Governments, Communities, and Experts Assembled in Bogotá to Transform Emergency, Critical and Operative Care in the Pan American Health Organization Region

Introduction

In low- and middle-income countries (LMICs), 54% of injured patients die before reaching the hospital [1,2]. Of those who make it to the emergency room, 40% pass away due to inefficiencies in critical care systems [3,4]. Time from injury to arrival at a hospital can be up to 3.5 hours – five times longer than in high-income countries (HICs) [6]. These sobering facts underscore the importance of robust emergency, critical, and operative care (ECO) systems and their integration in the universal health coverage (UHC) framework. In January 2025, Operation Smile hosted a regional consultation meeting in Colombia supporting the World Health Organization’s Global Strategy Action Plan (GSAP) for integrated ECO care. This event brought together members of civil society, academia, non-state actors, member states, and United Nations agencies to contribute the perspective of the Pan American Health Organization (PAHO) region. Challenges in service delivery, health information systems, health workforce, and health systems financing were identified. Recommendations and proposed steps forward were outlined. Ultimately, ECO care is foundational to equitable and resilient health systems in the PAHO region and the globe.

Background

Emergency, critical, and operative care (ECO) systems encompass a continuum of health services delivered across the patient’s life span, following a patient-centered approach, ranging from primary and preventive care to maternal and child health, surgical care, and rehabilitation [7]. Emergency services include pre-hospital and emergency unit care and their referring networks, while critical care involves continuous advanced monitoring and intensive support by skilled providers in critical care departments or high dependency units. Although separate entities, emergency and critical care are significantly intertwined with the shared goal of providing timely interventions to reduce death and disability. Finally, operative care involves surgical and anaesthetic care for a variety of conditions from pregnancy to trauma at all spectrums of life [7].

Emergency care has been on the global health agenda for over a decade, but until recently, each ECO care component had been an independent focus of international health policy. For example, in 2007, the WHA60.22 on Health Systems: emergency care systems resolution was adopted to promote the importance of health care policy in improving global access to emergency care [8]. Patients in low-resource settings are particularly vulnerable to the impact of physical disabilities from conditions that could have been treated operatively [9]. Recognizing this growing burden, the global health community acknowledged the importance of strengthening the surgical and anesthesia component of global health through the 2015 adoption of WHA68.15: Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage. Since the Lancet Commission on Global Surgery a decade ago, the mission has been to increase access to safe, timely, and affordable surgical care closer to the patient’s home [10]. This led to the promotion of national surgical, obstetric, and anesthesia plans (NSOAPs) to include surgery as part of the UHC framework. Appreciatively, Zambia was the first country to launch an NSOAP in 2017, and in 2024, Ecuador became the only nation in the Pan American Health Organization (PAHO) region to launch an NSOAP [11]. These national initiatives aligned with the broader global shift as international attention to critical and emergency care increased further with the 2019 adoption of WHA72.16 on Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured [12].

In low- and middle-income countries (LMICs), over half of all deaths occur within the prehospital, emergency, critical, and operative care continuum [13]. Over the past decade, it has become apparent that supporting these distinct areas of healthcare is not enough—their integration is vital to achieving satisfactory care in the UHC framework. It is estimated that the integration of ECO components could prevent a third of disabilities and over half of deaths in low-resource settings, underscoring the life-changing potential of an integrated approach [7]. ECO care integrates interventions from the community to health facilities in order to prevent injury, promote health, and rehabilitate patients after hospitalization. It helps prevent short- and long-term disability and minimizes suffering to those affected by it. Integrated planning and implementation of ECO services can address gaps in care, which result in significant avoidable mortality and morbidity. Furthermore, it improves communication, collaboration, and efficiency across the system, both for day-to-day care and in response to health emergencies globally [14]. Well-organized, high-quality ECO services are essential to achieving UHC and improving prevention and management of other health needs, such as maternal and child health, communicable, and non-communicable diseases [7,15]. This role was made more evident when the COVID-19 pandemic exposed gaps in healthcare systems, leading to preventable deaths. Following this realization, the World Health Organization (WHO) member states adopted WHA76.2 in 2023 [16]. This resolution prioritizes the integration of ECO care into UHC frameworks and health emergencies preparedness in national policies. It equally recognizes global disparities in access to ECO services and context-specific variabilities in the ability to integrate these services.

