February 2019, Volume 69, Issue 1


Surgical Care for all - much work to be done

Authors: Syed Ather Enam  ( Department of Surgery, Aga Khan University, Karachi, Pakistan. )
Sadaf Khan  ( Department of Surgery, Aga Khan University, Karachi, Pakistan. )

Surgical care is an essential aspect of a population's health. The Global Health initiatives can be traced back to the post-World War II era. However, Global Surgery remained a neglected component of public health systems. Over the last few decades, the impact of noncommunicable diseases (NCDs) has come into focus. Amongst NCDs, surgical disease makes up almost 30% of the global burden of disease.1 The vast majority of the population living in Low and Middle Income Countries (LMICs) is unable to access safe and affordable care in a timely manner. This situation was worsened by the assumption that the cost associated with the management of surgical disease was too great to warrant inclusion in public health initiatives. However, this stance changed with the report of The Lancet Commission on Global Surgery in 2015.2 This report defined six indicators to assess and monitor surgical systems. Subsequently, the passage of the World Health Assembly resolution 68.15 "On strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage" reiterated the importance of surgical care as an essential component of health care systems.3 Additionally, Global Surgery was incorporated in the UN's Sustainable Development Goals.4 The Lancet Commission on Global Surgery coincided with the publication of the Disease Control Priorities 3rd Edition (DCP-3).5 This document focused on essential surgical care. It presented a list of 44 surgical procedures. Of these, there were 28 emergency surgical procedures that included trauma and obstetric issues, in addition to other surgical emergencies. The DCP-3 Essential surgical procedures covers common surgical diseases, th treatment of which has a significant affect on the life and livelihood of the population, and greatly impacts the economic growth of the country. Additionally, in 2016, Caesarean section, laparotomy and management of open fractures were defined as 'Bellwether procedures'. It was felt that first-level hospitals should have the ability
to perform these procedures safely and in a timely fashion.6 The large majority of Pakistan's citizens do not have access to standard surgical care. It is estimated that there are 10 million surgical procedures required to address the surgical disease burden in our population. The two major challenges to the delivery of medical, as well as surgical-care, are access and affordability. Neglected infrastructure, flawed workforce development strategies, and absence of protection from impoverishing or catastrophic expenditure as a result of treatment, also add to the crisis. Since The Lancet Commission on Global Surgery was published, there has been a concerted effort around the world to engage in research and policy development in order to improve the state of surgical care across LMICs. With the intention of increasing awareness about Global Surgery and its components, we present this special supplement of JPMA. We hope that this effort will help
fulfill the purpose of the 4th AKU Annual Surgical Conference - to Enlighten, Educate, and Engage.


1. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health 2015; 3 (Suppl 2): S8-9.
2. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015; 386: 569-624.
3. World Health Organization. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage [Internet] Sixty-eighth World Health Assembly 2015 May 26 [cited 2018 December 24] Available from: http://apps.who.int/gb/ ebwha/pdf_files/WHA68/A68_R15-en.pdf
4. Sustainable Development Goals [Internet] New York, NY: United Nations; 2015 [cited 2018 December 24] Available from: h t t p s : / / s u s t a i n a b l e d e v e l o p m e n t . u n . o r g / ? m e n u = 1 3 0 0
5. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors. Essential Surgery: Disease Control Priorities. 3rd ed. Volume 1. [Internet] Washington, DC: The International Bank for Reconstruction and Development / The World Bank; 2015 [cited 2018 D ecember 24] Avail able from: http://dcp-3.org/surgery.
6. O'Neill KM, Greenberg SL, Cherian M, Gillies RD, Daniels KM, Roy N, et al. Bellwether procedures for monitoring and planning essential surgical care in low- and middle-income countries: caesarean delivery, laparotomy, and treatment of open fractures. World J Surg 2016;40:2611-9.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: