Advocacy

In 2014, ASAP became one of the charter members of the Global Alliance for Surgery, Obstetrics, Trauma and Anesthesia Care, also known as the G4 Alliance. This entity brings together leading international organizations dedicated to advocating for the neglected surgical patient to raise the profile of surgical care in the global health policy and development agendas.  The activities of the G4 Alliance are available here.

** UPDATE: On January 29, 2015, the World Health Assembly Executive Board unanimously passed Agenda Item 10.1, “Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage”.  This item was ratified at the 68th World Health Assembly in May 2015.

 

What is the World Health Assembly?  What should I know about it?

The World Health Assembly (WHA) is the decision-making body of the World Health Organization (WHO). Representatives from each of the United Nations Member States meet annually in May in Geneva, Switzerland on a specific health agenda prepared by the WHA Executive Board. The sixty-seventh World Health Assembly
 will meet May 19–24, 2014.

The WHA Executive Board (EB) is comprised of representatives from 34 countries who serve three-year terms.  The EB sets the agenda for the annual WHA meeting.  The EB meets twice annually – once in January, and once following the WHA meeting in May. The current composition of the WHA EB can be found here: http://www.who.int/governance/eb/eb_members/en/index.html.

 

What are the current provisions for surgery at the World Health Organization?

There are several surgical programs at the World Health Organization including:

The WHO Programme for Emergency and Essential Surgical Care (EESC) is dedicated to strengthening health systems, achieving universal health coverage, and ensuring the safety and efficacy of clinical procedures in Anesthesia, Surgery, Orthopedics, and Obstetrics. The EESC is directed by Dr. Meena Cherian, an anesthesiologist. http://www.who.int/surgery/en/

The Global Initiative for Essential and Emergency Surgery (GIEESC), a program of EESC was established in December of 2005. GIEESC members represent 116 countries.   http://www.who.int/surgery/globalinitiative/en/

Safe Surgery Saves Lives– the “Surgical Checklist”: http://www.who.int/patientsafety/safesurgery/en/

WHO Emergency and Trauma Care Modules – http://www.who.int/surgery/publications/immesc_emergency_trauma_care/en/

Violence and Injury Prevention http://www.who.int/violence_injury_prevention/en/

WHO Global Alliance for Care of the Injured – http://www.who.int/violence_injury_prevention/services/gaci/en/

 

What is a resolution?

A resolution is the mechanism used by United Nations agencies to implement policy change.  Resolutions are non-binding and meant to serve as recommendations. At the WHO, resolutions, once passed, provide recommended guidance in global health policy to be implemented at the country level.  http://en.wikipedia.org/wiki/United_Nations_resolution

 

What is the Resolution on Surgery and Anesthesia that I’ve heard about?

While there have been several resolutions passed within WHO related to surgery (see below in this section), there is not a resolution stating that surgical care (i.e. surgery, anesthesia, pre and post-operative care and the related systems, supplies, metrics & evaluation, and financing) is a necessary component of global public health.

The reason that it is important to have a formal statement in the form of a WHA resolution is that these inform the priorities, policies and planning for health care within each WHO Member State.  The Ministers of Health (or equivalent) of each country are guided by the recommendations of the WHO when implementing healthcare decisions for their country.

To date, many feel as though surgical care is excluded from political and financial support because it has not had a WHA resolution endorsing it.  The reasons behind this are manifold, but historically related to anecdotes about surgical care being considered too expensive and complex to incorporate into public health strategies.

With the changing epidemiological landscape of the 21stCentury, (increasing incidence of trauma and non-communicable disease – including cancer and heart disease, etc.), and better evidence on the relative cost-effectiveness of surgical care – especially when considering the impact of obviating disabilities, there is a growing appreciation for the importance of integrating surgical care into a robust public health approach.

Past resolutions related to surgical care include:

Resolution WHA56.24 requested the WHO Director-General to provide technical support for strengthening trauma and care services to survivors or victims of violence.

Resolution WHA57.10 recommended Member States to strengthen emergency and rehabilitation services for victims of road-traffic injuries.

