions, resources, and people whose
primary purpose is to promote, restore or maintain health” [2]. The WHO building blocks
framework is commonly used to conceptualize
health systems [2]. It describes the health system
to consist of six components or “building blocks”:
service delivery, workforce, health information
system, essential medicines, nance, and leadership/governance (Fig.5.1). A health system converts inputs, such as workforce and essential
medicines and technologies, into the immediate
output of service delivery, which can be measured in terms of its coverage, access, quality,
and safety, and ultimately into the outcomes and
goals of improving health outcomes, equity, and
nancial risk protection.
One critique of this framework is that health
systems do not only consist of a laundry list of
individual components but also the dynamic
interaction between the components to improve
health outcomes. Another aw of the framework
is that it conceives the health system as a “black
box”. Inputs are automatically converted to outputs, and the process that occurs in between is
Fig. 5.1 The World
Health Organization
building blocks
framework, adapted
from WHO (2010) [2]
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47
assumed to be opaque [3]. However, the process
that translates inputs to outputs can and must be
understood and studied. There is increasing attention within health system research to do so.
In recent years, there has been a shift to view
health systems as complex adaptive systems. They
are dynamic, interconnected, dependent on history
and context, socially constructed, and shaped by
power [4]. The eld of HPSR is dedicated to the
study of health systems. It draws on economics,
political science, sociology, anthropology as well
as public health and epidemiology [4].
Box 5.1 Denitions of Key Terms
Health policy and systems research (HPSR) is
an emerging eld that seeks to understand and
improve how societies organize themselves in
achieving collective health goals, and how
different actors interact in the policy and
implementation processes to contribute to policy
outcomes. By nature, it is inter-disciplinary, a
blend of economics, sociology, anthropology,
political science, public health and epidemiology
that together draw a comprehensive picture of
how health systems respond and adapt to health
policies, and how health policies can shape
− and be shaped by − health systems and the
broader determinants of health.
Health systems consists of all the organizations,
institutions, resources, and people whose
primary purpose is to promote, restore or
maintain health.
Health system strengthening is any array of
initiatives and strategies that improve one or
more of the functions of the health system and
that leads to better health through improvements
in access, coverage, quality, or efciency.
Surgical care is an overarching term used to
denote care for adults and children delivered by
anesthetists, obstetricians and gynecologists, and
surgeons from various backgrounds including,
but not limited to, adult and pediatric general
surgery, orthopedics, neurosurgery, urology,
ophthalmology, otorhinolaryngology, and
vascular surgery, as well as nursing, midwifery,
and all allied health professionals.
Surgical system strengthening is strengthening
of health system components that are required to
deliver surgical, obstetric, and anesthesia care to
improve the outcome of diseases requiring
treatment by surgical, obstetric, and anesthesia
care.
What Is Health System
Strengthening?
Despite being an increasingly popular concept in
global health, health system strengthening
remains misused and misunderstood. Health system strengthening represents a new direction in
global health that arose in reaction to vertical,
disease-focused programs that dominated global
health for much of the twentieth century. In contrast to vertical programs focusing on ensuring
the necessary inputs for the delivery of single
interventions, health system strengthening takes
a horizontal approach and improves the overall
functioning of the health system to tackle multiple diseases. The WHO denes health system
strengthening as “any array of initiatives and
strategies that improve one or more of the functions of the health system and that leads to better
health through improvements in access, coverage, quality, or efciency” [5]. This denition
requires the interaction between the building
blocks to create improvement across health services and health outcomes.
Chee et al. distinguished health system
strengthening from health system support activities [6]. While health system support activities ll
health system gaps to improve short-term outcomes, health system strengthening makes the
system permanently function better in the long
term. There is concern that health system
strengthening is broad and vaguely dened.
Several sets of criteria for health system strengthening activities have been developed to address
this [6, 7]. In order for interventions to qualify as
“health system strengthening”, they must:
1. Yield benets for more than one disease area.
2. Address constraints that cause sub-optimal
health system performance or improve the
interaction between health system
components.
3. Create long-term sustainable impact beyond
the duration of the intervention.
4. Improve the goals of the health system: health
outcomes, equity, and nancial risk
protection.
