VIRTUAL CONSULTATIONS TO DEVELOP THE REGIONAL ACTION ... · Three virtual consultations to develop...

18 and 20 March 2020 Virtual

Meeting Report

VIRTUAL CONSULTATIONS TO DEVELOP THE REGIONAL ACTION FRAMEWORK FOR ACHIEVING

SAFE AND AFFORDABLE SURGERY IN THE WESTERN PACIFIC REGION (2021-2030)

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WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

WPR/DHS/MCQ(02)/2020 English only Report Series Number: RS/2020/GE/09(PHL)

MEETING REPORT

VIRTUAL CONSULTATIONS TO DEVELOP

“THE REGIONAL ACTION FRAMEWORK FOR ACHIEVING SAFE AND

AFFORDABLE SURGERY IN THE WESTERN PACIFIC REGION (2021-2030)"

Convened by:

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

Virtual

18 and 20 March 2020

Not for sale

Printed and distributed by:

World Health Organization

Regional Office for the Western Pacific

Manila, Philippines

June 2020

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NOTE

The views expressed in this report are those of the participants of the Virtual

Consultations to Develop “The Regional Action Framework for Achieving Safe and

Affordable Surgery in the Western Pacific Region (2021–2030)” and do not necessarily

reflect the policies of the World Health Organization.

This report has been prepared by the World Health Organization Regional Office in the Western Pacific for those who participated in the Virtual

Consultations to Develop “The Regional Action Framework for Achieving Safe

and Affordable Surgery in the Western Pacific Region (2021-2030) on 18 and 20 March 2020.

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CONTENTS

CONTENTS ............................................................................................................................................................... 4

INTRODUCTION ..................................................................................................................................................... 5

1.1. MEETING ORGANIZATION ................................................................................................................................. 5 1.2. MEETING OBJECTIVES ........................................................................................................................................ 5

2. PROCEEDINGS ............................................................................................................................................... 5

2.1. OPENING SESSION ................................................................................................................................................. 5 2.2. DRAFT REGIONAL ACTION FRAMEWORK .................................................................................................. 6

2.2.1. Background: global and regional situations of surgical care .................................................. 6 2.2.2. Contextualizing integration of safe and affordable surgery into health systems ............. 8 2.2.3. Implementation framework ................................................................................................................... 9

3. CONCLUSIONS ............................................................................................................................................. 15

ANNEX 1 .................................................................................................................................................................. 16

ANNEX 2 .................................................................................................................................................................. 17

Key words General surgery / Health systems plans / Regional health planning / Surgical procedures, operative

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1. INTRODUCTION

1.1. Meeting organization

Three virtual consultations to develop “The Regional Action Framework for Achieving Safe

and Affordable Surgery in the Western Pacific Region (2021–2030)” were held on 18 and 20

March 2020. The consultations were attended by 10 temporary advisers, representing the Royal

Australasian College of Surgeons, National Center for Global Health and Medicine, Program in

Global Surgery and Social Change (PGSSC) at Harvard Medical School and Mongolian

National University of Medical Sciences, as well as four staff from the World Health

Organization (WHO) Regional Office for the Western Pacific. See Annex 1 for a list of

participants and Annex 2 for consultation schedules and agenda.

1.2. Meeting objectives

The objective of the virtual technical consultations was to review the zero draft of “The Action

Framework for Achieving Safe and Affordable Surgery in the Western Pacific Region (2021–

2030)”, which is to be presented at the seventy-first session of the WHO Regional Committee

for the Western Pacific in October 2020.

2. PROCEEDINGS

The zero draft Regional Action Framework was sent electronically to the temporary advisers

prior to the consultations. The three consultations took place separately but followed the same

agenda with the aim of seeking inputs from the advisers on the zero draft Regional Action

Framework.