Resolution WHA60.22 on emergency-care systems recognized that improved organization and planning for the provision of trauma and emergency care, including surgery, is an essential part of integrated health-care delivery.

Resolution WHA58.23 on disability recommended Member States promotes early intervention to prevent and treat disability and strengthen community-based rehabilitation programs are linked to primary health care and integrated in the health system.

Resolution WHA66.10 on non-communicable diseases recommended measures to prevent and control cardiovascular diseases, cancer, diabetes and chronic respiratory diseases.

 

What is the historical background regarding the Resolution on Surgery and Anesthesia?

The efforts to introduce a WHA resolution on the importance of surgery and anesthesia in global health were started in about 2009.  Over the past five or so years, efforts have focused on increasing awareness of this issue; soliciting input on the nature of such a resolution, particularly from surgeons in low and middle income countries; and gathering letters of support and endorsement from surgical and anesthesia societies, academic medical centers, and non-profit organizations.  In 2013, attention was focused on the countries comprising the WHA Executive Board (EB) with the hopes that one or more would formally propose the surgical care resolution.

In January 2014, the WHA EB met to finalize the agenda for the 67thWorld Health Assembly in May 2014.  The themes relevant to surgical care at this meeting include non-communicable diseases (EB 7.1); disability (7.3); health related Millennium Development Goals (MDGs) and health in the post-2105 UN Development agenda (8.1); violence, particularly against women and girls (8.4); health systems (9) and universal health coverage (9.6 and 9.8).

At the January meeting, the importance of surgical care was emphasized for at least two agenda items.  Dr. Emmanuel Makasa of Zambia made a formal statement during the discussion on the Disability agenda item (7.3) with regard to “’tabling a resolution in this house (in the near future) together with other member states that aims at strengthening Essential and Emergency Surgical Care at the primary level of healthcare as a way of preventing disabilities arising from road traffic accidents and other domestic and industrial injuries.”  Another statement was made from Senegal on the need to consider surgical care during the Health Interventions and Technology agenda item (9.6).  Our appreciation is extended to them both.

At the close of the January EB meeting, a representative from Senegal requested that the topic of surgical care be placed on the agenda for the next meeting of the EB (May 26-7 immediately following the WHA meeting).   This request was approved and the surgical care topic was accepted for inclusion on the upcoming agenda. The May EB meeting will establish the themes for discussion at the WHA for the upcoming year.

During the week long May 2014 WHA proceedings there were two related events to raise awareness of the importance of surgical care on the global public health agenda.  The side meeting on ‘Improving Safe Emergency and Essential Surgical Care and Anaesthesia’, held at the Palais des Nations, attracted more than 200 attendees.  A panel of speakers included Ministers of Health from Zambia, Nigeria, and Rwanda and speakers designated by the Ministries of Health of Australia, USA, Timor-Leste and Egypt. Each of the four NGOs in official relations with WHO: the International College of Surgeons (ICS), International Federation of Surgical Colleges (IFSC), International Society of Orthopaedic Surgery and Traumatology (SICOT), and World Federation Societies of Anaesthesiologists (WFSA) made formal statements.  And further comments were heard from delegations representing the ministries of health of over 45 member states.

Later that evening, a well attended “Reception for Global Surgery and Anaesthesia Partners” was held at the InterContinental Hotel which gave attendees, including official WHA delegates as well as representatives from civil society, additional opportunity to discuss the importance of surgical care.  Ambassador Jimmy Kolker of the US Office of Global Affairs made a formal statement of support, and additional statements were heard from the WFSA, ICS, IFSC, and the International Federation of Medical Student Associations (IMFSA). Sponsors of the reception included Gradian Health Systems, the Henry Family Foundation, Operation Smile, and the Johns Hopkins global surgical team.

On May 26, 2014 the WHA Executive Board unanimously passed the EB Agenda Item “Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage”.  This topic then became part of the formal agenda for 2014-2015.  Per Dr. Meena Cherian, Director of the WHO’s Emergency & Essential Surgical Care (EESC) program, “over 30 Member States and 6 NGOs, the Assistant Director General, and the Director General all voiced their support of the EB Agenda Item”.   (Summary of Statements)

On January 29, 2015, the World Health Assembly Executive Board unanimously passed Agenda Item 10.1, “Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage”, with no amendments.  28 countries and 6 NGOs made formal statements of support. 

