Context:

Surgical care in India has long been a neglected aspect of public health, reflective of broader challenges faced by low- and middle-income countries. Despite being home to a population of 1.4 billion, the focus on surgical care has been limited over the last seven decades, with insufficient attention given in the National Health Policy of 2017. 

The Current Landscape:

India's Health Management Information System categorizes surgeries not requiring general or spinal anaesthesia as 'minor.' In the fiscal year 2019-2020, over 14 million minor surgeries were recorded, constituting a quarter of all surgeries. However, experts argue that this figure grossly underestimates the actual need for surgical interventions.

The Lancet Commission on Global Surgery (LCoGS) recommends six key indicators to assess surgical care at a population level. These include –

●       timely geographical access,

●       workforce density of surgeons, obstetricians, and anaesthetists,

●       surgical volumes,

●       perioperative mortality rate,

●       risk of impoverishment, and

●       risk of catastrophic expenditure.

Comparing India to countries like New Zealand, the disparity in surgical rates becomes evident, with estimates ranging from 166 to 3,646 surgeries per 100,000 people.

Barriers to Access:

The right to access surgery is, unfortunately, a luxury for millions of children and adults in India, transcending the severity of their conditions and financial capacities. Over 90% of rural Indians are estimated to lack access to surgery when needed. Several factors contribute to this dire situation.

            Timely Access: Many individuals face challenges reaching hospitals on time, particularly in rural and hilly areas where a lack of facilities, poor road networks, and limited transportation options, including ambulances, impede timely access.

            Resource Availability: Even when individuals reach healthcare facilities, the inadequacy of essential resources for treatment becomes apparent. Shortages in the Surgical, Anesthesia, and Obstetrics (SOA) workforce, especially in non-metropolitan areas, pose a significant challenge.

            Disparities: Disparities based on geographical location and financial capabilities further undermine the capacity to perform enough surgeries. Major surgeries are met with less than 7% coverage in rural India.

            Quality of Care: The quality of surgical care is pivotal for safe outcomes, hinging on factors such as the training of surgeons, availability of equipment, and appropriate peri-operative care. Perioperative mortality data, however, remains heterogeneous and incomplete.

            Financial Impact: The absence of universal healthcare coverage and limited surgical-care capabilities in public health facilities force many to seek care in private hospitals. This, in turn, leads to devastating financial impacts, with over 60% of surgery patients in rural India facing catastrophic expenses and potential impoverishment.

Initiatives Addressing Gaps:

Despite these challenges, numerous initiatives have emerged to address the gaps in India's surgical care system. Civilian initiatives and subnational programs, such as the Association for Rural Surgeons of India, EMRI Green Health Services offering emergency and trauma care, and organizations like SEARCH and JSS serving difficult-to-reach tribal populations, contribute significantly.

Moreover, individual surgeons and groups like the Global Surgery India Hub have played a role in technological innovations and research networks, aiming to enhance surgical care. While these initiatives are commendable, systemic gaps persist, requiring a more comprehensive approach to bridge the existing disparities.

The Need for a Surgical Action Plan:

A fundamental issue contributing to the inadequacies in surgical care is the lack of problem recognition. Surgical care access, the burden of preventable diseases due to surgery, and the economic toll of surgery are not yet integral parts of public health discourse in India. This neglect is evident in health policymaking and planning, as highlighted by the limited focus on surgical care in the National Health Policy (2017).

Addressing the Issue:

To improve the state of surgical care in India, several steps need to be taken:

            National Surgical Obstetric Anaesthesia Plans (NSOAPs): Drawing inspiration from other countries in Africa and South Asia, India needs to initiate and implement NSOAPs or equivalent policies. These plans would provide a framework for enhancing surgical care accessibility, workforce development, and infrastructure improvement.

            Data Monitoring and Evaluation: Investment in data collection for monitoring and evaluating surgical care indicators is crucial. The lack of comprehensive data has been a significant obstacle, and integrating surgical care data into existing surveys and systems, along with creating dedicated data collection mechanisms, can pave the way forward.

            Public Awareness and Advocacy: Creating awareness about the importance of surgical care as a fundamental aspect of public health is essential. Advocacy efforts should aim to integrate surgical care into mainstream health policy discussions and emphasize its role in preventing disease burden and economic hardships.

            Universal Healthcare Coverage: Expanding the reach of universal healthcare coverage can significantly reduce the financial burden on individuals seeking surgical care. This involves strengthening public health facilities to provide free or subsidized surgical care.

Conclusion:

India's current scenario in surgical care is emblematic of challenges faced by many low- and middle-income countries. While commendable initiatives exist at the grassroots level, systemic gaps persist, emphasizing the need for a concerted effort to integrate surgical care into the broader public health discourse. Recognizing the right to access surgery as a basic necessity and implementing comprehensive policies and strategies will be essential for addressing the disparities and improving the overall state of surgical care in India.