Surgical Care In The Global Health Agenda: The Role Of Frontline Academic And Clinical Practitioners In Implementing World Health Assembly Recommendations

The 77th World Health Assembly (WHA) held in Geneva in May 2024 saw continued integration of surgical care within the global health agenda[1]. The WHA brings together key stakeholders in the global health policy and advocacy community, including state and non-state actors, academics, and providers, to set priorities for improving health outcomes globally. For the global surgery community, several decisions made at this WHA present direct and indirect opportunities to advance surgical care access and provision worldwide. This commentary provides an overview of the major resolutions and decisions, highlights their significance, and outlines the path forward for implementation, emphasizing the role of frontline providers.

Implications of the World Health Assembly for Surgical Care

At the WHA, the decision-making body of the World Health Organization (WHO), Member States of the WHA adopts various types of decisions, resolutions, and action plans, each with distinct goals in shaping global health. Decisions are typically administrative or procedural, guiding the operations of WHO and setting its priorities. Resolutions are formal texts that outline specific health issues, recommend actions, and often signify international commitment to addressing those issues. Action plans are detailed strategies outlining steps, timelines, and responsibilities to achieve specific health goals.

Two formative resolutions that have significantly impacted the global surgery community to date are WHA 68.15 and WHA 72.16 [2, 3, 4]. WHA 68.15, adopted in 2015, focused on strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage (UHC)[2]. This resolution marked a critical step in recognizing surgery as an essential part of health systems[5]. WHA 76.2, adopted in 2023 emphasizes integrated emergency, critical, and operative (ECO) care for universal health coverage and protection from health emergencies[3]. WHA resolutions reflect a global consensus on the need to prioritize surgical care within broader health initiatives. These resolutions serve as guiding frameworks for member states to implement policies that enhance surgical services, improve patient outcomes, and ensure resilience in the face of health emergencies and specific recommendations for the WHA Secretariat and civil society to support the Member States [6]. In order to operationalize formative resolutions towards the advancement of the global surgery cause, further action plans are needed.

The consistent inclusion of surgical care in these high-level instruments underscores surgical care’s critical role in achieving universal health coverage (UHC) and responding effectively to global health challenges[5, 7]. At WHA 77, the gains for Global Surgery community were vast and varied and are summarized in Table 1. A significant development is the Commitment to Developing an ECO Strategy and Action Plan (2026-2035)[8]. The global commitment to an implementation framework for WHA 72.16 will help operationalize strategies to improve ECO care. Through engagement with professional societies, country delegates and global surgery advocacy groups like the G4 Alliance, frontline providers can safeguard the critical role surgery plays in reaching UHC through ECO care. For countries that have developed, implemented or revised national surgical plans (NSPs), the shift towards developing a global strategy and action plan is an opportunity for renewed, revised and integrated surgical care strengthening. NSPs are a demonstrated policy instrument for advancing surgical care services[9, 10]. Integrating NSP implementation into this global action plan could be a pivotal moment for NSP implementation efforts.

The introduction of the first-ever investment round for sustainable financing by WHO (2024) is another crucial step towards securing stable funding for various health programs. This initiative aims to support WHO’s programs, potentially benefiting global surgery projects through enhanced financial support. This is particularly pertinent as inadequate funding of surgical care programs limits the development of robust and responsive health systems[11]. Although the explicit prioritization of surgical care is not stated, the global surgery community can advocate for the allocation of these funds by highlighting the critical role of surgery in achieving universal health coverage and improving health outcomes. Engaging with WHO decision-makers and participating in policy discussions will be essential to drive funding towards essential surgical services[11]. 

While WHA 77 saw various gains and opportunities for surgical care in the global health agenda, there was a missed opportunity. As per WHA Decision 70 (22), passed in 2017 requiring Member States to report back to the WHA every two years on their progress, Member States committed to collect robust data on emergency and essential surgical care[16]. This would have made 2024 a reporting year for the WHA 68.15 resolution. The failure to follow up points to two problems: one of monitoring and evaluation challenges and another of accountability by Member States to strengthen surgical care.

