Strengthening Surgical Systems: The 2023 Kids Operating Room Global Report

Strengthening Surgical Systems: The smartest investment in Global Health

Global Report 2023

Kids Operating Room

Authors

Garreth Wood

Nicola Wood

David Cunningham

Maíra Fedatto PHD

Special Thanks to

Emma Bryce MPH

Maija Cheung MD

Ava Yap MD

Madeleine Carroll MD

Centre for Health Equity in Surgery & Anaesthesia – University of San Francisco California (CHESA/UCSF)

CHU Pédiatrique Charles De Gaulle, Burkina Faso

Menelik II Hospital, Ethiopia

Muhimbili National Hospital, Tanzania

National Hospital Abuja, Nigeria

Design by Sam Calder

Foreword from KidsOR Chairman, Garreth Wood

Good patient outcomes, accessibility, affordability and availability are core components of a wellfunctioning health system. Surgery is the service that cuts across many treatment scenarios in all health systems, including non-communicable diseases such as cancers, trauma and maternal and child health conditions. Yet in low- and middleincome countries (LMICs), 90% of people cannot access the surgical care they need as surgery has been stereotyped as too complex, too expensive or having too limited a role to play in treating the global burden of disease. In other words, health systems across LMICs are restrained in their capacity to function, in no small part, because they lack comprehensive surgical care.

When we look at global health rhetoric, there is a clear distinction between what is said and what is done. Many global health actors focus their message on the importance of strong and resilient health systems to achieve international goals such as Universal Health Coverage (UHC) and many of the Sustainable Development Goals (SDGs). The World Health Organization (WHO) supports this approach, recognising the key role of safe surgical care to achieve these goals. However, resources, funding, and agendas continue to go elsewhere; typically concentrating on diseasebased interventions while ignoring how the epidemiology of disease has changed in

many LMICs - meaning global health funding increasingly disconnects from local wishes, local priorities and the local people who are meant to benefit.

At Kids Operating Room we have shown that world-class surgical care can be delivered by local teams in local hospitals, giving their populations the care they need and want. It can be done extremely cost-effectively, and it can help deliver many of the necessary building blocks of a functioning health system.

While world leaders have repeatedly recommitted to reduce childhood morbidity and mortality and ensure child survival, to do so without full consideration of the subsequent demands on health systems has been negligent. The increasing surgical burden on children’s health globally is being ignored and this must end to prevent countless, needless deaths. Surgery is an inexpensive, indispensable part of, and integral component of, a functioning health system. The burden of disease has changed in low-resource settings. The leading funders of global health need to accept that more of the same isn’t working. It’s time to walk the talk and create strong and robust health systems. And the data is clear, surgery delivered by skilled local teams is the best place to start.

Above: A life-changing operation takes place in a KidsOR Operating Room. Mulago, Uganda.

Introduction

The patterns of disease in low- and middleincome countries (LMICs) are changing rapidly. This epidemiological transition has resulted in a largely increased prevalence of death and illness now attributable to noncommunicable diseases (NCDs) and injuries. Non-communicable diseases account for 71% of all deaths globally and the highest risk is seen in LMICs in sub-Saharan Africa1

Surgical care must be seen as crucial for any strategy to address the global burden of disease, as 30% of deaths worldwide are attributable to surgically amenable causes, including NCDs and trauma2

According to the World Health Organization (WHO) no country is on track to achieve the objectives of the global action plan for the prevention and control of NCDs3. Likewise, the world is falling short on the Sustainable Development Goals (SDGs). Undeniably, global health efforts have successfully decreased global mortality over the past decades through investments in disease-specific programmes. However, the observed epidemiological transition has created a need for developing robust, accessible and resilient health systems. Only by doing this can we challenge the growing NCD burden as well as sustaining effective disease-specific interventions.

In the mid-2000s, the health systems strengthening (HSS) concept emerged on the global health agenda. The WHO published its framework describing a health system in terms of six core components or ‘building blocks’: service delivery; health workforce; health information systems; access to essential medicines, vaccines and new technologies; financing; and leadership/governance4. An efficient health system should be able to deliver effective, preventive and curative health

services to the full population, equitably and efficiently, while protecting individuals from catastrophic health care costs5

Surgical and anaesthesia care are needed at all levels of a health system. They rely on the development of health systems infrastructure and so can be considered an indicator of health system readiness. Improving surgical care not only provides a scalable path to strengthen health systems in multiple domains but has a huge potential to reduce mortality and morbidity.

Kids Operating Room is a global health charity working to provide every child with access to safe and quality surgery. This report illustrates how investment in surgical and anaesthesia care is central to supporting health systems strengthening in each of the six building blocks. Surgical and anaesthesia care overlap with the health needs of every child as well as with other global priorities such as maternal health and pandemic preparedness.

Improving access to surgical and anaesthesia care is recognized by all United Nations’ member states as an indispensable part of health systems strengthening and a key step towards the achievement of the Sustainable Development Goals. But one question remains: what is the smartest way to improve access to surgical care? With 27% of the world’s population under 15 years of age, improvements in child health have a large and multidimensional impact. This ranges from social benefits such as school and educational attainment and economic benefits to countries in terms of a healthy future labour force 6 .

Investing in children’s surgery is the smartest intervention in global health.

The WHO Health Systems Framework

System Building Blocks

Service Delivery

Health Workforce

Health Information Systems

Access to Medical Products, Vaccines & Technologies

Quality

Safety

Financing

Leadership / Governance

Coverage

Access

Overall Goals / Outcomes

Improved Health Responsiveness

Social and Financial Risk Protection

Improved Efficiency

“When you invest in surgical services, you get more bang for your buck than any other investment in health care … Strengthening surgical care strengthens the entire health system and contributes to better health outcomes in all departments. Our focus is making available a safe and affordable surgical health care service that must be well-integrated and contribute to the overall health strategic plan and development of a country”

Professor Emmanuel Makasa

Health Systems Strengthening and Surgery

Famed social justice and global health equity advocate, the late Dr. Paul Farmer, coined surgery as the ‘neglected stepchild of global health’ despite being fundamental to the care of treatable conditions that account for around 30% of the global burden of disease. Despite vast evidence that the cross-cutting nature of surgical care impacts a wide variety of diseases and conditions, there has been little discussion on how strengthening surgical services can address the six major building blocks of a strong and resilient health system.

Surgical and anaesthesia care is an integrated platform for delivering timely health services for acute illness and injury. It cannot be treated as an optional extra function of health-care systems.

In 2015 the Lancet Commission on Global Surgery urged countries to integrate surgical and anaesthesia care as an integral component of health care and health systems. They recommended the implementation of national surgical, obstetric and anaesthesia plans (NSOAPs), and the proposed framework was founded on six areas adapted from the WHO HSS building blocks7. This transformational approach seeks to guide surgical care development towards a health system strengthening approach. However, donors’ funding and decision-making agendas remain concentrated on disease-based improvements despite evidence against this approach. Multi-sectorial systems strengthening is needed to achieve Universal Health Coverage (UHC), which is a top priority of both the United Nations, WHO and those LMICs who will benefit. UHC was included in the Sustainable Development Goals as a key part of the SDG

3.8 target that aims to “achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality and affordable essential medicines and vaccines for all”. The role of safe surgery and anaesthesia goes beyond ensuring good health and wellbeing (SDG 3), as seen below:

Surgical disease is inadequately addressed globally, in LMICs and in sub-Saharan Africa in particular. Surgically treatable conditions contribute substantially to the global burden of disease. Despite emergency and essential surgical and anaesthesia care being at the core of a functioning health system, 1.75 billion children, 87% of which live in LMICs, continue to lack access to high-quality, affordable, timely and life-changing surgical care.

Adjunct Professor of Global Surgery and the Founding Director of the Southern Africa Development Community’s University of Witwatersrand Regional Collaboration Centre for Surgical Healthcare Improvement.

WHO Building Blocks and NSOAP Pillars

Service Delivery

• Surgical Volume

• System Coordination

• Quality & Safety

Service Delivery

Workforce

• Surgical, Anesthetic, Obstetric Providers

• Allied Health Providers

Information Management

• Information Systems

• Research Agenda

Infrastructure

• Surgical Facilities

• Facility Readiness

• Blood Supply

• Access & Referral Systems

Access to Medical Products, Vaccines and Technologies

Financing

Health Workforce Financing

• Health Financing & Accounting

• Budget Allocation

Health Information Systems

Governance

• Leadership & Management

Leadership/ Governance

“We cannot address the ever-increasing, unsustainable costs of health care without getting to the foundation of how care is provided. Nor can we achieve the social and moral goals we share – care that is safe, appropriate, effective, and high quality for every patient, in every community – without rethinking and redesigning delivery.”

Jim Yong Kim, MD, PHD

Service Delivery

Good health service delivery, as defined by WHO, means providing effective, quality and safe care – either prevention, treatment or rehabilitation – to the entire population. It is important that services are based on the population’s health needs and consider contextual factors such as funding, staff, medicines and supplies.

Infrastructure and logistics as well as patient safety and quality of care are the core of the service delivery building block. KidsOR creates surgical capacity through the provision of dedicated specialist facilities and equipment to positively impact how surgical services are delivered in our partner countries.

To ensure that our paediatric surgical intervention produces real impact on service delivery, our strategy and action plans are developed through intensive research and extensive consultation with Ministries of Health, surgical colleges and front-line physcians. Likewise, relevant nongovernmental organisations and other providers are taken into consideration to avoid duplication and fragmentation of services. Understanding structural barriers that exist in accessing surgery, including cultural and financial challenges, is key in identifying gaps as well as responding to opportunities and meeting specific needs.

Enabling surgical service delivery: An impact study from Burkina Faso

Our local capacity building approach has been shown to be very effective in enabling surgical service delivery at partner hospitals, especially in surgical volume and peri-operative mortality rate, the main indicators of an effective service delivery. Quality and safety are prioritised as we recognise that increased surgical volume will only achieve health and economic wellness if procedures are of high quality.

CHU Pédiatrique Charles De Gaulle (CHUP CDG) in Burkina Faso is the only hospital in the country specialising in paediatric surgery. KidsOR upgraded three Operating Rooms at CHUP CDG in September 2019, ensuring safe and highquality spaces with specialised paediatric surgical and anaesthetic equipment.

Physician and anthropologist. 12th President of the World Bank Group, co-founder of Partners in Health and former director of the World Health Organization’s HIV/AIDS department.

Increasing effective service delivery: An impact study from Ethiopia

Opening a dedicated paediatric Operating Room in Menelik II hospital, Addis Abba led to a 2.7 fold increase in operations. There were 113 operations in the 7-months pre-installation compared with 307 operations in the 7-months post installation. The increase in surgical procedures also meant that more congenital anomalies were treated.

Congenital anomalies are medical conditions that children are born with and have significant social and economic impact.

The significant impact of this increase in treatment can be measured using Disability Adjusted Life Years (DALYS), which quantify the years of healthy life lost due to premature death or disability. Following the installation, total DALYs averted increased 4-fold, showing the long-term impact of this intervention on the children accessing surgical services.

Post-Install

44 Monthly Operations

Pre-Install

1,232

DALYs Averted

Pre-Install

16 Monthly Operations

Post-Install

4,859

DALYs Averted

Ethiopia - 1 Operating Room

“The number of trainees and paediatric surgeons goes up every year. And they will be the voice of advocacy for paediatric surgery. It’s very well having an operating room, but you do need it staffed. And once staffed, they will (also) be advocating for improvements in care. The key is always people”

Dr. Eric Borgstein

Health Workforce

Worldwide, countries often face health workforce challenges and shortages, which have been further magnified by the COVID-19 pandemic. A global pulse survey published in February 2022 by the WHO revealed that the lack of available health workers was the main constraint to ensuring the delivery of essential health services during the pandemic. In total, 92% of countries reported disruptions in at least one essential health service. Elective surgeries were disrupted in 59% countries while emergency, critical and operative care in 38%8

It is therefore clearer than ever that an equitably distributed, skilled and motivated health workforce is key to achieve global goals such as UHC and the successful delivery of essential health services.

A well-trained and motivated health workforce leverages health, social, gender equality and economic benefits. In addition, scaling up the surgical workforce can potentially prevent over 500,000 deaths annually of under-5 children9.

Case-study: Paediatric Surgical Workforce Density in sub-Saharan Africa Paediatric

Paediatric surgeon and Professor of Surgery at the University of Malawi College of Medicine.

