Surgical equity

16.9 million lives were lost from conditions requiring surgical care in 2010

Unrecognised need

Until recently, surgery was not recognised as a significant contributor to the global disease burden and was not a top priority in the eyes of global public health agencies. But recent estimates from The Lancet claim that five billion people lack access to safe and affordable surgical services.

Five billion people cannot get safe and affordable surgical and anaesthesia care, 90 per cent of people in LMICs can’t even get basic surgical care

Jim Yong Kim MD, PhD, 12th President of the The World Bank

Five billion affected

Many surgical needs are unmet. The landmark Lancet global surgery report (see following page) estimates that there is demand for an additional 143 million surgical procedures each year. This unmet need contributes up to 30 per cent of the global burden of disease and, if met, could address 25 per cent of all treatable disabilities. 4.7 million deaths could be prevented each year, a figure that exceeds the mortality rates of HIV/AIDS, tuberculosis and malaria combined. Figures vary, but he WHO estimates that there were 16.9 million premature deaths due to lack of safe surgical care in 2010.

Lack of surgeons

The surgical capacity of the developing world is low. There are roughly 0.5 surgeons per 100,000 people in the developing world and five times fewer within sub-Saharan Africa. For comparison, Austria has almost 98 surgeons per 100,000 people. Surgeons trained abroad will often learn on equipment that will not be available to them locally. Many will decide not to come back to their country of origin.

Basic surgeries such as setting broken bones or delivering babies via cesarean section are among the most cost-effective health interventions in developing countries

The World Bank

Redesigning surgery around local resources

Local adaptations

Rural hospitals often do not have running water, stable electricity sources or access to roads. Resource shortages mean that crucial equipment and supplies (such as medical oxygen) are either reused or unavailable, anaesthesia cannot be provided and hospitals depend on the help of non-specialists. Let’s redesign surgical care in poorer countries from the ground up instead of trying to adapt the solutions found elsewhere. We should use local talent, transport links and build upon existing resources to create materials, tools and approaches to surgery that are innovative and suitable for local communities.

Financial barriers

Seeking surgical care has disastrous financial consequences for over 80 million people and their families every year, nearly 60 per cent of who face a ‘catastrophic health expenditure’ due to non-medical costs, such as reaching the surgery in the first place.

Challenge Prizes

The Challenge Prize Centre at Nesta wants to steer the discussion towards improving the access to and capacity of surgery in developing countries. Prizes are powerful tools for incentivising the creation of longterm solutions to social challenges by stimulating new enterprise and endeavour.

Global Surgery 2030 The Lancet commission on global surgery report

Key Messages

• Five billion people lack access to surgical and anaesthesia care. • 143 million additional surgical procedures are needed annually. • 33 million people face catastrophic health expenditure. • Investment is affordable, saves lives, promotes economic growth. • Surgery is an indispensable part of health care.

2030 Targets

• Access to surgery: minimum of 80 per cent national coverage. • Specialist workforce: minimum of 20 per 100,000 people. • Surgical volume: minimum of 5,000 procedures per 100,000. • Tracking of surgery-related mortality rates.

• Protection against impoverishing and catastrophic expenditure.

1. Postoperative infections

How can we minimise postoperative infection? Infections have plagued recovery since the inception of surgery. Postoperative infections complicate up to 25 per cent of all treatments in resource limited settings, and are the largest cause of hospital acquired infections in low and middle income countries. Infections can double the length of hospital stay and add financially devastating costs to patients, facilities, and health systems. Furthermore, patients who develop infections have a much higher risk of dying. While infections will be difficult to eradicate, they can be reduced dramatically if critical standards of infection prevention and control are maintained before operation, during operation, and after operation. These standards include the How to increase access to safe blood transfusions? Haemorrhage - an escape of blood from a ruptured blood vessel - is the surgeon’s most feared calamity. Haemorrhage control and meticulous technique is the role of a skilled surgeon, however blood loss continues to plague operations even when they seem to have gone well. Replacing blood volume is essential to a high-functioning hospital, particularly one with surgical capacities ranging from caesarean delivery to cancer and trauma care. Blood banking is complex and requires sophisticated processes to collect and store whole or component parts such as plasma, red cells, and platelets, and assure that these products are screened for infectious diseases and are safe for transfusion. Procuring and storing blood also has profound cultural assurance of sterility of the operating room environment and instruments, the appropriate and judicious selection and timing of antibiotics, the maintenance of normal body temperature during surgery, supplemental oxygen therapy, and the appropriate decontamination and preparation of the surgical site. Due to process breakdowns, lack of communication, poor operating theatre resourcing, inconsistent power and autoclave functioning, limited knowledge of local organism antibiotic susceptibility, and poor water quality, the ability to deliver on these well documented standards is frequently absent. Each of these challenges represents an opportunity for innovative solutions that could take the form of both products and services dealing with infections or improving on their