Implementing surgical policies, including those set out in the WHA resolutions, faces several system-level challenges. One of the most pervasive obstacles is inadequate funding which restricts countries’ abilities to expand surgical capacity through infrastructure, workforce and supply chain development[10, 11, 17, 18]. Weak health infrastructure and workforce shortages make timely access difficult particularly in rural areas [19]. Additionally, political will is often lacking with policy-makers hesitant to spend on surgery due to its perceived high cost, despite its cost-effectiveness[5, 17, 18, 19]. These systemic barriers to surgical policy implementation highlight the role frontline providers can play in advocating for resources, contributing to pragmatic policy solutions and adapting global strategies to local contexts.

The Way Forward

While the resolutions and commitments made at the 77th WHA represent significant strides toward improving global surgical care, the successful implementation of these initiatives relies heavily on the active involvement of the WHO, countries, and the civil society. Global surgery advocates have an important role in supporting the implementation at country level. Frontline researchers and frontline providers are an essential change-driver for achieving the goals set forth by the WHA.

Responsibilities of Frontline Providers:

• Advocate for Implementation: Frontline providers can advocate by actively ensuring that country delegates are following through on their commitments at the WHA through direct engagement with health ministries and diplomates. Additionally, providers can engage local health authorities and civil society organizations, such as the G4 Alliance (Global Alliance for Surgical, Obstetric, Trauma and anaesthesia Care) [21]. The G4 Alliance is a preeminent global surgery advocacy organization who convene and represent organizations, including professional societies, non-profit organizations and academic centers[21]. This includes official engagement with the WHO through which engagement with G4 can help support the mobilization of adequate resources for the enhancement of surgical services at all levels.
• Engage in Policy Development: Frontline providers provide a unique, pragmatic perspective to health policy[22]. Frontline providers can participate in policy development and refinement through relevant research and dissemination to ensure they meet the practical needs of the surgical care community. Frontline providers have contributed to the development of NSPs in several countries, beginning from the stakeholder engagement meetings through to the policy-writing process [23]. To our knowledge, frontline providers, including surgical care providers, private sector providers, and members of academia have engaged as key partners in the NSP development process across most of the NSPs developed to date. To name a few, Nigeria, Namibia, Rwanda, Tanzania, Zimbabwe, Zambia, Madagascar, and Ecuador’s NSPs have been developed with the support of frontline providers [19, 20, 21]. Now the responsibility of the frontline provider is to sustain the engagement and be continually involved in the implementation phase.
• Promote Integrated Practices: To support the integration of cohesive ECO policy practices into surgical systems, the development and implementation of interprofessional collaborations and skills development programs, across a diverse range of providers involved in ECO care, is essential. For example, the Basic Emergency Care, the new joint WHO/ICRC/IFEM learning program, for first contact healthcare workers, offers frontline providers a comprehensive, standardized, systematic approach to providing cost-effective, life-saving management for emergency conditions [22, 23]. Another example is the emerging role of provider communities in developing “communities of practice” to improve support of surgical providers in remote settings. This fosters mentorship, sharing of best practices and ultimately the integration of more comprehensive clinical care across the health system [28].
• Enhance Community Involvement: Fostering community engagement to support the sustainable inclusion of surgical care into UHC programming, is particularly important in low-resourced settings [29]. Engagement with patient communities allows for contextually appropriate interventions to be devised. For example, the Africa Surgical Outcomes Study (ASOS-2) showed how engagement with communities in study interventions (for enhanced post-operative surveillance) was a successful method for improving post-operative outcomes [26].

Conclusion

By embracing these responsibilities, frontline providers can drive the global surgery community toward achieving the goals set forth at the 77th WHA, ultimately improving health outcomes worldwide. Implementing WHA resolutions offers tangible benefits to providers and patients by enhancing access to safe, timely, affordable emergency, critical and surgical care, and building stronger and more resilient health systems. Global surgical care is now a permanent feature on the agenda, but its successful implementation depends on the dedication and efforts of practitioners in academic and clinical settings to effect meaningful change.