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Surgery can save more lives than some diseases take

- Deborah Minors

A Zambian surgeon has driven the adoption of a World Health Organization resolution to make surgery accessible as a component of universal health coverage.

Dr Emmanuel M. Makasa delivered the prestigious AJ Orenstein Lecture in the Faculty of Health Sciences and hosted by the Adler Museum of Medicine on 30 August 2016.

His lecture, entitled: The cutting edge: Towards universal health coverage and sustainable goals, focused on the need to invest in surgery and anaesthesia as a means to achieving universal health coverage, and his efforts – and success – in securing a World Health Organisation resolution towards achieving this.

The day before the AJ Orenstein Lecture, the Department of Surgery at Wits submitted an article to Lancet Global Health, entitled: The pathway to equitable access to surgical care in South Africa: setting an agenda of research and implementation based on messages from the first National Forum.

The National Forum on Surgery and Anaesthesia South Africa (NFSASA) and the Lancet Commission on Global Surgery were launched at the University in December 2015.

A surgeon cut out for diplomacy

Makasa is an orthopaedic and trauma surgeon. He earned an MBChB and MMed in Orthopaedics and Surgery from the University of Zambia and an MPH in Global Health Epidemiology from the University of Alabama at Birmingham.  

As former Deputy-Director: Emergency Health Services in the Ministry of Health in Zambia, Makasa was tasked with setting up emergency health services in Zambia.

“We were very under-resourced. We realised the surgical burden of disease is huge, in Zambia and elsewhere,” he says.

This and his experience as secretary general of the Zambia Medical Association and of the Surgical Society of Zambia respectively equipped him for his ultimate crusade: that of a global health diplomat intent on putting essential surgery and anaesthesia on the universal healthcare agenda.

“Most global healthcare programmes are specific – TB or HIV. Surgery is not a disease but it doesn’t support just one thing, it supports everything,” says Makasa.

Surgery as a primary healthcare imperative

In 2010 Makasa began gathering evidence at country level to make a case for surgery as a primary healthcare imperative. This situation analysis was partly in response to Zambia’s inability to meet the maternal healthcare targets of the Sustainable Development Goals (SDGs).

“Most mothers were dying because of matters relating to surgery, such as bleeding and post-partum complications,” says Makasa.

Furthermore, Zambians were dying in road traffic accidents because the emergency response was too slow or hospitals and emergency services only available at tertiary level.

“Sometimes, in road traffic accidents, if you don’t get help in 30 minutes, you die,” he says.

Although surgery is a high-impact intervention, Makasa found that the capacity to deliver it was limited to predominantly tertiary hospitals, which housed both skills and facilities. In addition, the surgical disease burden would potentially amount to a 1.8% loss in the GDP per annum by 2030. 

“Improve surgery at a district level and productivity will improve.  If you invest in surgery, then outputs from other healthcare programmes are more successful,” says Makasa.

Universal Healthcare and the Sustainable Development Goals

In 2011 Makasa took up a post at the United Nations, where he is now Counsellor – Health, Permanent Mission of the Republic of Zambia to the UN. The Zambian model made a strong case for the role of surgery and anaesthesia in universal healthcare and contributing towards several SDG targets.

“Surgery is a missing piece, a master piece, of primary healthcare and we have to bring it closer to the people,” says Makasa.

In his role as global health diplomat, Makasa motivated and orchestrated a place for surgery on world health agendas. He was a member of The Lancet Commission on Global Surgery which published a report: Essential Surgery. The report made a case for surgery and the economics of surgery. The World Bank Group published it in a reference book:  Disease Control Priorities in Developing Countries. These publications systematically assess the cost-effectiveness of interventions that would address the major sources of disease burden in low- and middle-income countries.

“There are economic benefits to improving surgical and anaesthesia capacity,” he says.

Makasa subsequently chaired and led the global intergovernmental negotiations that resulted in the adoption of the first ever World Health Organization resolution) on to address: Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Agenda item 17.1 was tabled at the 68th World Health Assembly on 26 May 2015.

WHA68.15, Agenda item 17.1

WHA68.15 is a political commitment to strengthen specific surgery and anaesthesia interventions to attain universal healthcare. These types of surgeries include cataracts, abscess drain, circumcision, hernia, etc.

“These could be done by a surgeon, a paramedic, or a GP with surgical skills. It’s about the service, not the person,” says Makasa.

Although SDG 3 is the main goal that surgery will address, as it relates to maternal health and child mortality, the resolution also impacts goal 3.6, which relates to deaths from injuries and road traffic accidents.

The resolution also addresses aspect of SDGs 1, 2, and 10, which related to alleviating poverty, hunger, and inequality respectively, because people whose lives are saved by surgery are empowered to work and become self-sustaining and productive. SDG 9 (industry, innovation and infrastructure) is addressed as the resolution on surgery requires the establishment of services and facilities where they are accessible. SDG 19 (partnerships for the goals) requires a strong commitment to global partnerships and cooperation – a goal to which WHA68.15 has clearly contributed.

Makasa’s next mission is to ensure that WHA68.15 moves beyond mere political commitment. This requires him to ensure there is a budget line for the implantation of WHA68.15 in the “people-centred health service delivery” category of the WHO’s Programme Budget 2020–2019.

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