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Many activities labeled as health system
strengthening remain vertical and diseasefocused, risking undermining rather than improving the functioning of health systems. Ultimately,
health system strengthening activities must not
only improve health system functioning but also
improve the health outcomes for the population.
The diagonal approach is increasingly used,
which combines the vertical and horizontal
approach to improve health system functioning
through targeting several health services or disease areas.
Why Is Global Surgery Health System
Strengthening Important?
For decades, global surgery activities predominantly constituted of health system support
activities that were based in a single facility,
focused on service delivery to ll gaps, and
lacked sustainable impact beyond the duration
of their implementation. Health system
strengthening marks a new era in global surgery. The shift from short- term clinical service
delivery by visiting specialists toward teaching, capacity building, and longer-term workforce development mark some of the rst steps
toward health system strengthening in global
surgery.
Improving surgical care delivery in LMICs
has the potential to fulll many criteria for health
system strengthening.
• Firstly, surgical care is cross-cutting. It
encompasses multiple interventions for mul-
tiple disease areas. Up to a third of the global
burden of disease is estimated to require surgi-
cal care [1]. Surgical care is an example of a
service delivery platform, which can provide a
range of services that require common health
system components. For example, the provi-
sion of Caesarean sections, appendicectomy,
and open fracture management all require the
common inputs of operating theatres, surgical
instruments, anesthesia services, central steril-
ization, blood bank, radiology, and laboratory,
among other components. For this reason,
“surgical care” in global surgery often refers
to not only surgical specialties but also obstetric and anesthesia care, bundled together as
“SOA care”.
• Secondly, improving surgical outcomes
requires not only individual hospitals but the
entire health system at the national and sub-
national levels. It requires functioning interconnection between facilities at the different
levels, such as pre-hospital transport, referral
systems, and telecommunication systems.
• Thirdly, scaling up safe and affordable surgical care has enormous potential to improve
health outcomes and nancial risk protection. Surgical care is critical to achieving the
Sustainable Development Goals (SDG), particularly SDG target 3.1 of reducing the global
maternal mortality ratio to less than 70 per
100,000 live births [8]. 3.7 billion people are
estimated to be at risk of catastrophic expenditure due to surgical care. Improving the access
and affordability of surgical care could reduce
the nancial risk incurred in seeking surgical
care [1].
• Lastly, improving health system components
involved in delivering surgical care could
address health system operational con-
straints. Curative hospital-based care has
traditionally been underdeveloped in LMICs
due to the focus on infectious diseases and
vertical programs on the global health
agenda. As such, strengthening health services for surgical care could improve the outcome of a range of services beyond surgical
care, such as emergency care and intensive
care.
The indispensable role of surgical care in
health system strengthening toward achieving
universal health coverage (UHC) has been recognized by World Health Assembly (WHA) resolution 68.15 [9]. More recently, during the
COVID-19 pandemic, the versatility of surgical
systems has become apparent as surgical operating theatres, human resources, and supply chains
provided critical surge capacity for pandemic
preparedness not only in LMICs, but also in
HICs.
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Improving surgical services could contribute
signicantly to health system strengthening.
Therefore, we dened surgical system strengthening as the strengthening of health system components required to deliver SOA care, which in
turn, should improve the outcome of diseases
requiring treatment by SOA care.
Key Steps inSurgical System
Strengthening
Similar to health system strengthening, surgical
system strengthening has become a buzzword in
recent years. Some initiatives labeled as surgical
system strengthening are, in fact, vertical, based
in single facilities, and target micro-level behavioral changes of individual clinicians without
taking a system-based approach. Prior to the
advent of the eld of global surgery, health system support activities for individual building
blocks, such as equipment donation and teaching,
have already been occurring through surgical
missions for decades. Efforts that truly strengthen
and not just support surgical systems must have
sustainable, long-term impact. Despite increasing recognition of the importance of surgical system strengthening, its optimal method remains
undened [10]. There is a need for more studies
to evaluate the impact of surgical system strengthening initiatives. As the focus of global surgery
shifts from health system support activities delivered by visiting surgeons to strengthening surgical care systems in LMICs, it must be led by
LMICs. A criticism of health system strengthening is that it can remain donor-led and donordened, similar to the vertical infectious
disease-focused programs from which it is trying
to distinguish itself [11]. In this vein, health system strengthening reects a mere shift in donor
agenda rather than a fundamental shift in the
power of priority-setting from external parties to
the countries. Surgical system strengthening
interventions must be locally contextualized to
address the most critical health system constraint
in each country or sub-national region.