2.1. Opening session

Dr Howard Sobel, Coordinator of the Maternal Child Health and Quality Safety Unit at the

WHO Regional Office for the Western Pacific, welcomed the participants. In his opening

remarks, he thanked the temporary advisers for their support and participation in the virtual

consultations. He explained that “safe and affordable surgery” has emerged as a priority

because of requests from Member States and that WHO has developed a programme based on

the health systems approach. He emphasized that the Regional Action Framework will support

Member States to achieve safe and affordable surgery as a step towards universal health

coverage (UHC) through overall health systems strengthening efforts. The opening session

concluded with participant introductions and a review of the consultations’ objective.

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2.2. Draft Regional Action Framework

The WHO Regional Office staff participating in the consultations presented each section of the

zero draft Regional Action Framework and collected feedback from the temporary advisers.

The Regional Action Framework begins with an overview of the global and regional situations

of surgical care and then outlines integration of safe and affordable surgery into health systems

and the five strategic actions for country implementation. The WHO staff explained that the

Regional Action Framework had been developed to be applicable to the widely different

contexts of countries in the Western Pacific Region.

2.2.1. Background: global and regional situations of surgical care

The background section of the zero draft Regional Action Framework begins by introducing the

global movement around surgical care. Safe and affordable surgery is a vital part of a well-

functioning health system. Therefore, it is an essential component towards achieving UHC and

health-related Sustainable Development Goals for the future.

Recognizing the global unmet need for surgical and anaesthetic services, Member States

adopted World Health Assembly resolution WHA68.15 on “Strengthening Emergency and

Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage” in

2015. According to the resolution, each year more than 234 million surgical procedures are

performed globally for common conditions such as obstructed labour, birth defects, cataracts,

cancer, cardiovascular diseases, diabetes, acute abdominal conditions, burns and injuries from

domestic, industrial and road accidents. However, surgically treatable diseases remain among

the top 15 causes of physical disability worldwide. Moreover, at least 11% of the world’s

burden of disease stems from conditions that could be treated successfully through surgery,

with higher proportions in low- and middle-income countries. Unsafe surgical care procedures

cause complications in up to 25% of patients, causing 1 million annual deaths during or

immediately following surgery.1 Costly lapses in safe surgical care afflict even countries with

advanced health systems. The resolution called for universal access to an integrated network of

quality, safe, effective and affordable surgery and anaesthesia services to be accessible at the

primary health care and first-level referral hospital levels.

1 WHO guidelines for safe surgery 2009: safe surgery saves lives. Geneva: World Health Organization;

2009 (http://apps.who.int/iris/bitstream/handle/10665/44185/9789241598552_eng.pdf?sequence=1).

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The regional situation of surgical care in the Western Pacific Region was described with

available data from a literature review. Country-specific data on timely access (within 2 hours)

to hospitals that perform bellwether procedures, specialist surgical workforce (number of

specialist surgical, anaesthetic and obstetric providers per 100 000 population) and number of

surgical procedures were summarized in a table.

In the Western Pacific Region, countries face widely varying geographical challenges,

infrastructure, workforce capabilities, established networks, accurate health data funding and

financial barriers.

Among 14 Member States with available data from the literature review, including 11 Pacific

island countries (PICs), only five countries achieved the target of 2-hour access to facilities that

can perform bellwether procedures (i.e. caesarean section, laparotomy and management of open

fractures) for at least 80% of their population.

In PICs, the specialist surgical workforce ranges from 1.6 per 100 000 population in Samoa, to

30 per 100 000 in Nauru, and 63.9 per 100 000 in Australia. In the case of island nations,

people living outside the major population centres currently access necessary surgical services

by boat or air. Also, an increasing number of people are facing complications that require

specialized treatment unavailable domestically and seek treatment abroad. Harvard Program in

Global Surgery and Social Change maintains that surgical care can lead to a risk of financial

catastrophe and impoverishment. Almost half (47.7%) of the population in the Lao People’s

Democratic Republic face the risk of catastrophic expenditure for surgical care (2017),

compared to 0.3–0.5 % in Japan and the Republic of Korea (2010–2017).

The temporary advisers provided the following feedback for this section:

• The definition of surgery may vary across countries, and data are not always

comparable. Countries should be allowed to decide what to include in their scope. For

reference, however, the Regional Action Framework can include a definition of

surgery to indicate possibly a broader scope of surgery and surgical care systems. The

scope may include anaesthesia and perioperative care as well as obstetrics and

gynaecology.

