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.

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.

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

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: