Emergency and Essential Surgery: the backbone of primary health care
General situation
Surgery is often the only solution to prevent disabilities and death from conditions resulting from road traffic accidents, falls, burns, disasters, domestic violence, pregnancy related complications, infections and congenital defects.
Until recently, surgery was neglected as a developing country public health issue because:
- it was assumed to be an expensive tertiary care intervention requiring sophisticated equipment and expertise;
- there was insufficient reliable data to indicate that surgery could be cost-effective in developing countries.
But now
Based on recent WHO country assessments, surgery is beginning to be seen as an integral part of primary health care, a preventive strategy and a cost-effective way of dealing with many health challenges specific to resource poor settings.
Examples of surgery as primary health care:
1) Washing and removing dead or damaged tissue from an open fracture:
Open fractures are characterized by a rupture of the bone sticking out through the skin. The condition is often complicated by deep wound and localized infection (osteomyelitis). A simple way to avoid the infection is to wash the injury with sterile, saline and distilled water, and early closure of the skin. When osteomyelitis develops, it becomes a chronic infection, which requires multiple complex surgeries to treat. Learning straightforward skills to treat an open fracture minimizes disability.
2) Treatment of a traumatic joint dislocation (shoulder, elbow, hip):
Neglected joint dislocations result in severe disability with partial to complete loss of joint function. In the majority of cases, a simple manual intervention by a trained health professional can put the joint back in position. The manoeuvre requires only sedation for most patients and can be performed in the emergency room.
3) Drainage of abscesses:
The pathological condition resulting from either bone, joint or muscle infections is a common source of morbidity in developing countries. Untreated infections may result in severe or permanent disability to the patient. The drainage of the wound, by collecting the pus through an incision over the affected area, is indicated to treat bacterial infections in muscles or bones. In case of a bone infection, a hole may need to be made in order to remove the pus. Joint illnesses require a more complex surgical procedure. However, the drainage can be easily performed at primary care level as long as safe anaesthesia is available.
4) Casting technique to prevent clubfoot (also known as Ponseti):
Clubfoot is an inborn deformity of the foot, usually marked by a curled shape or twisted position of the ankle, heel, and toes. The cause is most likely to be a genetic disorder. Manually aligning the child's foot in order to stretch the tight ligaments and tendons is a basic and effective clinical intervention. A cast that extends from the toes to the groins has to be applied afterwards, maintaining the correction obtained by the alignment of the foot and relaxing the tissues. Treatment should begin during the first week or two of life to take advantage of the favourable elasticity of the tissues at that age.
Fact file
- Each year injuries kill more than five million people, accounting for nearly 1 in every 10 deaths worldwide;
- An estimated 500,000 women die each year from pregnancy related complications requiring surgical interventions;
- Road traffic injuries are the second leading cause of death for children between the ages of four to 14;
- Almost 50% of the world's injury-related mortality occurs in young people aged between 15-44 years - the most economically productive members of the global population;
- The burden of disease related to injuries, particularly road traffic injuries, interpersonal violence, war and self-inflicted injuries is expected to rise dramatically by the year 2020;
- The quality of emergency and essential surgical care is often constrained by inadequate basic equipment for interventions that are simple but vital, such as resuscitation, giving oxygen, assessing anaemia and inserting a chest drain;
- Death and disability in the most vulnerable groups (namely, women and children) are easily prevented or corrected by surgery, provided this service is made available in a timely manner;
- Most essential and surgical interventions can be delivered at the first referral level health facility (rural or district hospital, health centre, primary healthcare facilities) provided the health care staff possess a few basic skills and some basic equipment;
- It is estimated that more than 100 000 babies are born worldwide each year with congenital clubfoot. 80% of the cases occur in developing countries and most are untreated or poorly treated;
- Globally, neglected clubfoot is the single most serious cause of physical disability among congenital musculoskeletal defects.
Africa
- There are fewer than 100 surgeons practicing in Uganda for a population of about 24 million — a surgeon to population ratio of 1:30,000. Almost 95% of these surgeons work in urban areas;
- Gambia and Malawi have currently no qualified local anaesthesiologists and have to 'import' specialists from other countries in order to provide surgical care to patients;
- Although a reliable oxygen supply is important and life-saving in any clinical setting, a survey in one African country (Tanzania) showed that 75% of district hospitals had an oxygen supply for less than 25% of the year;
- A study of anaesthesia services in Uganda shows that only 23% of anaesthetists have the facilities to deliver safe anaesthesia to adults, 13% to children, and 6% for a Caesarean section. (Anaesthesia. 2007 Jan; 62 (1): 4-11).
Asia
- In most of South-East Asia, health care, and especially surgical care, is concentrated in major hospitals in big cities;
- In villages and small towns the health infrastructure exists on paper, but even minor procedures are not carried out because equipment does not work and surgeons are reluctant to undertake operations for which they are not well trained;
- Demand for surgical services account for about 10-15% of all hospital admissions in the region;
- The inadequate response of the public sector to the demand for surgical services has resulted in a major growth of the private sector in the past 10 years;
- Deterioration in the public sector has meant that surgical training has suffered.
What is WHO doing?
In October 2004, in order to provide normative standard guidelines to improve global equality of priority emergency, surgical and anaesthesia services, WHO implemented the Integrated Management of Essential and Emergency Surgical Care (IMEESC): an e-learning tool kit presenting the organization's recommendations for minimum standards in emergency and essential surgical care, trauma, obstetrics and anaesthesia at country-level.
The IMEESC tool was first introduced in Mongolia for a pilot training workshop - which has now become a standard WHO action strategy in various Member Countries. The tool is also used to teach safety during clinical procedures, infection control and HIV prevention as well as management in disasters and emergencies.
Over one year later, in December 2005, WHO established the Global Initiative for Emergency and Essential Surgical Care (GIEESC), a broad partnership of internationally recognized organizations and individuals which aims to contribute to the Millennium Development Goals 4, 5 and 6 (Reduce child mortality; improve maternal health; combat HIV/AIDS, malaria and other diseases) by improving access to safe use of emergency and essential surgical procedures and equipment at primary health care facilities.
The members of the GIEESC agree to collaborate in facilitating progress in the following areas:
- Global advocacy to promote wider and safer use of emergency and essential surgical practices (including anaesthesia)
- Encourage and support the establishment of national programmes on essential surgical care
- Promoting training in surgical and anaesthesia techniques to reduce blood loss, prevent HIV and other blood borne pathogens
- Needs assessment to target the main gaps in essential surgical practices at country-level
- Organization of delivery of care (training workshops)
- Monitoring and evaluation of essential surgical procedures (two years after the training workshops)
- Impact assessment (five years later)