• Selected global and regional data on surgical care in the zero draft Regional Action

Framework should be updated, namely data on the number of surgical procedures

performed globally every year and the number of surgical procedures per 100 000

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population in Japan and Mongolia. The advisers mentioned that they would share

references with the latest data.

2.2.2. Contextualizing integration of safe and affordable surgery into health systems

The section on contextualizing integration of safe and affordable surgery into health systems

presents four key health system considerations for achieving safe and affordable surgical care:

availability gaps, safety gaps, affordability gaps and ensuring timely response to people’s

needs.

There is no one-size-fits-all formula to achieve universal access to safe and affordable surgery.

Universal Health Coverage: Moving Towards Better Health, an action framework for the

Western Pacific Region, identifies five essential attributes of national health systems:

accountability, efficiency, quality, equity, and sustainability and resilience. Making surgery

safe and affordable requires a deep understanding of the functionality of these attributes along

with social, economic, political, geographical and historical contexts that influence national

health systems. It also needs levers in the health system where specific interventions can be

incorporated.

Where are the availability gaps?

Availability is determined by having the right skills and human resources for health, equipment,

technology, infrastructure and supplies to operate within an effective regulatory framework.

Most of Asia has sufficient infrastructure that can be strengthened to improve the availability of

surgical care. In sparsely populated PICs, limitations in available, capable staff combined with

small population sizes can lead to expensive overseas referrals. Many health interventions are

effective when they are delivered in a timely manner, and delayed interventions may pose a risk

to patients’ lives.

What are the safety gaps?

Every country has had surgical complications. Estimates show that in high-income countries, as

many as 1 in 10 patients is harmed while receiving hospital care. The harm can be caused by a

range of adverse events, with nearly 50% of them considered preventable. Critical lapses in

safety include failures in the preoperative and pre-anaesthetic assessment of a patient’s

allergies, blood type, loss of airway or respiratory function, aspiration, blood loss, omission,

duplication or mixing up of perioperative medications, surgical site infections, postoperative

sepsis, retention of instruments and sponges, inaccurately identified surgical specimens and

postoperative pulmonary embolism or deep vein thrombosis.

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What are the affordability gaps?

In much of Asia, health insurance programmes or government budgets cover a portion of

surgical care costs. Still, countries differ in terms of the surgical services covered, the degree to

which people have access to coverage and the limitations for direct payments for surgery

services. In PICs, as well as in many rural settings in Asia, transportation costs linked to

accessing surgery services and other non-health-care costs increase the costs of surgical

services for households.

What are the gaps in providing timely access to respond to people’s needs?

The appropriate volume of surgical care can be determined by surgical needs and supply of

surgical care. Insufficient volume of surgical care can increase waiting times for surgery,

leading to increased complications and potentially avoidable lifelong disability for surgical

patients. The waiting time for elective surgery varies from days to months, depending on the

type of surgery and the country. In addition, low surgical volume can reduce proficiency among

practitioners, negatively impacting on patient safety.

The following points were discussed for this section:

• One of the biggest gaps of surgical care systems may be accessibility to surgical

services in PICs as well as mountainous countries. A sustainable workforce needs to be

developed in PICs to deliver good-quality surgical services.

• The Tanahashi model that outlines interrelationships of health service coverage

measures would be helpful to understand the relationships between the four areas of

consideration and actual coverage.

• It may be difficult to find information to respond to economic and financial questions,

such as the benefits package of health insurance, entitlements, government

reimbursement and specific financial barriers. Relevant experts will be needed to

provide detailed information in a given country.

2.2.3. Implementation framework

The implementation framework comprises five strategic actions. It fosters stakeholders to

develop a shared vision of what can be achieved while considering the health system attributes,

components and influencers. Integrating the framework into the overall UHC efforts in each

country is recommended. The vision becomes the driving force to address gaps in and better

utilize the health system. The approach also depends on identifying real-world experiences,

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including patient and health worker journeys to find local innovations and solutions as part of

the path towards UHC. Safe and affordable surgery can act as a tracer of how countries are able

to provide access to quality services without experiencing financial hardship, which is at the

core of the UHC agenda. In alignment with establishing the entitlements of the population to

access quality health services, improving service delivery based on the population needs and

developing financial arrangements that protect against financial hardship are key for successful

implementation of the framework.