Sustainably building the paediatric surgical workforce

To complement our work installing Operating Rooms, KidsOR is funding paediatric surgical training in collaboration with number of partners, most notably Smile Train. There is a significant lack of paediatric specialist surgeons in LMICs, especially in sub-Saharan Africa (SSA) where many countries have a low Paediatric Surgical Workforce Density (PSWD). Our Africa 2030 strategy highlights our funded scholarships in partnership with COSECSA and WACS, and so far, our program has seen 11 paediatric surgical graduates who joined the paediatric surgical workforce in countries across Africa including Tanzania, Burundi and Ethiopia.

The Lancet Global Surgery 2030 report recommends that each country scale up their surgical workforce to 20 surgical providers per 100,000 population by 2030, a goal that KidsOR is committed to support alongside our various partners

Scholarship Graduates

Total Paediatric Surgeon Graduates since the start of the training program

“Good data provides the basis for process and outcome evaluation as necessary initial steps towards surgical quality improvement. The availability of a robust health information and data system also provides the data to support planning resource allocation and generate evidence-based policies to advance care.”

- Prof Emmanuel Ameh Professor & Chief Consultant Paediatric Surgeon at National Hospital Abuja, Nigeria

Health Information Systems

The health information system building block has four key functions: 1) data generation; 2) compilation; 3) analysis and synthesis; and 4) communication and use. It is fundamental to inform the delivery of evidence-based healthcare, strategic service planning, allocation of resources, and policy making. However, few LMICs’ health information system have the capacity to gather, synthesize information and promote reliable and timely information.

The World Health Assembly Resolution 68.15 ‘strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage’ urged Member States to improve data collection, monitoring and evaluation for policy and decision-making.

Evidence-based plans and policies need to be implemented to ensure the successful expansion of access to essential surgical services. Monitoring and evaluation are necessary to ensure and sustain both improved access to surgical services and their quality and safety. Proper surgical records and adequate followup are crucial to ensuring safe procedures and their monitoring. (World Health Organization).

KidsOR’s Global Data Program is the largest, multisite, multi-country and multi-disease paediatric surgical database for LMICs in the world.

KidsOR’s Paediatric Surgical Data Program is simultaneously a monitoring and evaluation tool and a pillar of KidsOR’s global intervention itself. The program provides data analysis capabilities and research capacity building at partner hospitals, working with the primary researchers at each facility to develop the databases. The information captured includes important data points such as age, diagnosis, type of surgeon performing the procedure, socioeconomic factors, trainee presence and occurrence of surgical site infection.

The paediatric surgical databases established at each partner hospital are an integral tool in strengthening surgical systems. To ensure their long-lasting impact, a strategy is being piloted where the continuation of these health information systems is transitioned to the local surgical teams with the support of their local affiliated university or hospital research teams.

The Health Information system building block has four key functions:

InformationHealthSystems

Access to Medical Products, Vaccines and Technologies

Access to vaccines, medicines and other health products and technologies is unequal across the world and pose an enormous economic burden on health systems and households in LMICs10. Policies to enable this access is crucial to achieve the Sustainable Development Goals, in particular target 3.8 of achieving UHC.

The treatment of disease of any kind is highly dependent upon proper access to health products for prevention, diagnosis, treatment, palliative care and rehabilitation11. In surgery, access to anaesthetic, pain medications and consumables is fundamental. It has been observed that shortages of surgical consumables such as catheters, sutures and cannulas, contribute to the lack of access to safe surgical care12. Although supply chains can be complex, fragmented and multi-factorial, their consideration is needed to enhance health system efficiency, accessibility, and performance.

Recognising that analgesic and anaesthetic medications are a fundamental component to surgery, in 2013 the WHO published a list of specific medications that should be widely available in surgical settings.

As part of our data collection program at KidsOR, we capture information on types of anaesthesia used and the type of anaesthesia provider present for each operation. We also capture the availability of anaesthetic, pain and antibiotic medicines which allows for greater understanding within this fundamental building block in surgical systems. This information has an important use in advocating for essential medicine supply strengthening within surgical services around the world.

When it comes to new technologies, the clinical benefits of laparoscopy are welldocumented and include lower infection rates, shorter hospital stays, and decreased postoperative pain. However, implementation can be complex and requires rigorous assessment. Laparoscopic procedures are technically more challenging and can lead to varying complications. Laparoscopy requires a greater number of consumables as well as specialised equipment and necessitates advanced training for surgeons and anaesthesiologists alike. To date, KidsOR has provided laparoscopic equipment to six sites.