We highlight several steps to consider in surgical system strengthening. This provides a guid-
ance rather than a prescription and should be
tailored to country-specic contexts.
Securing Political Commitment
Securing political commitment is a prerequisite
for surgical system strengthening due to the historically low priority of surgery on the global
health agenda. While surgical system support
activities have occurred in decentralized settings
around the world through surgical missions,
charity hospitals, and humanitarian assistance,
surgery has been the “neglected stepchild of
global health” on the agenda of the WHO and
major global health funder [12].
In recent years, advocacy and diplomacy by
the global surgery community have elevated the
position of surgery on the global health agenda.
Globally, the WHA resolution 68.15 recognized
emergency and essential surgery as a critical
component of UHC in 2015 [9]. Similar
regional resolutions were passed by the
Southern African Development Community in
2018 and at the Pacic Health Ministers
Meeting in 2019 [13]. In 2020, Member States
of WHO Western Pacic Region unanimously
endorsed the Action Framework for Safe and
Affordable Surgery in the Western Pacic
Region (2021–2030) at the seventy-rst
Regional Committee Meeting [14]. Nationally,
nine countries have made political commitments through developing national strategic
plans for SOA care, and many more countries
are in the process of doing so.
Political commitment at the national level has
been generated through a mixture of international
diffusion of global and regional commitments,
top-down leadership, and bottom-up mobilization. The leadership of surgeons who hold key
positions in governments and Ministries of
Health has resulted in high-level political commitments by a number of countries. In other
countries, the mobilization and advocacy of SOA
providers and non-government organizations
have exerted bottom-up pressure on governments
leading to the agenda adoption of surgical system
strengthening.
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Conducting Health System
Assessments
Once the political commitment has been
secured, surgical system strengthening could
begin with an analysis of health system capacity, gaps, and opportunities for SOA care provision. This could include a literature review,
quantitative facility assessment, and qualitative
stakeholder interviews. Chapter 7 is devoted to
the summary of the various approaches and to
the methodologies of conducting such
assessments.
A quantitative surgical assessment tool (SAT)
has been developed by the WHO in conjunction
with the Program in Global Surgery and Social
Change (PGSSC) at Harvard Medical School
[15]. This covers all six building blocks of the
health system. Data is collected through a hospital walkthrough, a review of operating room
logbooks, and admission and discharge records.
A criticism of this tool is that it is focused on
inputs and outputs without paying attention to
the interaction between building blocks, critical
points of operational constraint, population
health needs, and the outcome of surgical care.
More in-depth facility assessments could be
developed to suit country-specic contexts (see
Chap. 7).
Qualitative stakeholder interviews could supplement the quantitative SAT.These could qualitatively explore the dynamic interaction between
inputs, critical system constraints, and the process that converts inputs to outputs and outcomes
in more depth. Not only do the interviews serve
as a means of obtaining information, but they
also provide an opportunity to engage and mobilize stakeholders.
A review of the literature could shed light on
the population’s health needs in terms of the burden of surgically treated diseases and the country’s social, political, economic, and cultural
context. In addition to the academic literature, a
review of the grey literature and policy documents could provide information on existing initiatives, upon which surgical system strengthening
interventions can build.
Priority Setting andPlanning
A comprehensive national strategic plan for surgical system strengthening could be developed
within which individual surgical system strengthening activities nestle. Strategic planning is useful for surgical system strengthening for a number
of reasons. A plan could (1) secure ongoing political commitment, (2) guide coordinated resource
allocation to reduce fragmentation, and (3) provide a long-term vision for sustainable impact.
Several frameworks could guide strategic
planning for surgical system strengthening,
including the National Surgical, Obstetric, and
Anesthesia Plan (NSOAP) framework developed
by the PGSSC and the WHO Regional Action
Framework for Safe and Affordable Surgery,
tailored to the Western Pacic context [14, 16].
The planning process involves several
components.
1. A policy direction: vision- and priority-setting
of the package of SOA care that should be
available at different levels of health facility
on a ve- to ten-year time scale.