Strategic Action 1 is to identify principle stakeholders committed to making safe and affordable

surgery an integral part of moving towards UHC. Countries should establish, enhance or

refocus a group of stakeholders who are critical for the strategic integration of safe and

affordable surgery into UHC and who will be involved in the process from beginning to end.

Stakeholders from national health insurance, ministries of health, finance, labour and education,

professional groups, academe, civil society and communities should be involved in the strategic

integration of safe and affordable surgery into UHC. Bringing them in from the start will enable

the development of a shared vision toward this end. Expertise within or in addition to these

stakeholders should include health economics, financing, epidemiology, human resource

planning and management, hospital planning and management, medical professional groups

from emergency care and surgery, and others. Stakeholders should agree on the terms of

reference of the group, including roles, responsibilities of each member, timelines and

monitoring mechanisms. For some countries, integrating the aims and activities towards the

framework of safe and affordable surgery into some existing stakeholder engagement could be

feasible.

To implement Strategic Action 1 and monitor the progress, actions and indicators are set for

countries and WHO. Actions for countries are to (1) identify critical stakeholders and (2)

establish a functional stakeholder group that participates end-to-end in the planning process,

including setting a shared vision, diagnosing the critical gaps, planning and reviewing progress.

An indicator for countries is functional stakeholder group established. The action for WHO is

to provide secretarial and technical support to ensure the right people participate from

beginning to end in the planning process. The indicator for WHO is number of countries with

functional stakeholder groups.

Strategic Action 2 is to establish a shared vision for access to surgical services with key

stakeholders. Often, the solution to addressing a public health problem relates to improving the

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health system. Non-strategic “fixes” to the health system will almost certainly result in

inefficient use of scarce resources. It is prudent for principal stakeholders to establish a shared

vision by mutually understanding where a country or subnational region is and gaining

consensus on where they think they feasibly can be with strategic use of resources. The

leadership of the ministry of health is key for this action’s success. The framework focuses on

five key steps for this action.

(1) Estimate surgical services currently available per level of surgical facility.

Stakeholders can review 44 essential surgical services, augment the list with other

critical surgical services according to the local context and estimate their availability

per level of health facility, such as primary care facility, first referral hospital and

higher-level hospital.

(2) Estimate the impact of barriers to access of populations to the current situation.

Stakeholders can estimate the percentage of the population that does not have access to

these facilities for any reason (e.g. financial, access to transportation, language or

sociocultural).

(3) Estimate the relative contribution of financial, transportation, language and

sociocultural barriers to limiting access to safe surgery.

Comparing the estimates in steps 1 and 2, stakeholders can recognize gaps between the

availability and accessibility of each of safe surgical procedure. They then can discuss

the relative contributions of financial, transportation, language and sociocultural factors

to inhibiting access to each surgical procedure.

The estimates in steps 1, 2 and 3 can be validated in Strategic Action 3.

(4) Identify key safety issues around the delivery of surgical services.

Discuss with stakeholders the known safety incidents around the delivery of surgical

services and anaesthesia.

(5) Develop a shared vision of what can be achieved by 2025 and 2030.

Based on the analysis in steps 1 to 3, stakeholders can discuss and reach a consensus on

the availability and accessibility gaps that feasibly can be addressed by 2030. This step

is repeated for each surgical service. The exercise can be done at national and

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subnational levels. Summarized information can then be used to articulate a shared

vision for access to safe and affordable surgical services by 2025 and 2030.


countries and WHO. The action for countries is to convene principal stakeholders to go through

a systematic process to identify the state of availability, accessibility and safety of essential

surgical services per level of surgical facility. Indicators for countries are (1) review done, and

(2) clear national vision created. The action for WHO is to provide technical support for

countries in reviewing the current situations of surgical services. Indicators for WHO are (1)

number of countries that have reviewed the current situations of surgical services, and (2)

number of countries that have a national vision of surgical services.