Dr Zaitun Bokhary is a paediatric surgeon at Muhimbili National Hospital and the president of the Women’s Medical Association of Tanzania and explained the challenges regarding laparoscopic equipment. Dr Zaitun highlighted that no specific training was available in Tanzania and the hospital had to partner with several international stakeholders since all the staff involved with laparoscopic surgery needed meticulous tutoring. Maintenance was also flagged as a significant challenge.

‘Laparoscopic surgeries at Muhimbili National Hospital have increased capacity building. I learned from doctors [coming from abroad] and now I am teaching (…) But there are some challenges and challenge number one is the training’.

“Lack of drugs delays the management of patients and their correct management, another obstacle to the optimal management of patients in developing countries is the use of drugs known to have significant side effects. Indeed, safe anaesthesia means using effective drugs with few side effects.”

-Dr Bertille Kélan Ki

Head of Anaesthesia and Intensive Care Department at Centre Hospitalier Universitaire Pédiatrique Charles de Gaulle in Burkina Faso

Access to Medical Products, Vaccines and Technologies

Anaesthesia Drug Availability:

When looking at 25,889 records across the KidsOR database, 95% had the necessary anaesthesia equipment and/or medicines during operations. However, 5% did report some anaesthesia resources missing during operations.

95% Not Missing

5% Missing

When looking at operations that did report anaesthesia resources missing, medication was the highest reported resource missing.

41 Oxygen

47 Blood

575 IV Fluid

96 8 Medication

Financing

According to the WHO, a sustainable health financing system needs to ensure adequate funds not only to provide quality services but also to protect patients from financial catastrophe or impoverishment. Additionally, UHC states that all individuals should receive health services without suffering financial hardship.

Despite vast evidence on the critical need for surgical care and on the health and economic benefits seen from scaling-up surgical services, national governments and external funding bodies have not secured appropriate budgets to strengthen health systems. Inadequate financing is as much a barrier as poor infrastructure and insufficient surgical workforce. Earmarked funds to disease-specific interventions have been prioritised by donor countries and institutions for decades while ignoring the shift in the epidemiology of LMICs.

This shift in disease burden has been observed for the last 25 years in both low-income countries (LICs) and LMICs. While communicable diseases (CDs) such as HIV/ AIDS, malaria and tuberculosis remain, their prevalence has steadily decreased. Meanwhile, non-communicable diseases (NCDs) such as hypertension, diabetes, cancer and injuries have increased in prevalence and are seen as the fastest growing disease category worldwide. This shift is referred to as an epidemiologic transition.

Given that 86% of premature deaths from NCDs occur in LMICs13, development assistance for health (DAH) should be allocated with careful attention to these changing patterns of disease prevalence and the corresponding treatment, prevention and management strategies. However, this has not been seen in the case of NCDs, including surgical care, which is critic to address most non-communicable diseases.

2.5 billion

2 billion

1.5 billion

1 billion

500 million

“Safeguarding people’s health relies on resilient health systems that ensure everyone has access to the good-quality services they need, without facing financial hardship (...) Health expenditure must be seen not simply as a cost, but as an investment in health security, productivity, and inclusive economic growth.”

-Dr. Tedros Adhanom Ghebreysus WHO Director-General

Total Disease Burden by Cause, World, 1990 to 2019

Total disease burden measured by Disability-Adjusted Life Years (DALYs) per year. DALYs measure the total burden of disease - both from years of life lost due to premature death and years lived with disability. One DALY equals one lost year of health life.

Communicable, maternal, neonatal, and nutritional diseases

Non-communicable diseases (NCDs)

source: Our World in Data; IHME Global Burden of Disease (2019)

Paediatric Surgery: A good investment

The WHO states that investing in surgery is cost-effective and our studies provide concrete evidence of this. Cost-effectiveness analyses were conducted at two KidsOR sites in Uganda and Nigeria. These two sites were chosen because they were distinct in their pre-installation surgical capacity and patient population.

In Uganda, the hospital had no children’s surgical capacity before installation and cases were predominantly emergent, life-saving cases, while in Nigeria the hospital had a pre-existing children’s surgical service and saw predominantly elective cases. From the KidsOR perspective which includes donated equipment and installation, the cost to save a year of healthy life was US dollars $6.40 in the Ugandan site and $77 in the Nigerian site.