2. A strategic plan: the development of a set of
strategies based on the analysis of key health
system gaps and opportunities for improvement to realize the broad policy direction.
3. An operational plan: in conjunction with a
long-term national strategic plan, an operational plan should be developed in order to
translate the long-term strategy into shorterterm implementation.
Having a strategic plan does not automatically
result in the strengthening of surgical systems.
The plan must be translated into action. Strategic
plans are at risk of isomorphic mimicry. A country might mimic other successful countries and
devise a plan that looks good on the shelf but
does not translate well into action [17]. Attention
is paid to appearance rather than function. “Looks
like” substitutes for “does”. Two strategies are
essential in countering the risk of isomorphic
mimicry: developing a short-term operational
plan and bottom-up, inclusive, and genuine stake-
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holder engagement. The strategic plan must be
co-created with the people who will implement it
[18]. A deliberative priority-setting process is
critical in ensuring that the priorities reect the
needs of the population and have the buy-in of
stakeholders.
Designing andImplementing Locally
Contextualized Interventions
The strategic plan must be supplemented with
short-term actions. According to Kotter’s eightstep model for leading change, the generation of
short-term wins could (1) aid plan implementation, (2) mobilize and empower stakeholders, and
(3) make changes stick [19] (Fig.5.2). As a part
of the strategic planning process, two to ve
areas of critical health system constraint could be
selected for targeted short- to medium-term
interventions.
Fig. 5.2 The Kotter
eight-step model for
leading change [20]
8. Institute
change
Table 5.1 lists some examples of existing and
possible interventions by health system component. This list is by no means exhaustive and
should not be interpreted as a laundry list. It
merely provides ideas for possible surgical system strengthening interventions. Many initiatives
introduced by visiting HIC surgeons default to
teaching and checklist use, as these health system
gaps tend to be the most visible to them. However,
these interventions target individual clinician
behavior at the micro-level and do not address
system-level decits. Longer-term workforce
development initiatives that have evolved from
short-term teaching constitute some of the earliest surgical system strengthening efforts. Health
system gaps, such as biomedical engineering,
sterilization services, or waste management,
might not be as familiar to visiting surgeons who
are used to operating in health systems where
these components are well-functioning. However,
these components can be equally deserving of
1. Create a
sense of
urgency
2. Create a
guiding
coalition
7. Build on the
change
6. Accomplish
short-term
wins
3. Develop a
vision and
strategies
4.
Communicate
the change
vision
5. Remove
barriers to
action
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Table 5.1 Surgical system strengthening interventions
by health system building block
Health system
building block
Infrastructure Refurbishing operating room,
Workforce Workforce training and planning
Service delivery Telemedicine
Information
management
Finance Developing a social insurance
Governance Guidelines and accreditation
Surgical system strengthening
interventions
recovery room, and critical care
space and patient ow
Strengthening surgical equipment
and consumable procurement
Streamlining supply chains
Improving central sterilization
services
Strengthening biomedical
engineering
Surgical instrument innovation
and development by LMICs
Task-shifting
Early diagnosis and screening
(e.g., cervical and breast cancer
screening)
Service delivery redesign (e.g.,
outreach, regionalization of
services)
Strengthening emergency and
mass casualty response
Improving referral pathways
Registry development
Research capacity building
Incorporation of LCoGS
indicators into routine health
indicators
scheme with coverage of surgical
care
Improving the efciency of
surgical care delivery to reduce
cost
Developing a mechanism to assist
patients with nancial recovery
post-surgery
standards for surgical care
Creation of ministerial advisory
committees or focal persons for
surgical care
attention as workforce development in LMICs.
Therefore, global surgery practitioners should
stretch our imagination and heed close attention
to local health system needs to identify the most
critical intervention. Ultimately, the optimal
intervention should be selected and designed
with the country-specic context in mind.
This categorization in Table 5.1 merely indicates the predominant health system component
under which interventions fall. It does not intend
to unnecessarily fragment the health system and
underplay the interaction between components.
In fact, each intervention requires the coordination of several health system components. For
example, task-shifting would require not only
workforce training but also sound policy and
guideline development to delineate the scope of
practice of healthcare professionals of different
cadres.
