Surgical care is a neglected part of public health in India, where millions of people lack access to timely, safe, and affordable surgery.
Status of surgical care
Globally, 5 billion people lack timely access to safe and affordable surgical care, with over a fifth of them living in India
11% of the global burden of disease requires surgical care or anaesthesia management or both. Some studies have estimated this burden to be as high as 30%.
The Lancet Commission for Global Surgery (LCoGS) - It estimated that 5000 surgeries are required to meet the surgical burden of disease for 100,000 people in Low and Middle Income Countries.
A research found that only 6.81% of need for major surgical operations was met for rural India.
13.6% of the institutional deliveries were c-sections falling within the WHO- prescribed range of 10-15%.
There were marked variations at state and district-levels and significant rural-urban differences for surgical rates and c-section proportions.
What are LCoGS Indicators?
New Zealand- In 2015, LCoGS researchers found that New Zealand, which has universal health coverage, had 5,000 surgeries per 100,000 people.
India-With a population of about 1.4 billion, the rate of surgeries in India is somewhere between 166 and 3,646 surgeries per 100,000, depending on the setting, population, and other factors.
Indicators- It has proposed indicators for Low and Middle Income countries.
Population- Within two hours of a surgical care facility (timely geographical access)
SOA density- The number of surgeons, obstetricians, and anaesthetists per 100,000 people
Surgical volume/rates- The number of essential and emergency surgeries per 100,000 people
Perioperative mortality rate- It is defined as a mortality within 30 days of surgery per 1,000 procedures
Population at risk of impoverishment due to seeking surgery
Population at risk of catastrophic expenditure (over 10% of their annual household expenses) due to seeking surgery.
Together, these indicators build a picture of surgeries as a part of healthcare at the population level and on the ground.
What are the concerns in the right to access surgery?
Right to surgery-Millions of children and adults around India, regardless of the severity of their condition, injury, need or affordability, are forced to treat the basic right of surgery as a luxury.
Regional disparity-More than 90% of rural Indians are estimated to not have access to surgery when required.
Poor accessibility- Many people are unable to reach the hospital on time due to poor road network, lack of vehicles etc., It is more prevalent in the rural, remote and hilly areas that together house more than two-thirds of the population.
LCoGS recommends that at least 80% of the population should be within two hours of a surgical facility.
Lack of manpower- The size of Surgeons, Obstetricians or Anaesthetists (SOA) workforce is small in several parts of India, especially beyond metropolitan and tier II cities and at crisis levels in rural public health system.
LCoGS suggests that there should be at least 20 SOA per 100,000 people.
High cost- The capacity to perform enough surgeries is also undermined by disparities based on where one lives, how much one is able to pay, etc.,
The met need for major surgeries is less than 7% in rural India.
Low quality and safety- The quality of surgical care determines whether someone will have safe outcomes. This depends on surgeons traning, equipment availability, and the presence of appropriate perioperative care. The mortality rate is a sensitive indicator of safety but data on perioperative mortality is heterogeneous and missing in several instances.
Absence of universal healthcare coverage- Due to limited surgical-care capability among public health facilities that provide free or subsidised care, the financial impact on people forced to seek care in private hospitals can be devastating.
More than 60% of surgery patients in rural India face catastrophic expenses and several thousand risk impoverishment.
Policy paralysis- India has no National Surgical Obstetric Anaesthesia Plan (NSOAP) or equivalent policy to address the surgical needs of the population.
What has been done by the government to plug the gaps in surgical care?
Plug systemic gap- India’s current surgical system gets by on civilian initiatives and subnational programmes including countless surgeon-led small private establishments and government teaching and public district hospitals.
Rural surgeons- They have gathered under Association for Rural Surgeons of India to offer
Emergency and trauma care
Free ambulance services in multiple states
Improved accessibility- Society for Education, Action, and Research in Community Health (SEARCH) and Jan Swasthya Sahyog (JSS), serves tribal populations in difficult-to-reach areas.
Improved research- Individual surgeons working on technological innovations and groups such as Global Surgery India Hub, which strengthen research networks, have also contributed to improving surgical care.
What lies ahead?
The need of the hour is to consider surgical care accessibility, reduce preventable disease burden and the economic toll on surgery in the mainstream public health.
India needs National Surgical Obstetric Anaesthesia Plans like the countries in Africa which would strengthen the surgical care capability.
India should focus on investments in data for monitoring and evaluation of surgical care indicators which would integrate surgical care to make the country global health capital.
Strengthen the primary health care system and integrating surgical services at all levels of health care delivery and increase the training and deployment of SOA, especially in rural and remote areas1.
Providing universal health coverage and financial protection for surgical patients1.
Implementing standard protocols and guidelines for surgical care and monitoring the outcomes and indicators.