Strategic Action 3 is to diagnose gaps and strengthening of surgical service delivery system vis-

à-vis the vision. Achieving the vision requires using scarce resources strategically. “Pain

points” that disproportionately affect access to safe surgery are identified through a

comprehensive review of the existing attributes of the health system. These may include

regulations, capability of staff, logistics, funding and financial protection in the current system.

Health system performance in providing access to surgery is measured vis-à-vis the estimated

expenditure to identify possible efficiency gains and opportunities to improve access to safe

and affordable surgery.

Every country, even high-income countries, has surgical mishaps. Communication between the

surgeons, anaesthetists and nurses, use of checklists, surveillance and establishing quality

improvement mechanisms including surgical audits are key to reducing and eliminating errors

during surgery. The effectiveness of these measures is also reviewed.


countries and WHO. Actions for countries are to (1) conduct comprehensive assessments of

gaps in regulations, mechanisms for ensuring safety, staff capabilities, logistics and supply,

funding, financial protections in the current system, including through patient and health

worker journeys; and (2) through a detailed analysis of the health system performance in

providing patients access to safe and affordable surgery, diagnose which of the gaps are critical

to address. The indicator for countries is critical gaps diagnosed through assessment and health

system analysis. The action for WHO is to compile existing tools and develop a comprehensive

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approach to identify gaps and diagnose the ones that are critical to address. The indicator for

WHO is number of countries that have diagnosed the critical gaps.

Strategic Action 4 is to develop a national action framework for improved access to safe and

affordable surgery. The national action framework should be built on strategic solutions that

address the diagnosed critical gaps. The solutions need to be framed within the existing health

system, and the national action framework can be integrated into the existing policy plans,

documents and policies. This provides opportunities to find solutions by updating existing

strategies, plans, policies, guidelines, laws, health facility and human resource credentialing,

licensing and accreditation, insurance and financing mechanisms, preservice curricula, essential

medicine and technology lists, etc. Some of these may not exist and will require creating new

ones. Additionally, transformation may be achieved by innovative technologies, upskilling of

existing staff, repurposing external service delivery to capacity-building and other such

solutions. Finally, mechanisms to continually improve the safety of surgical and anaesthetic

services and referral should be included.


countries and WHO. Actions for countries are to (1) develop consensus on a strategic national

action framework including where the strategic solutions are incorporated into the health

system and (2) develop consensus on an annual implementation plan. Indicators for countries

are (1) national action framework endorsed and (2) annual implementation plan endorsed. The

action for WHO is to support health system analysis to maximize the efficiency of the national

action framework including coordination of partners. The indicator for WHO is number of

countries with a national action framework endorsed.

Strategic Action 5 is to establish a mechanism of monitoring, evaluation and surveillance.

Measuring progress is critical to ensuring a country is on track toward universal access to safe

and affordable surgery. Each country needs to develop its own measurement of progress based

on their national action framework. Evaluation can also involve including indicators in national

surveys. WHO will provide a sample monitoring and evaluation framework from which

countries may select indicators.


countries and WHO. Actions for countries are to (1) monitor progress toward implementing the

annual implementation plan and national action framework and (2) establish or strengthen a

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surgical surveillance system within the health information system. Indicators for countries are

(1) annual reports on progress toward the actions in the annual implementation plan and

national action framework and (2) annual reports of surveillance indicators. Actions for WHO

are to (1) provide technical support to countries to establish a monitoring and evaluation

framework and (2) provide technical support to countries to establish a surgical surveillance

system. Indicators for WHO are (1) number of countries with annual reports on progress toward

the actions in the annual implementation plan and national action framework and (2) number of

countries with annual reports of surveillance indicators.

For the implementation framework, the following points were discussed:

• The implementation framework is applicable for a wide range of countries. Although

the process will be the same, applicability will be localized.

