The Politics of Global Surgery: A Panel Discussion with Policy Experts on Advancing the Field Amid Persistent Challenges

Introduction

2025 marks the inaugural decade of the Global Surgery Movement. Progress toward making surgical care accessible, safe, and affordable has been shaped by key milestones. The movement’s roots trace back to 1980, when WHO Director-General Dr. Halfdan Mahler underscored the global lack of surgical access as a matter of social justice [1]. Although launched with considerable commitment from governments, organizations, and frontline surgical care providers alike, challenges ranging from the pandemic to geopolitical conflicts have interfered with its momentum since the Lancet Commission on Global Surgery in 2015 [2]. Following the 2015 World Health Assembly resolution WHA68.15 that recognized surgery and anesthesia as essential components of Universal Health Coverage, countries initiated National Surgical, Obstetric, and Anesthesia Plans to operationalize surgical systems strengthening in this domain [3–6].

On 24 July 2025, the Program in Global Surgery and Social Change (PGSSC) convened an hybrid roundtable discussion via Zoom, to discuss the politics shaping surgical systems strengthening in low- and middle-income countries (LMICs). Professor Salome Maswime (S.M.), Dr. Walt Johnson (W.J.), and Professor Nobhojit Roy (N.R.) shared their perspectives on a discussion co-moderated by PGSSC’s Director of Policy and Advocacy, Dr. Kee B. Park (K.P.), and research fellow Dr. Nardos Getachew Bulfeta. This article presents the key reflections of the roundtable panel discussion, highlighting the perspectives and policy reflections shared by the participating policy experts.

In his opening remarks, Dr. Park emphasized that health is inherently political and that academia should move beyond solely publishing research to directly engaging in critical discussions on the policy front. The conversation focused on understanding the effects of the current global health landscape, differing perspectives on the cohesion of the Global Surgery movement, and reshaping future efforts for sustained success in surgical care provision for all.

The Challenges

The discourse reflected on the financial constraints faced by the World Health Organization due to heavy reliance on voluntary and earmarked contributions [7]. This has only been made worse by recent austerity measures and staffing cuts in light of shifts in the political and global health financing landscape that limit capacity for financial and strategic support to LMICs [8]. Historically sidelined national health priorities such as surgical care provision, will further be tested both at the policy level and on the front lines [9]. In addition to preexisting surgical system limitations, surgeons will encounter patients who are sicker due to malnutrition and untreated co-morbidities.

Fragmentation and Siloed Efforts

A persistent challenge lies in the fragmentation of work streams within the global surgery community. Funding silos, institutional turf wars, and professional sub-specializations have fostered divisions where stakeholders often defend their niche interests and donor allocations for fear of diluting their influence or resources. This results in inefficiencies and missed opportunities, reflected in failure to tackle root causes. “Different NGOs (non-government organisations) cumulatively perform approximately 1500 obstetric fistula repairs/year, which is impressive on its own, but 4000 new ones occur annually” (W.J.),  due to lack of timely obstetric care.

The diversity of surgical specialties, each advocating separately and championing different priorities, hinders consensus-building on unified goals or advocacy positions. “Our weakness is that we don’t know what to prioritize; we have grand answers that will be too hard to commit to” (N.R.) In comparison, global health movements, such as maternal health, coalesced around clear, patient-centered messages and shared objectives, enabling greater policy traction. Successful health movements often focus on a few accessible technical interventions that resonate widely and can be scaled efficiently. The lack of a unifying, comprehensible narrative weakens engagement with policymakers and funders who seek tangible results and measurable outcomes within defined timelines.

Limited Political Proficiency

A disconnect persists between clinical surgical practice and public health policy. The global surgery community operates within clinical paradigms focused on individual patient care and specialized technical skills, whereas public health stakeholders work within a broader context of population health and resource allocation. Surgeons and surgical leaders must develop public health competencies and adeptly “code-switch”, speaking the language of health economics, policy, and system strengthening. This skill is crucial for influencing government decisions, where competing priorities and finite resources require clear communication that surgical care delivers substantial population health benefits.’

Moreover, there is a pressing need for policy-relevant technical documents, guidelines, and implementation frameworks on surgical capacity-building, offered in terms that are accessible to policymakers. Without this translation, surgical advocacy risks remaining insular and disconnected from national health planning processes limiting crucial financing strategies that support surgical systems.  “We are no longer the neglected stepchild the late Paul Farmer once described, but we are the absent child.” (S.M)[10].

The Way Forward

Clear and Unified Advocacy

Surgical and anaesthesia care address a broad spectrum of health conditions spanning infectious, maternal, neonatal, non-communicable diseases, and injuries, forming a cross-cutting sectors of resilient health systems; [2] yet, while interventions characterized by vaccines or medications are easily conceptualized and communicated, the complexity and technical nature of surgical care pose a considerable communication hurdle. The global surgery movement must, therefore, develop clear, simple, and implementable advocacy messages.

Following a pragmatic debate on whether the movement should prioritize broad health system strengthening or focused, targeted interventions, the discussion recommends building strategic, digestible, and tiered -short-term, mid-term, and long-term- goals to readily capture political and donor interest. “Health systems will fall in line once you have a common mission.” (N.R.) A logical starting point can be to champion access to surgical care. Advocating for access to lifesaving emergency surgeries and reduction of surgical waitlists holds tangible appeal to both the public and policymakers without favoring a single specialty.

The missing link to drive unity is a strong and deliberate leadership, to prevent siloes efforts in the ongoing work within the global surgery community. The objective of this leadership is not to impose uniformity but rather to cultivate complementarity among diverse global surgery programs, organizations, and units. Aligning strategies through effective leadership can ensure that the collective efforts of stakeholders reinforce, rather than duplicate one another. This approach is critical for the direction of cohesion needed to guide the global surgery movement through its next pivotal steps.

Community Engagement and Grassroots Mobilization

“… Public health is driven by the public.”(N.R). Movement-building in global health is most effective when it is grounded in affected populations and community advocates, not solely driven by top-down technical experts. “It starts with the community understanding why surgery is so important for them, and then partnering with us on our efforts.”(S.M.) Storytelling can become a useful tool that amplifies global efforts to bridge the public to frontline workers. In global surgery, surgical services are often feared, poorly understood, or regarded as inaccessible by many communities. Effective messaging must demystify surgery, emphasize its life-saving potential, and foster trust through improved community education. Care must be taken with messaging and branding, such as campaigns on “safe surgery”, which could inadvertently reinforce preexisting anxieties.

Embracing community-level actors such as traditional birth attendants, bone-setters, general practitioners in rural areas, and mid-level providers who deliver surgical care broadens the movement’s relevance and reach. Systematically integrating these surgical care providers counters the elitism sometimes found in surgical professional spheres and encourages more inclusive models of care.

Conclusion

Building on Paul Farmer’s description of surgery as the “neglected stepchild of global health,” this panel discussion observes a shifting paradigm in which surgical care risks becoming not merely neglected, but absent from global health discourse and related investment frameworks.[10] Still in its formative years, the Global Surgery movement possesses the opportunity to learn from the experiences of other global health domains and to chart a more cohesive, resilient path forward. This timely reflection on the inaugural decade of the movement highlighted pitfalls and revealed the following actionable recommendations.

1. Addressing the leadership vacuum is critical to building unity and fostering cross-sector collaboration. Leadership is key to providing strategic direction, mitigating siloes and fragmentation in workflows, and enhancing focus, cooperation, and measurable progress. This enables a strong rally behind specific, well-defined projects and campaigns with a timeline—rather than big-picture goals.
2. Strengthening political, economic, and financing strategy execution requires engaging with multiple “codes”, that shape policy processes, stakeholder dynamics, and the interplay of economic and political factors. Such expertise enables sustained and effective engagement in public health forums, strategic decision-making, strengthening financial frameworks that facilitate efficient resource mobilization, and ensures alignment of interests. Developing these skills is crucial for embedding surgical care into health systems and securing policy alignment.
3. Professional surgical societies are invaluable partners that can provide critical technical expertise, helping shape national surgical priorities. They can support governments by establishing evidence-based guidelines and standards of care, quality improvement programs, and capacity building through workforce training and education. They also lead innovation and research, fostering partnerships to strengthen surgical ecosystems, promoting advocacy and global partnerships
4. Effective community-level engagement in surgical care necessitates a clear narrative to redefine perceptions and reduce biases. Empowering grassroots advocacy and allowing communities to develop their agency fosters robust participation across the continuum of surgical care: in prevention, screening, and rehabilitation.

While the panel drew from experts with extensive experience in global surgery and health systems, we acknowledge that geographic representation was more concentrated in established academic centers. Several contributors, although based in these institutions, maintain active collaborations, advisory roles, and field programs across low- and middle-income countries, ensuring that contextual perspectives inform the discussion. Nonetheless, we recognize that greater inclusion of LMIC-based practitioners would further enrich future dialogues and enhance the global relevance of policy-oriented recommendations. In paving this deliberate path, Global Surgery has the opportunity to shift from aspiration to lasting transformation, effectively weaving surgical care delivery into the global health fabric, and advancing renewed political commitments toward achieving the Sustainable Development Goals by 2030.