Representative image. Photo: JAFAR AHMED/Unsplash
Globally, non-communicable diseases (NCDs) are beginning to receive the required attention. Once regarded as a “silent killer” of the rich, they have slowly started surpassing communicable diseases as the major cause of death in the developing world. In 2019, shows NCDs accounted for nearly two-thirds of all deaths in India. Rapid urbanisation, changes in lifestyle modalities, and a rise in substance abuse are some risk factors for the epidemiological transition. Among NCDs, cardiovascular diseases have the largest share in mortality (Figure 1).
While the revised guidelines form an important step toward tackling NCDs, they leave an essential component of NCD management out: surgical care. Timely provision of safe and affordable surgical care services lower mortality and prevents the detrimental outcomes arising from several non-communicable diseases. For example, radical excision of tumorous growths can be among the most effective methods employed for cancer treatment. Further, contrary to popular belief, surgical treatment of multiple disease conditions including NCDs is cost-effective even in low- and middle-income countries. The best example would be cataract surgery for the treatment of blindness. Not providing surgery to those in need leads to disease burden and associated loss of productivity and economic burden as high as $20.7 trillion across 128 countries. Hence, building robust surgical care service networks can improve lives and better the economy.
The Lancet Commission on Global Surgery (LCoGS) in 2015 reported that around 5 billion people around the world do not have access to safe, affordable, and timely surgical care when needed. Additionally, 143 million surgical procedures are needed in low- and middle-income countries each year to save lives and prevent disability. The situation in India paints a correspondingly grim picture with only 6.81% of the need for major surgical procedures (i.e., those requiring anaesthesia) being met in rural India. Over 90% of the population in India lacks access to timely, safe, and affordable surgical care. Integration of surgery in policies, programmes, and guidelines is urgently needed.
The 68th World Health Assembly acknowledged emergency and essential surgical care as an integral part of universal health coverage. Even so, policy attention to surgical care has been limited across the world including India. Document analysis of major health policy, planning, and programmatic reports of India over the last several decades has depicted relatively poor prioritisation of surgical care when compared to non-surgical conditions. Further, older policy documents showed better prioritisation of surgery as compared to the more recent documents, including the most recent National Health Policy of 2017. This seems to hold true for the revised NCD guidelines.
We conducted a similar analysis of the revised NCD operational guidelines to assess the priority given to surgical care in the management of non-communicable diseases. A thorough screening of the guidelines using a predetermined set of surgical and non-surgical (control) keywords was conducted. The document was electronically searched for a particular keyword and the number of mentions obtained against each search were recorded. Mentions, in this context, refer to the number of times the keyword appears in the document. The number of mentions obtained for a keyword depicts prioritisation. The mentions per keyword allow a comparison of surgical and non-surgical prioritisation. For easier visualisation, 52 surgical keywords were divided among eight subgroups- Surgery, Trauma, Anaesthesia, Pediatric surgery, Obstetric, Blood, Oncology, and Blindness. Other than Oncology, all surgical subgroups had lower prioritisation than the non-surgical group (Figure 2). Overall, surgery and related conditions have been under-prioritised in the NCD document, especially when it comes to pediatric surgery, anaesthesia care, blood management, etc.
In the surgical group, cancer and related keywords showed the maximum number of mentions which is justifiable considering it is the third most prevalent NCD in the country (Figure 3A). Among non-surgical keywords, TB/tuberculosis was mentioned heavily (Figure 3B).
Overall there was a limited focus on surgical care in the revised guidelines. While there was sufficient coverage of cancer: prevention, population-based screening, referral and treatment at the tertiary level, surgical management of other NCDs is largely ignored. The majority of the references made to surgery were also in the context of oral cancers. Emergency management of cardiac and stroke cases included some reference to surgical interventions. Blindness was mentioned but mainly focused on the integration of the pre-existing National Programme for Control of Blindness & Visual Impairment with the new NP NCD programme without cousin on ophthalmic surgeries. Common surgical procedures like incision, excision and amputation were not mentioned in the entire document which is surprising considering the need for these basic operations to control the progression of disease processes. The importance of pediatric surgery, the role of anaesthesia and the need for blood banking were alarmingly absent.
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To summarise, while the revised guidelines focus on aspects of prevention and management of common noncommunicable diseases, they pass over surgical care. The guidelines could have included a scheme for surgical treatments, especially those that should be delivered at the level of district hospitals. Cost-effective surgical package options that are essential for the management of NCDs could have been included. Adequate allocations for a well-trained surgical workforce and well-resourced infrastructure are needed. More importantly, the guidelines could have pushed for the integration of surgical care and perioperative services at all levels – primary, secondary, and tertiary – of health care delivery to avoid access disparities. Pediatric surgical care deserved high attention given the large child and adolescent populations and their NCD burden.
In the absence of deserved attention in existing policies, plans, and guidelines, India should potentially follow the path taken up by several other low- and middle-income countries to develop and implement a national surgical plan. Such a plan would help improve policy prioritisation of surgical care that can directly impact the surgical preparedness of health facilities across India, particularly in the rural scenario where poor infrastructure and lack of trained surgeons make the delivery of basic surgical services challenging. Providing surgical care to all is solving an endgame problem that can have a society-wide positive impact in the long run.
Ritika Shetty is a medical intern at Terna Speciality Hospital and Research Centre. She is also a researcher at the Association for Socially Applicable Research (ASAR), India. Siddhesh Zadey is a co-founder of ASAR, India and chair of the G4 Alliance SOTA Care in South Asia Working Group.