The resolution can be read as presented – http://apps.who.int/gb/ebwha/pdf_files/EB136/B136_R7-en.pdf.

This item will now proceed for ratification at the 68th World Health Assembly in May 2015.

 

Who supports the WHA Resolution on Surgery and Anesthesia?

Countries that have shown support to date include:

Angola, Armenia, Australia, Bangladesh, Burundi, Cameroon, China, Cuba, Cyprus, Denmark, Ecuador, Egypt, Estonia, Fiji, The Gambia, Germany, Ghana, Greece, Italy, Indonesia, Iran, Ireland, Japan, Kenya, Lebanon, Lithuania, Malaysia, Myanmar, Monaco, Mongolia, Namibia, New Zealand, Nigeria, Papua New Guinea, Pakistan, Romania, Rwanda, Samoa, Saudi Arabia, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, Spain, Sudan, Switzerland, Sweden, Taiwan, Timor Leste, Trinidad and Tobago, United Kingdom of Great Britain and Northern Ireland, United States of America, Zambia, Zimbabwe

 

What are the next steps?  How can I help get it passed?

With knowledge that the resolution on surgery and anesthesia will come before the 2015 WHA for a formal vote, it is increasingly important to communicate with the WHA representatives from your respective countries on the importance of a systems approach to global public health that includes surgery and anesthesia care.

There are WHA representatives who still may not think of surgery as an integral part of public health, and additional education may be in order regarding the importance of surgical care in achieving the existing MDGs as well as for the “post – 2015 agenda” of Sustainable Development Goals (SDGs).

The May 2015 meeting convenes all the countries participating in the World Health Organization. Countries listed above are those that we are aware of that have expressed support to date – we need to continue to support the WHA representatives from these countries and encourage them to reinforce the message at the upcoming meetings in both formal comments as well as informal dialogue with their colleagues.  (If there are other countries in support, please provide details to asap@gmail.com so that this information can be updated appropriately.)

 

Related Initiatives:

Continued advocacy efforts are also focused on the consensus process for defining the Sustainable Development Goals (SDGs) that will supplant the Millennial Development Goals in 2015.  The UN Open Working Group on the SDGs has had ongoing input from the surgical community at a series of formal and informal events with a goal of ensuring that the SDGs are inclusive of surgical and anesthesia care (tentatively associated with SDG 3

 

On January 17-18, 2014 the inaugural meeting of the Lancet Committee on Global Surgery was held in Boston, MA, USA.  The US representative to the WHA, Dr. Nils Daulaire, opened his comments by stating, “The US views surgery as a basic part of healthcare delivery in every country.”  Via video message, Dr. Jim Kim, President of the World Bank stated, “Surgery is an indivisible, indispensible part of global health.”  Video from that meeting can be viewed on the Commission website (http://www.globalsurgery.info/video/) and all slide presentations here: http://www.globalsurgery.info/january-meeting-presentations/.

The official launch of the Lancet Commission on Global Surgery report will take place on April 27, 2015 at the Royal Society of Medicine in London, UK.   http://www.globalsurgery.info

 

The third edition of Disease Control Priorities was launch on February 5, 2015 in Las Vegas, NV, USA and features an entire volume on surgical care – http://www.dcp-3.org/volume/1/essential-surgery.

See the key Essential Surgery messages from the report – http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60091-5/fulltext.

 

Thank you.  We hope you will continue to contribute your voice!

Congratulations to all of you for this notable progress.  We are so grateful for your passion, commitment, and tireless advocacy on behalf of surgical patients around the world. And for the teamwork that has resulted in a united voice and a common message. A critical juncture now exists in the months leading up to the 2015 World Health Assembly to ensure that the concept of “access to safe surgery and anesthesia when needed” becomes ingrained as integral to quality global public health.

And keep in mind that the real work will be in implementing the resolution once it is passed (hopefully in May 2015).