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Improving Surgical Care Requires a Team Approach

Posted by plosmedicine on 31 Mar 2009 at 00:28 GMT

Author: Doruk Ozgediz
Position: Fellow in Pediatric Surgery
Institution: Hospital for Sick Children
Additional Authors: Robert Riviello
Submitted Date: August 23, 2008
Published Date: August 27, 2008
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

We could not agree more with Dr. Dunser: improved surgical care in Africa will require a team approach including not only anesthesia staff, but also nursing and other support services.(1) More attention must be paid to the workforce for surgery and perioperative services as a part of the global crisis in human resources for health.(2) The global volume of surgery is estimated to be more than double the number of childbirths—this volume, combined with significant disparities in the volume and distribution of surgical care, make surgery an important issue in global public health.(3) The recently launched “Safe Surgery Saves Lives” Initiative of the World Health Organization is taking a multidisciplinary approach to this global priority.(3) In many countries, there are even fewer physician anesthesiologists than specialist surgeons. For example, in Uganda, there are approximately ten Ugandan physician anesthesiologists for a population of 30 million people, and non-physician anesthetic officers provide almost all anesthesia services to the rural poor in district hospitals. Studies of surgical outcomes in similar settings have suggested that perioperative morbidity and mortality are significant.(4) Task-shifting of health services from physicians to mid-level providers has been advocated for the management of the HIV and TB epidemics in low-income countries, and similar principles should be applied to surgical care.(5) In some low-income countries, outcomes of surgical care have been comparable between mid-level providers and physicians.(6) A growing number of training and educational initiatives are slowly increasing the resources available to all health personnel, especially in rural areas, providing surgical and perioperative care to poor populations.(7) Though the provision of essential surgical care by non-physicians plays a critical role in delivering surgical services, it is not a complete substitute for training specialists. As regards physician training, teaching models from high-income countries may not be effective in more resource-constrained settings, though long-term partnerships between academic training institutions in high and low-income countries might be part of the solution. In some countries, non-governmental organizations provide essential surgical care through visiting surgical-anesthesia-nursing teams, though the collective contribution of this community is unknown.As clinicians working in these settings, we are struck by what seems to be a very high unmet need for surgical services—though the precise need is unknown. In addition to responding to this enormous demand for direct care provision, we also need to advocate for the integration of surgical, anesthesia, and perioperative services with ongoing initiatives in global public health.

1. Ozgediz D, Galukande M, Mabweijano J, Kijjambu S, Mijumbi C, Dubowitz G, et al. The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda. World journal of surgery. 2008;32(6):1208-15.

2. Ozgediz D, Riviello R, Rogers S. The surgical workforce crisis in Africa: a call to action. Bulletin of the American College of Surgeons. 2008;93(8):10-6.

3. Weiser TG, Regenbogen S, Thompson K, Haynes A, Lipsitz S, Berry W, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008 epublication June 25, 2008.

4. Fenton PM, Whitty CJ, Reynolds F. Caesarean section in Malawi: prospective study of early maternal and perinatal mortality. Bmj. 2003 Sep 13;327(7415):587.

5. WHO. Task shifting: global recommendations and guidelines. 2008 [cited; Available from:

6. Vaz F, Bergstrom S, Vaz ML, Langa J, Bugalho A. Training medical assistants for surgery. Bulletin of the World Health Organization. 1999;77(8):688-91.

7. Surgical Care at the District Hospital. 2003 [cited 2007 December 20]; Available from:

No competing interests declared.