• For Strategic Action 1, appropriate stakeholders are needed, beyond the narrow

definition of surgery. In addition to stakeholders indicated in the zero draft, bilateral or

multilateral funding partners (e.g. Japan International Cooperation Agency, Korea

International Cooperation Agency and World Bank), the private sector, industry,

information technology services and disaster risk reduction experts could be

considered.

• Strategic Action 2 includes qualitative approaches for a shared vision among all

stakeholders. In contrast, Strategic Action 3 includes quantitative methods to validate

data on the actual situation of service delivery and surgical systems to find gaps and

areas for strengthening in a given county. These approaches make sense in terms of

getting all stakeholders involved.

• For Strategic Action 3, WHO in the Region is working with the Harvard PGSSC on

comprehensive assessment tools across all elements of safe and affordable surgery. The

advisers expressed interest in the tools. The WHO Regional Office will share the

assessment tools for their comments once they are ready.

• In Strategic Action 4, countries come up with solutions. They do not have to start from

zero. Rather, solutions should link to existing health systems.

• For monitoring and evaluation in Strategic Action 5, no specific timeline or indicators

are indicated, given the diversity of Member States. They can decide their own timeline

and indicators in their country framework. WHO cautions against collecting too much

data.

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Overall, the zero draft Regional Action Framework was considered helpful as a guidance

document for countries without being overly prescriptive.

3. CONCLUSIONS

The three virtual consultations were concluded with appreciation to all participants. Because of

the limited extent of elaborating the detailed descriptions for the Regional Action Framework

due to the modality of virtual consultations, the technical advisers agreed on providing the

WHO Secretariat with written comments and suggestions for the Regional Action Framework.

Based on them, the WHO Regional Office will finalize the zero draft Regional Action

Framework and share it with Member States for their review in preparation for the Regional

Committee session in October 2020. Further, the WHO Regional Office is requested to finalize

and share with the advisers for their review the assessment tools for surgical services and

surgical systems, which are complementary to the Regional Action Framework.

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Annex 1

LIST OF TEMPORARY ADVISERS AND SECRETARIAT

1. TEMPORARY ADVISERS

Date and time of

the consultation Name Affiliation Email

13:30–15:00

18 March 2020

Dr Elizabeth McLeod Royal Australasian College of

Surgeons, Australia [email protected]

Dr Norihiro Kokudo National Center for Global Health and

Medicine, Japan [email protected]

Dr Kazuhiko Yamada National Center for Global Health and


Dr Hidechika Akashi National Center for Global Health and


19:30–20:45

18 March 2020

Dr John G Meara Program in Global Surgery and Social

Change, Harvard Medical School, USA

[email protected]

rd.edu

Dr Kee Park Program in Global Surgery and Social

Change, Harvard Medical School, USA [email protected]

Dr Zachary Fowler Program in Global Surgery and Social


d.edu

Dr Lina Roa Program in Global Surgery and Social


11:00–12:00

20 March 2020

Dr Sergelen Orgoi Mongolian National University of

Medical Sciences, Mongolia [email protected]

Dr Sarnai Drdene Mongolian National University of

Medical Sciences, Mongolia [email protected]

2. SECRETARIAT

Organization Name Designation Email

WHO Regional Office for

the Western Pacific

Dr Howard Sobel Coordinator [email protected]

Mr Tomas Roubal Health Economist [email protected]

Ms Ding Wang Technical Officer [email protected]

Dr Mai Inada Technical Officer [email protected]

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Annex 2

VIRTUAL CONSULTATIONS TO DEVELOP “THE REGIONAL ACTION

FRAMEWORK FOR ACHIEVING SAFE AND AFFORDABLE SURGERY IN THE

WESTERN PACIFIC REGION (2021–2030)"

VIRTUAL MEETING DETAILS

DATE : 18 MARCH 2020, WEDNESDAY

TIME : 13:30–15:00 (Manila time)

DATE : 18 MARCH 2020, WEDNESDAY


DATE : 20 MARCH 2020, FRIDAY


AGENDA

1. Opening session

2. Review of the zero draft Action Framework for Safe and Affordable Surgery in the

Western Pacific Region (2021–2030)

3. Closing session

www.wpro.who.int

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