Surgery Pushed to Center of Health Planning

Last year, a group of surgery specialists released a report in the medical journal The Lancet that shook the medical and health care world.

According to data they collected in 110 countries, 5 billion of the planet’s 7.5 billion people don’t have access to safe and affordable surgery. “Of the 313 million procedures undertaken worldwide each year, only 6 percent occur in the poorest countries, where over a third of the world’s population lives,” the report said.

Since 2010, lack of access to surgery in poor countries such as Cambodia has led to 16.9 million deaths—a third of deaths worldwide, easily surpassing the 3.83 million deaths due to HIV/AIDS, tuberculosis and malaria combined.

As the report notes, the price is high both in human and financial terms, as this may contribute to reducing poor countries’ economic productivity by $12.3 trillion between last year and 2030, cutting their potential economic growth by as much as 2 percent each year.

“Of all causes of death, 30 percent could be treated with surgery: That’s huge,” said Kee Park, a neurosurgeon who took part in the Cambodia Society of Neurosurgery’s annual meeting this month in Phnom Penh.

“Seventy percent of the surgical burden that is not met in developing countries is injuries,” said Dr. Park. “It’s different than surgical burden in high-income countries where it’s cancers and strokes and back pain and so on.”

“And the No. 1 cause for mortality from injuries in low and middle income countries is head injuries,” he said. The number of head and spine injuries brought to Preah Kossamak Hospital in Phnom Penh increases each year, said Dr. Park, who served as neurosurgeon consultant at that public hospital for three years.

“There are more cars on the road, the roads are better now; and—literally—people are getting run over left and right.”

The Lancet report, released in April last year, created such a stir in the field that one month afterward, the World Health Assembly, in which U.N.-member countries define the World Health Organization policy, unanimously approved a resolution calling for “Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage.”

The goal is to give 80 percent of the world’s population access to safe and affordable emergency access to 28 basic surgical procedures within 2 hours of their homes, Dr. Park said. “Right now, it’s less than 10 percent,” he added.

An initiative has been launched to help developing countries assess their needs in reaching that goal and, as part of the Harvard Medical School’s Program in Global Surgery and Social Change, Dr. Park is overseeing this initiative in Asia. Talks are now underway with the government of Cambodia to help the country evaluate the situation.

The initiative is also something of a feasibility study, taking into account existing resources in each country—Cambodia currently has only 23 non-foreign neurosurgeons. But victims of accidents who sustain head injuries do not necessarily need to crisscross the country to find a brain surgeon, Dr. Park said. With today’s technology, a mobile phone with a camera and fairly large screen could allow a surgeon in the provinces to consult with a neurosurgeon on call in Phnom Penh, he said.

Surgical services are currently limited mostly to public and private hospitals in Phnom Penh and urban centers such as Siem Reap City, Battambang City or Kampot City, with 300 or so Cambodian surgeons sharing their time between private and public hospitals.

Setting up basic surgical services in provincial hospitals, where staff, skills and equipment are severely lacking, is no small endeavor.

“Surgical services are the most important but also the least cost-effective and the most complex in terms of management in a hospital,” said a Cambodian medical specialist and public-health strategist who requested anonymity for fear of harming his relations with the Health Ministry.

“It takes a whole multidisciplinary team,” he said. “One cannot train surgeons in the hope that surgical services will then develop. You have to train anesthesiologists, nurses, hygienists for sterilization and so on.”

Any approach to increasing access to surgery would need to maximize efficiency using existing human resources, such as dividing the country into four regions and setting up four regional hospitals with full surgical services and medical facilities, the doctor said.

“To be realistic, one cannot approach public health strictly in terms of medical services,” he said. “One must have a blueprint, a business plan in mind…because it’s a matter of using available means and resources in the most effective way.”

While human resources are thin in essential areas such as anesthesiology, there are some positive trends—the University of Health Sciences (UHS) expects to see about 30 new anesthesiologists graduate by 2018.

But training the people who would make a major push to increase access to surgery possible remains a crucial challenge, and one that has only been made more difficult by recent shifts in foreign funding.

While the UHS now has sufficient Cambodian doctors and professors to teach students to become general practitioners, specialized studies, whether in anesthesiology, orthodontics or pediatric surgery, require foreign professors with expertise in the latest techniques and developments in the field, said Mam Bun Socheat, a heart surgeon and vice dean at the university.

France has helped the university bring in French professors as part of a doctor-training program launched in 1996 and coordinated by Claude Dumurgier, who said it has been a success.

“In 1996, there was no urologist in the country; now there are 22,” Dr. Dumurgier said. And they are highly qualified: For example, a prostate surgery performed by a Cambodian urologist a few months ago in Siem Reap City met with the highest international standard, he said.

The French program also included helping medical students obtain internships at hospitals in France. More than 300 doctors have undertaken internships in French hospitals since the 1990s.

The program’s 20th anniversary this year, however, was marked by France ending it. The nation is still indirectly giving money to Cambodia through the Global Fund to fight HIV/AIDS, tuberculosis and malaria, said Pascale Turquet, cooperation attache at the French Embassy. “This does not mean that one withdraws from the field of training, but a choice was made to opt for multilateral aid,” she said.

One French expert remains at the university. Aron Julien, part of the International Program and Skill Lab, works with students in a 3D simulation laboratory that the university has acquired.

“Those Cambodian students are fluent in both French and English…with open and critical minds,” Dr. Julien said. “This bodes well for the country and the future of its health care system.”

The university plans to continue calling on French and other foreign experts to teach in specialized fields, but this will have to be funded through the Cambodian government’s budget, Dr. Bun Socheat said.

There is currently no public data on the Health Ministry’s medical facilities and surgical capacity throughout the country.

Ministry of Health spokesman Dr. Ly Sovann declined to comment on the situation, saying this was not his field of expertise. Or Vandine, who heads the department of human resources, planning, health financing and hospital services at the ministry, could not be reached for comment.

Sok Buntha, president of the Cambodian Society of Surgery, said that foreign involvement in the field would remain essential, as human resources must be the first priority in efforts to improve quality and expand access to surgery.

“We lack surgeons in Cambodia,” Dr. Buntha said last week. “This is why continuing education and international cooperation is so important.”

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