'Best buys' for surgery in South Africa

Abstract

A new era in surgery has emerged.[1] A discipline faced with multi ple challenges in the universal health coverage environment is discovering how to integrate surgical care provision into the global health agenda. The traditional perception that surgery is less cost effective than other available interventions, such as medicines or public health interventions, is being challenged by new emerg ing evidence suggesting that surgery can represent good value for money.[2] Surgical care is not a pathologybased intervention, but rather a dynamic system that has a crucial role to play in managing the burden of disease, including communicable and non communicable diseases.Several recent developments have highlighted the crucial role of surgery in the health system. The 2015 World Health Assembly resolution 68.15 outlined the importance of 'Strengthening emergency and essential surgery and anaesthesia care as a component of universal health coverage. ' [3] In addition, the Lancet Commission on Global Surgery 2030 synthesised much of the evidence supporting the role of surgery and modelled a number of scenarios.[4] Key messages from these developments reflecting the role of surgery globally and the consequence of failure to address the unmet surgical need are:• 5 billion people cannot access safe surgery when needed • 33 million individuals face catastrophic expenditures paying for surgery and anaesthesia annually • Investing in surgery is affordable, saves lives, and promotes economic growth.In South Africa (SA), there is a need to develop a care package for the different levels of service delivery in the public health system, including a package for district hospitals. Developing these packages requires an understanding of the economic implications of intervention implementation. The content of these packages could then inform the development of a national surgical plan.The success of an initiative focused on developing and implemen ting surgical care packages at different levels of care will be deter mined by many factors, including the ability of educational institu tions to facilitate the skills transfer of appropriate competencies, and the availability of appropriate infrastructure and systems to allow the delivery of the different care packages. Surgical care is strongly linked to technology. There is a flood of new technologies and innovation in the surgical care environment, and determining the appropriate intervention for the right setting requires an evidencebased evaluation of the technologies. The spectrum of interventions that could be considered appropriate ranges from lowtechnologydriven procedures with a wide reach that can be offered to patients at primary care level, to highend technologies that can only be performed at tertiary care level.So what surgical options should we offer? This question is at the heart of priority setting, which draws on the best traditions of evidencebased medicine, health economics and medical ethics, and can help us to identify what health interventions and technologies can an...