3. Blood banking and transfusions

management. implications, as many cultures relate to blood in ways that go beyond its medical use. Current blood banking systems can be stretched during times of crisis and mass casualty. Prior work investigating blood substitutes have been disappointing, and the ability to transform the way facilities procure, store, and transfuse blood could revolutionize care around the world. Innovations in this space range from tech-driven drone delivery systems to ‘walking’ blood banks, i.e. community-centered blood banks pioneered by militaries using fellow soldiers as a source for warm, whole blood. Tech or not, leveraging all available resources will require overcoming a number of process and protocol challenges.

2. Safe anaesthetic care

How could we adapt anaesthetic machines and procedures to deliver better care in low resource settings? Prior to the first use of ether, surgeons were known more for their speed and determination than for skill. Surgery has become exponentially safer since the dramatic improvements in anaesthesia over the last 40 years. Starting with the standardisation of anaesthetic machines, engineered safety features, and monitoring standards pioneered by anaesthetic professional organisations, mortality from anaesthesia is a fraction of prior rates. However, this improvement is not universal across the countries and regions. What should we focus on in improving the operating suite? While skills, teamwork, and standards all play an important role in improving surgical and anaesthetic delivery and care, the operating theatre is a domain that continues to drive the need for improved technology and innovation. From early improvements in instruments, to minimally invasive ‘keyhole’ and catheter-based surgery, to robotic surgery, devices have revolutionized operative techniques. This has translated into faster recovery, reduced pain, longer life, and lower complication rates. Yet these improvements are not universally available and many surgical theatres in LMICs do not fulfil the most basic requirements of surgical and anaesthetic interventions. Lighting, power, Anaesthesia-attributable mortality in resource poor settings is still hundredsfold higher than in high income countries, and the opportunities to improve training, monitoring, anaesthetic delivery, access to oxygen and medications cannot be overstated. Operations vary dramatically, but anaesthetic principles can be widely applied for the benefit of the patient, and with profound positive consequences for patients everywhere. There is an urgent need for affordable machines and procedures that are customized for low resource settings including equipment that can function with little

4. Operating theatre technologies

or no access to mains power. suction, water, oxygen and sterilisation are all essential components of a functioning facility, but are frequently absent or unreliable. For example, a third of LMIC hospitals lack reliable access to oxygen. Many solutions to these challenges exist, but are not available due to poor market demands, prices, procurement and logistics. Design flaws that ignore the realities of the environments into which they are introduced can be also a factor. Some contextappropriate devices are already having effects on care, from pulse oximeters for use during anaesthesia to portable solar power storage to ensure a night’s-worth of electricity. If these devices can be built, delivered, maintained, and integrated into the work and function of health facilities they could improve the surgical capacities of hospitals in LMICs.

Data for good

We have yet to fully make use of the digital revolution and distribute its benefits - fairly and inclusively - to people around the globe.

At a time when big data and AI are seen as an answer to many problems of the future, having access to information will become a privilege - and a growing divide. We want to empower people with the means and skills necessary to gain access to information, make sense of it and use it to benefit to them and their communities.

An inclusive vision for the future and challengedriven innovation will ensure that the Information Age is an age for us all.

Workshop facilitators

Lead facilitator

Harry Atkinson

Digital Content and Entrant Manager, Challenge Prize Centre, Nesta

Chris Gorst

Lead, Fintech Prize, Challenge Prize Centre, Nesta

Simona Bielli

Head of Programmes, Nesta Italia

Ricardo Santana

Project Manager, Challenges of our era summit, Nesta

Richard Duffy

Foresight Researcher, Challenge Prize Centre, Nesta

Our partners