From the societal perspective, which includes local healthcare and patient resource utilisation, the cost to save a year of healthy life is $37 in the Ugandan site and $152 in the Nigerian site.

These numbers are well below each country’s GDP per capita and is also substantially lower than other well-accepted healthcare interventions. Main reasons for the higher cost to save a year of healthy life at the Nigerian site are threefold: 1) two operating theatres installed in Nigeria versus one in Uganda, 2) a higher proportion of life-saving cases performed in Uganda, and 3) a lower life expectancy in Nigeria means less years of life saved per case.

Leadership/Governance

The WHO Framework on Health Systems

Strengthening defines the leadership and governance building block as ‘the role of the government in health and its relation to other actors whose activities impact on health’14 Likewise, the World Health Assembly in 2015 requested the WHO’s Director General to ‘foster multisectoral networks and partnerships, multidisciplinary policies and action plans, and support national, regional and global efforts to develop science-based approaches to prevention, screening, and implementation of emergency and essential surgical care and anaesthesia and to enhance teaching and training programmes’15.

While it is widely recognised that nongovernmental organisations can complement domestic efforts and plug persistent gaps, good coordination and alignment between global health actors’ interventions and LMICs’ needs and priorities is key to avoid fragmentation, duplication and inefficiency of health programmes16. Lasting and meaningful change occurs when health planning becomes more participatory and consultative with the inputs of a range of stakeholders.

The development of policies and frameworks is a top priority within the Leadership and Governance building block. In this sense, the National Surgical, Obstetrics and Anaesthesia Plan (NSOAP) was recommended by the Lancet Commission on Global Surgery as the policy framework for countries to evaluate

and strengthen their health systems’ capacity to deliver safe Surgical, Obstetric, and Anaesthetic (SOA) care. The development of NSOAPs have also enabled ministries of health to integrate surgical planning into their broader national health policy, strategy and plans.

National surgical plans can forge a roadmap for improving surgical care through a country‐driven process whilst engaging with local champions, civil societies, and external stakeholders to ensure domestic and international funds for development and implementation since building coalitions and working with external partners are also priorities within the Leadership and Governance building block.

As a trusted partner, KidsOR participated in the discussions for the development of NSOAPs in Zimbabwe and Namibia. In Zimbabwe, our Director for Africa was involved in the prioritisation and costing discussion and the outcome was the inclusion of children’s surgery in the strategy with appropriate targets regarding infrastructure, supplies, finance and service delivery.

Zimbabwe was the fifth country in the Southern African Development Community (SADC) region and ninth in Africa to develop and launch national surgical plans. As more countries successfully launch their NSOAPs, the plans must be extensively disseminated to help guide other countries and spur conversation on challenges and possible solutions.

“NSOAP needs a champion ... If anyone - any interest area - is left out, the process will not be as good”

- Dr. Abebe Bekele MD. Dean of the School of Medicine at the University of Global Health Equity (UGHE).

NSOAPs in the different African Countries

Why is developing NSOAPs important? Better coordination among governments and international partners, visibility, political will and platform for investment.

Completed NSOAP Process

Begun NSOAP Process

Committed to NSOAP Process

Advocating for Health Systems Strengthening

It is imperative for health policy to engage in advocacy. This can influence key policy decisions and directions at national, regional and global levels to realise societal objectives for population health.

The COVID-19 pandemic, while a devastating crisis, has exposed and aggravated structural weaknesses of health systems worldwide and consequently validated the argument for investment in health systems strengthening to prevent, prepare, and respond to future pandemics.

We witnessed several hospitals with strong surgical systems in place being able to increase the hospital capacity in terms of space, staff and supplies needed for safely admitting a large number of critically ill patients with COVID-1917 We can affirm therefore that surgical and anaesthesia professionals and systems are essential to any pandemic response. If the pandemic has precipitated a key policy window for the health systems strengthening agenda, it should include surgical and anaesthesia care.

In a post-pandemic world, we can build back better equitable and responsive health systems and thereby decrease disability and mortality from all diseases. In fact, we have another chance to motivate global and national investment in the health systems using the six WHO building blocks and make significant progress towards SDGs.

