An essential priority within global surgical research is exploring and identifying how emergency and essential surgical care can best be implemented in LMICs, where the needs are greatest and health systems are often the least developed. Published examples of well-functioning surgical services in LMICs are rare, and there is little information on the specific factors that make them successful. The process of progressive improvement in global surgical care is widely multi-factorial, and includes considerations of infrastructure, equipment, personnel, as well as education and training.

Research priorities in this area include designing and delivering a basic surgical package that is flexible enough to be adaptable to local needs, benchmarks for assessing requirements for delivering emergency and essential surgical care at first-level hospitals, strategies for measuring the impact of any improvements, and cost estimates for various interventions. Specific interventions may include the creation of new health care facilities and inpatient units, the addition of personnel such as surgical or anaesthesia providers, or the delivery of various types of equipment and supplies. Previous work has emphasized that such improvements may be best measured within comprehensive packages.

While significant resources have been allocated by academic and non-academic groups to measure burden and capacity in countries and regions, there has been very limited research on the design and implementation of solutions to these problems. Some of these solutions will of necessity entail the development of low-cost essential surgical equipment such as anaesthesia machines, consumables such as sutures, power sources, and/or orthopaedic implants.

In recent years, several global initiatives have been aimed at measuring and improving the quality of surgical care delivery. Examples include the WHO surgical checklist, the global pulse oximetry initiative, and a recent emphasis on post-operative mortality rate (Fig. 8.2). While a focus on quality of care is essential, there is limited consensus on which quality indicators are most meaningful, contextually appropriate, and likely to be embraced by providers and policy-makers in resource-poor settings. Some of this work has been a direct extension of surgical quality improvement initiatives in the United States, where quality improvement discussions often start with the large number of patients unintentionally harmed by hospitals and through medical errors and follow strategies adapted from the aviation and the automobile industries.

A significant component of the surgical burden is caused by multiple barriers to access for patients and families, such as poverty, transport costs, poor understanding of disease, low expectations of the health system, fear, cultural and spiritual factors, and other factors that influence health-seeking behaviour. For example, in many communities it is more common to initially pursue care from a traditional healer than from a medical professional. While some of these factors have been elucidated and addressed in other medical fields, very limited work has been done regarding surgical conditions. This may limit our knowledge base for designing interventions that have the potential to improve access to surgical care.

An essential limiting factor in scaling up the provision of surgical care in LMICs is the severe deficiency in the workforce, which is primarily comprised of the training, retention, and distribution of surgical and perioperative care providers. Surgical training is both lengthy and costly, and market forces work against newly trained surgeons being retained by the district-level hospitals where they are most needed. Surgical training in LMICs has traditionally been university-based, with sub-specialty expertise often gained through observerships in high-income countries (HICs). Newer models are based on cross-national professional colleges and academies (such as the West African College of Surgeons, the College of Surgeons of East, Central, and Southern Africa, and the Pan-African Academy of Christian Surgeons). Studies are needed to evaluate the quality and impact of such distributed training approaches and the best educational methods for surgical training in LMICs. This includes reviewing the essential components of curricula and identifying region-appropriate case volume and distribution to ensure proficiency. Courses and training tools geared towards high-income settings generally require significant modifications to contextualize to limited-resource settings.

Issues of migration of health professionals from low to high-income countries (the so-called ‘brain drain’) are not limited to surgical providers. Nonetheless, very little work has been done to quantify the extent and impact of this migration on surgical service delivery, nor to evaluate various approaches to addressing this issue. Similarly, the maldistribution of specialist medical providers, who typically aggregate in large cities at the expense of rural areas, has not been sufficiently studied. Research is needed to design and implement strategies for increasing the rural surgical workforce. These strategies might include policies such as increased salaries and benefits, continuing education opportunities, housing and educational benefits for children of providers, etc.

‘Stop-gap’ national task-shifting programs have been instituted in several LMICs, with occasional successful examples of non-surgeon physicians, physician assistants, clinical officers, and nurses used to complement the surgical workforce. Longitudinal studies are needed to evaluate such programs and their long-term impact not only on health care but also on national workforce. While such programs have been studied for short-term outcomes, they often lack other critical metrics, such as cost, to inform their potential implementation in other settings.

Surgical care has been aptly identified as a key primary care intervention and contributes to major challenge areas within global health, such as infectious disease and child and maternal health. Thus, surgery constitutes an important factor in the global success of meeting the 2015 UN Millennium Development Goals and later in the post-MDG era. There are, however, no studies defining the role of surgical care in meeting these global initiatives. As these initiatives link health improvement to economic growth, integrating surgical care into these important movements could represent an important strategy for encouraging investment in surgical care in LMICs. Potential examples of such integration, where surgical care plays a key role, include maternal mortality and child health initiatives, the growing focus on non-communicable diseases (NCDs) such as cancer, diabetes, and cardiovascular diseases, and infectious diseases such as HIV-associated conditions. Engaging major global initiatives to propose surgical public health targets that may use metrics such as mortality from specific surgical conditions or access to care are a critical research priority. A critical step towards appropriate attention to these issues was made in May 2015 when the World Health Assembly passed a resolution on the importance of essential surgical and anaesthesia care within universal health coverage.