Monitoring andEvaluation
Lastly, the impact of surgical system interventions should be monitored and evaluated. At the
system level, the LCoGS indicators on timely
access, surgical workforce density, surgical volume, perioperative mortality rate, and nancial
risk protection should be incorporated into routinely reported national health indicators
(Table5.2). In addition, other indicators may be
Table 5.2 Lancet commission on global surgery indicators [1]
Target by
Indicator
1. Access to timely essential surgery–
The percentage of the population that
can access, within 2hours, a facility
capable of providing bellwether
procedures (caesarean section,
laparotomy, and open fracture
management)
2. Specialist surgical workforce density –
Number of surgical, anesthesia, and
obstetric specialists per 100,000
people
3. Surgical volume – Procedures
performed in an operating theatre per
100,000 population per year
4. Perioperative mortality – All-cause
death rate before discharge in patients
who have undergone a procedure in an
operating theatre
5. % risk of catastrophic out-of-pocket
expenditure* on surgical care
6. % risk of impoverishment due to
out-of-pocket expenditure** on
surgical care
2030
80%
20
5000
Monitored
0%
0%
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required to track the performance of specic surgical system interventions, such as surgical consumable stockout rate or surgical site infection
rate, and the outcome of key surgically treated
conditions, such as maternal mortality and cervical cancer mortality.
Developing aToolkit forSurgical
System Strengthening
Health system strengthening has not been traditionally covered by medical education and surgical residency. How can surgeons equip themselves
with the knowledge and skills necessary to
strengthen surgical systems?
Although surgeons from HICs have played a
leading role in visiting teams and teaching, surgical system strengthening activities must be led
by practitioners from LMICs. Therefore, this
chapter is intended as much for LMIC practitioners as it is for HIC practitioners. HIC practitioners should play a supportive role in surgical
system strengthening in LMICs. However,
attention must be paid to protecting local ownership and autonomy and to ensuring this supporting role does not transform into a leading
one. For example, if HIC partners were to assist
with health system assessment, they must be
careful to use the data collected to assist LMIC
stakeholders to set priorities rather than to do so
on their behalf. In carrying out surgical system
strengthening activities, explicit attention
should be paid to enhancing local capacity for
implementation rather than to creating parallel
systems that drain from it.
Health system strengthening is new to HIC
and LMIC surgeons alike. Although HIC visiting
surgeons may be the expert in teaching and performing specialized operations, they are not necessarily experts in surgical system strengthening.
HIC surgeons are used to operating in wellfunctioning health systems where they might not
have an appreciation of all the components that
go into surgical care beyond the operating theatre, such as equipment innovation and design,
sterilization, and biomedical engineering. LMIC
surgeons, urged by their resource constraint envi-
ronment, often have a much more expansive view
of health systems than HIC surgeons.
Surgical systems in LMICs, though underequipped compared to surgical systems in HICs,
should not be a direct translation of HIC surgical
systems. The aws of some HIC surgical systems
should also be recognized. For example, the
health system in the United States is known to be
fragmented, inefcient, and high cost, with inadequate focus on community and primary care,
compared to some other HICs. Therefore, a critical awareness of the limitations of one’s knowledge and experience and constant self-reection
are essential to surgical system strengthening.
Surgical system strengthening requires the
knowledge of health systems and health policy,
skills in advocacy and diplomacy, an understanding of local context, and the building of coalitions. In order for surgeons to gain an
understanding of health systems and health
policy, they must expand their training beyond
the traditional academic surgery disciplines of
epidemiology and biostatics into economics,
political science, sociology, and anthropology.
This knowledge could be developed through formal postgraduate training, such as a Masters of
Public Health with health policy or health system
as concentrations. Outside formal degree programs, there are many opportunities to develop
an understanding of health systems by attending
short courses and reading key publications.
Health systems and policy publications could be
introduced to the journal club of academic surgery units, in addition to clinical epidemiology
studies that are commonly discussed.
Skills in advocacy, policy, and diplomacy
are best learned by practice rather than from textbooks. Although these skills are relatively new to
global surgery, fortunately, there is much that the
global surgery community could learn from
advocacy efforts towards other global health priorities, such as HIV/AIDS, tobacco control, and
climate change. Advocacy and policy workshops
of even a few hours in duration could be highly
effective. One could start small and practice honing these skills by setting up meetings with political representatives, organizing a public rally for
surgical care, and writing press releases.
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