To promote the integration of ECO care services, the WHO developed a Global Strategy for Integrated Emergency, Critical and Operative Care, 2026–2035, informed by extensive consultations across all WHO regions [17]. This newly proposed strategy builds on the organization’s track record of global strategies that have successfully mobilized countries and partners around shared goals. For example, the Global Vaccine Action Plan (GVAP) 2011–2020, endorsed by all 194 Member States at the 2012 World Health Assembly, aimed to prevent millions of deaths through expanded access to immunization. While not all targets were achieved, the initiative contributed to an estimated 24.6–25.8 million lives saved in the PAHO region alone [18]. Building on GVAP, the Immunization Agenda 2030 (IA2030) introduced critical improvements such as stronger local ownership, context-specific strategies, and broader engagement of stakeholders to ensure shared accountability and more effective implementation [19].

This paper highlights persistent challenges to integrating emergency, critical, and operative (ECO) care services in the PAHO region and outlines the recommendations emerging from the January 2025 consultation that directly informed the Global Strategy for Integrated Emergency, Critical and Operative Care, 2026–2035 [17]. This work underscores a clear opportunity and responsibility to close longstanding gaps in ECO care integration and strengthen health system resilience and responsiveness across the region.

Context

PAHO represents the WHO region of the Americas, comprised of 35 member states across North, Central, and South America, as well as the Caribbean. In addition to its role as the WHO regional office, PAHO also functions as an independent international public health agency representing an additional four associated member states (such as Puerto Rico and Aruba), two observing states (Spain and Portugal), and three participating states (France, the Netherlands, and the United Kingdom) [20]. In October 2024, during the 61st PAHO Directing Council, a strategy to increase access to integrated ECO care in the region was approved. The strategy for Integrated Emergency, Critical, and Operative Care 2025-2030, emphasizes the essential nature of these services and works to ensure UHC, health systems strengthening, and financial protection in the region [21]. In January 2025, members of civil society, academia, non-state actors, member states, and United Nations (UN) agencies met in Bogotá, Colombia, to contribute the perspective of the PAHO region.

The consultation session took place on the final day of a three-day event (Day 1: Workshops; Day 2: ACAN; Day 3: Consultation). A total of 47 individuals participated, representing a wide range of stakeholders. Two United Nations agencies, WHO and PAHO, were represented by five participants. In total, 14 Member States contributed 41 participants, ensuring coverage across all four PAHO subregions (Figure 1). Government representation included four ministries from Peru, Jamaica, Paraguay, and Belize. Academia was represented by four institutions, including Universidad de La Sabana and Harvard University. Professional societies were well represented, with a total of 17 associations: three surgical societies, six anesthesia and critical care societies, three nursing/midwifery societies, four emergency and trauma societies, and one pediatric society. Civil society and humanitarian organizations contributed 14 participants, while three patients also took part, ensuring that lived experience informed discussions (Figure 2). Gender balance was nearly equal, with 25 men and 21 women. Invitations were extended to ensure diversity across Member States, government, academia, and civil society, and priority was given to individuals with prior engagement in ECO care. Participants were deliberately selected as champions for integration, bringing both experience and commitment to advance the development of ECO care integration strategies.

Findings

The consultation session aimed to obtain feedback regarding the feasibility of ECO care integration, identify challenges, and determine areas where additional support is needed for successful integration (Table 1).

Service delivery

The PAHO region faces persistent barriers to access to care due to geographic, economic, and racial/ethnic inequities. Rural communities are disproportionately affected as travel to health facilities with sufficient services remains a significant challenge. For example, 40% of rural households in Peru could not access any healthcare services when needed, compared to 27% of urban households in 2020 [22]. Planning, organizing, and delivery of health services is one of the poorest performing sections in the Personalised Health index (PHI) across the Latin American region. PHI is a tool assessing ten health systems across regions. It provides insight into how close each region is to personalized health care, a possible surrogate for patient-centered care in the UCH framework [23].

Health information systems

In 2020, there was a call to action for data sharing in the PAHO region, comparing it to the Africa region’s ability to endure the  COVID-19 pandemic [24]. Five years later, the group in Bogotá recognized that ECO care data is insufficient for monitoring and evaluating individual components of ECO care, let alone its integration. Another challenge is the resistance to data sharing between hospitals and within the private and public sectors. Fortunately, several countries in the region stand out with high PHI scores in the health information section and can act as a template for similar countries in the region. Colombia ranks first in open government data, where efforts have been made to make health data available and accessible in a national portal. Likewise, Brazil has strong information exchange strategies that allow for cross-border data transfers and permits patients access to their health data [25].

Health workforce

Underinvestment in healthcare and education, dated curricula, and misalignments between the needs of the local community and the competencies of its healthcare workers have contributed to an insufficient healthcare workforce. Countries in the PAHO region have some of the lowest rates of nurse graduates, nurse-to-physician ratios, and physician-to-population ratios in the world. For example, in Colombia, the new nurse graduate rate is 8.1/100,000, the nurse to physician ratio is 0.7, and the physician to population ratio is 2.5. [26] Marked shortages, particularly in rural areas, lead to burnout that may compromise the quality of care provided. Retention of healthcare providers, particularly those with subspecialized training, is a significant problem. Poor professional training and a lack of national medical proficiency exams compromise care and patient outcomes [26]. Challenges to ECO care integration in the region also include inadequate training for existing healthcare providers and a lack of standardization of ECO care education.

Health system financing

Insufficient sustainable funding mechanisms in healthcare and its infrastructure have had consequences for the ability to provide equitable healthcare in the region. Although the percentage of GDP invested in healthcare is often used as a marker for comparison between countries, it is also essential to consider the health investment per capita and the allocation of these funds between the private and public sectors. For example, although 9.8% of Brazil’s GDP was allocated to health investment in 2022 compared to 9.6% in Australia, Brazil’s per capita investment in USD was 4 times less than that of Australia ($6,372.00 VS $1,573.00). Furthermore, in Brazil, almost 60% of the 9.8% of GDP allocated to healthcare went to private institutions, and less than 5% was allocated to the public health system [26].

Recommendations

At the end of the convening, participants appreciated the opportunity to share their input and reflect on the consultation session. It became clear to me that collaborative advocacy for policy change carries significantly more impact than individual efforts. We were encouraged by the WHO’s clear commitment to continue supporting countries with practical tools, training, and policy guidance, while actively fostering collaboration at regional and global levels. To meaningfully strengthen ECO care systems in the PAHO region and accelerate integration, priority must now be given to the following areas:

1. Innovative health systems financing
2. Strengthening health information systems
3. Encouraging community engagement

Sustainable financing is essential, as even the most well-developed plans can stall without adequate resources; reallocating funds and fostering strong stakeholder collaboration are critical for successful implementation and sustainable scaling. Robust health information systems enhance care quality and efficiency, support the measurement of impact, and inform funding and advocacy decisions. Lastly, meaningful community engagement is key to driving effective advocacy and ensuring long-term support for ECO care efforts. In addition to these priorities, several other recommendations were made by the group to strengthen ECO care systems and advance integration in the PAHO region:

Service Delivery

The group endorsed the implementation of evidence-based platforms to adopt ECO care protocols in diverse settings, supporting equitable and integrated delivery of ECO services. The group also recommended community engagement in workforce development and advocacy as a strategy to improve access to care by addressing key barriers to service delivery, such as geographic challenges, inadequate infrastructure, and workforce shortages. Community engagement is a cost-effective strategy with a long history of helping to address other global health concerns, such as tuberculosis [27,28]. Patient and community participation allows us to understand the barriers of ECO care integration from the patient perspective. It will enable the community to be a crucial part of advocacy and policy efforts that keep local governments accountable for addressing the community’s health needs.