Health systems strengthening is central to KidsOR’s strategic, research and policy agendas. We have aligned our strategic objectives and operations with the WHO six building blocks framework. In addition to the structural interventions that can address accessibility and surgical quality, we have sought to engage health leadership at global and national levels

with evidence to inform robust health planning and policy-making processes.

During 2022, KidsOR held multiple advocacy events, including the roundtable ‘Systems not symptoms: Tackling the root causes of the global health crisis’ held in the Houses of Parliament in London. Key global health figures, such as Dr Neema Kaseje, Founding Director of the Surgical Systems Research Group in Kenya and visiting surgeon for KidsOR and for Doctors Without Borders, discussed the role local surgical capacity and expertise plays in strengthening the wider health system. We have also had the opportunity to interview Global Surgery champions such as Professor Emmanuel Makasa, to raise awareness to audiences beyond the surgical world.

Moving forward we will continue to advance surgical care systems strengthening and advocate for health systems strengthening. We will engage in policy as well as advocacy, as well as coalition building and collaboration with different partners in global surgery. We aim to create resilient and well-financed healthcare systems, that are agile in responding to health challenge and able to sustainably invest in their own health workforce training programs.

KidsOR, WHO Bulding Blocks, and Health Systems Strengthening

Operating Rooms

Service Delivery

Access to Medical Products, Vaccines and Technologies

Scholarships, Training & E-Learning Platform

Health Workforce

Advocacy & Policy Initiatives

Financing

Leadership/ Governance

Data Collection & Research

Financing

Health Information Systems

References

1. NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4 https://pubmed.ncbi.nlm.nih.gov/30264707/

2. Kucchal T, Pigeolet M, et al. International organisations in global surgery: challenges and opportunities. Journal of Public Health and Emergency.2020

3. World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. World Health Organization; 2013. https://apps.who.int/iris/handle/10665/94384

4. World Health Organization. Everybody’s business–strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, Switzerland: World Health Organization; 2007.

5. World Health Organization. The World health report: 2000 : health systems : improving performance. World Health Organization, 2000. https://apps.who.int/iris/handle/10665/42281

6. Belli PC, Bustreo F, Preker A. Investing in children’s health: what are the economic benefits? Bull World Health Organ. 2005 Oct;83(10):777-84. Epub 2005 Nov 10. PMID: 16283055; PMCID: PMC2626422.

7. Meara JG et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015

8. World Health Organization. (2022). Third round of the global pulse survey on continuity of essential health services during the COVID-19 pandemic: November–December 2021: interim report, 7 February 2022. World Health Organization. https://apps.who.int/iris/handle/10665/351527

9. Potentially Avertable Child Mortality Associated with Surgical Workforce Scale-up in Low- and MiddleIncome Countries: A Global Study (2021) https://pubmed.ncbi.nlm.nih.gov/34110458/

10. Leisinger KM, Garabedian LF, Wagner AK. Improving access to medicines in low- and middle-income countries: corporate responsibilities in context. South Med Rev. 2012 Dec;5(2):3-8. Epub 2012 Dec 27

11. Access to medicines and vaccines: Report by the Director-General [A72/17]. World Health Organization; 2019. http://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_17-en.pdf?ua=1.

12. From the first mile to the last: Challenges of the global surgical supply chain https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC7983454/

13. WHO global report on trends in prevalence of tobacco use 2000-2025, fourth edition. Geneva: World Health Organization; 2021.

14. Yap A, Muzira A, Cheung M, Healy J, Kakembo N, Kisa P, Cunningham D, Youngson G, Sekabira J, Yaesoubi R, Ozgediz D. A Cost-Effectiveness Analysis of a Pediatric Operating Room in Uganda. Surgery. 2018 Nov;164(5):953-959. doi: 10.1016/j.surg.2018.03.023. Epub 2018 May 23. PMID: 29801729; PMCID: PMC6399742.

15. WHO. WHA 68.15: Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage (2015).

16. Spicer N, Agyepong I, Ottersen T, Jahn A, Ooms G. ‘It’s far too complicated’: why fragmentation persists in global health. Global Health. 2020 Jul 9;16(1):60.

17. Carenzo, L., Costantini, E., Greco, M., Barra, F.L., Rendiniello, V., Mainetti, M., Bui, R., Zanella, A., Grasselli, G., Lagioia, M., Protti, A. and Cecconi, M. (2020), Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy. Anaesthesia, 75: 928-934.

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