Health Information Systems

The group advocated for strengthening data collection, management, and sharing to not only improve the quality of care delivered but also aid in preparedness for health emergencies globally. The group also highlighted the need for metrics to measure the success of interventions and monitor and evaluate the impact of investments and ECO care integration on global health outcomes. In a 2018 Canadian study in ambulatory settings, data sharing through connected health information resulted in savings of $72.7M by reducing duplicated laboratory testing. This translates to patients getting back a total of 1.86M hours, producing $49.5M in economic output per year.[29] Therefore, data sharing is not only crucial for increasing healthcare access and patient outcomes but also has tremendous potential in economic growth through increased productivity and reducing redundancy.

Health workforce

The group suggested training the existing ECO care workforce through train-the-trainer models, providing initiatives for working in rural settings, recruiting healthcare professionals at earlier stages of life and from rural communities, involving community members in various aspects of ECO care delivery, and investing in the retention of skilled professionals. “The grow your own” strategies and “rural pathways” outlined by the WHO have shown benefit in recruitment and retention of health workers and increased job and educational opportunities, well worth the investment [30]. In rural India, nurses recruited from the rural and tribal communities have less attrition than those recruited from urban areas.[31] In rural Indonesia, the recruitment of early career doctors from remote backgrounds, as well as financial incentives, increased their willingness to work in remote areas [32].

Health system financing

To combat the lack of sustainable funding, the group recommended increasing advocacy efforts and stakeholder collaboration to develop innovative ways to reallocate funds into the public health sector and progress in ECO care integration. They also recommended that national governments develop and fund contextually appropriate plans that incorporate ECO care integration in existing health policies. While most of the funding for healthcare comes from national funds, stakeholder collaboration and the convening of funding sources have the potential to improve ECO care integration. Pooling of funds from various resources reduces duplication of effort and competition for resources. It also allows for more sustainable and less risky investments. The Salud Mesoamerica initiative 2015 is an example of a public-private partnership involving governments, multilateral funding sources, NGOs, and foundations, where almost $200M was invested in improving health disparities for maternal and child health services for 1.8 million people living in extreme poverty. The program ran for 10 years, improving health outcomes of women and children in eight PAHO region countries [33].

Conclusion

Engaging global health partners, leveraging regional expertise, utilizing WHO & PAHO tools, and implementing innovative public-sector resource management are essential to achieving effective integration of emergency, critical, and operative (ECO) care in the PAHO region. While many countries have developed National Surgical, Obstetric, and Anesthesia Plans (NSOAPs), implementation has often stalled due to fragmented and insufficient financing. These barriers can be addressed through pooled and coordinated investments from governments, NGOs, foundations, and development partners, reducing duplication and enabling sustainable investments in workforce development, education, and health information systems.

The principal follow-up to this convening was the development of the Global Strategy for Integrated Emergency, Critical and Operative Care (ECO), 2026–2035. The newly proposed strategy establishes clear expectations for Member States to develop national ECO action plans by the end of 2026, integrate ECO care into universal health coverage and health system governance, and report progress through 2035 [17]. However, effective implementation will require strengthened advocacy, leadership, and accountability across governments, professional societies, civil society, and development partners.

As members of civil society, and in support of moving from strategy to planning and implementation, Operation Smile has joined Harvard University’s Program in Global Surgery and Social Change, Universidad de La Sabana, and the Latin American Health Corporation, convening a forum focused on innovative financing mechanisms to address one of the most persistent barriers in the region: sustainable health financing. This workshop will promote education, collaboration, and practical approaches to financing not only ECO care integration but also broader universal health coverage goals.

This effort represents a call to action for ECO champions to move decisively from planning to implementation by mobilizing sustained financing, strengthening governance, and building ECO care systems that are resilient to political and budgetary shifts. An implementation roadmap with measurable targets and key indicators, adapted from the drafted Global Strategy for Integrated Emergency, Critical and Operative Care, 2026–2035, is provided to guide this process (Table 2) [17]. The consultative session in Bogotá demonstrated that alignment is achievable; translating this consensus into coordinated action offers a critical opportunity to expand equitable access to high-quality ECO care, enhance health system resilience, and protect populations across the PAHO region and beyond from preventable mortality and financial hardship.

The authors would like to acknowledge the delegates and patient groups who gathered in Bogota, Colombia in January as well as Operation Smile International and the representatives of the World Health Organization who supported this gathering.