National Surgical,

Obstetric and Anaesthesia

Planning

M A N U A L – 2 0 2 0 E D I T I O N
© United Nations Institute for Training and Research, 2020

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UNITAR. National Surgical, Obstetric and Anaesthesia
Planning Manual. Edition 2020. Geneva, Switzerland:
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Program in Global Surgery and Social Change (PGSSC)

Department of Global Health and Social Medicine
Harvard Medical School, Boston, MA, USA

Programme in Health and Development Global Surgery Foundation (GSF)

United Nations Institute for Training and Research (UNITAR) Geneva, Switzerland
Geneva, Switzerland
TABLE OF

Contents
1. INTRODUCTION/PREFACE 1

2. DEVELOPING A CASE FOR 5

PRIORITIZING AND PLANNING
SOA CARE
2.1 The current state of SOA care 7
2.1.1 Epidemiological burden of surgical disease 7
2.1.2 Access and capacity 10
2.1.3 Current funding and prioritization of surgery 11
on the international agenda

2.2 Why SOA care must be prioritized 12

2.2.1 SOA care is required to meet the SDGs 13
2.2.2 SOA care is required to reach goals of UHC 17
and primary health care coverage by 2030
2.2.3 Surgery is cost-effective 17

2.3 Why engage in national SOA planning? 18

2.3.1 Actor power: Visibility and stakeholder 18
engagement
2.3.2 Ideas: Building a cohesive vision 18
2.3.3 Political contexts: Integration and 18
accountability
2.3.4 Features of the problem: Making a case 19
through data
2.3.5 Efficiency 19
2.3.6 Platform for investment 19

3. THE SOA PLANNING PROCESS 21

3.1 General principles of planning 22
3.1.1 NSOAP models 22
3.1.2 WHO support 27

3.2 Steps for developing an NSOAP 27

3.2.1 Ministry support and ownership 28
3.2.2 Situation analysis and baseline assessment 29
3.2.3 Stakeholder engagement and priority- 29
setting
3.2.4 Drafting and validation 31
3.2.5 Monitoring and evaluation 31
3.2.6 Costing and budgeting 31
3.2.7 Governance 31
3.2.8 Implementation 31

3.3 Dissemination 31

UNITAR & HARVARD MEDICAL SCHOOL i

4. SITUATION ANALYSIS AND 33
BASELINING
4.1 Data in global surgery 34

4.2 Why conduct a situation analysis? 35

4.3 How to conduct a situation analysis 35

4.3.1 Define what information is needed 35
4.3.2 Review existing information 37
4.3.3 Comprehensive situation assessment 37
4.3.4 Conduct a SWOT analysis 39

4.4 Core surgical indicators 40

5. STAKEHOLDER ENGAGEMENT 45
AND PRIORITY-SETTING
5.1 Why do we need a multi-stakeholder 46
approach?

5.2 Stakeholder groups 46

5.3 Stakeholder identification 48

5.4 Initial engagement and priority-setting 48

5.4.1 Aims of engagement 48
5.4.2 How to engage 50
5.4.3 Setting priorities 52

5.5 Supplemental resources 55

6. DRAFTING AND VALIDATING 57

THE PLAN
6.1 Key considerations 58
6.1.1 Reflect views of stakeholders 58
6.1.2 Ensure priorities are evidence-informed 58
6.1.3 Align with priorities of the government 58
and ministry

6.2 Drafting the NSOAP 59

6.2.1 Integrating themes and establishing 59
consensus on priorities
6.2.2 Assembling a writing team 60
6.2.3 Drafting recommendations 60
6.2.4 Writing recommendations 63

6.3 Arriving at broad consensus on the 63

final NSOAP

6.4 Supplemental resources 64

ii UNITAR & HARVARD MEDICAL SCHOOL

7. MONITORING AND EVALUATION 67 10. FINANCING 95
7.1 Goals of Monitoring and Evaluation (M&E) 68 10.1 Introduction 96

7.2 Frameworks for surgical indicators 68 10.2 Incorporating the NSOAP within health 96
system financing
7.3 Selection of additional indicators 70 10.2.1 Aligning the NSOAP with the national 96
budgeting process
7.4 Data flow plan for indicators 71 10.2.2 Making a strong investment case to 96
inform budget allocation and decisions
7.5 Setting measurable targets for indicators 71 10.2.3 Mobilizing and sustaining political 97
support for NSOAP financing
7.6 Using the data 71
10.3 Resource mobilization for NSOAP policy 97
7.7 Supplemental resources 74 financing
10.3.1 The concept of fiscal space 97

8. COSTING AND BUDGETING 79 10.4 Funder stakeholder analysis and 102

engagement strategy
8.1 Steps involved in costing the plan 80
8.1.1 Assemble available costing information 80 10.5 Conclusion 103
8.1.2 Define the cost objects and the quantities 83
required
8.1.3 Determine the cost base 83 11. IMPLEMENTATION 105
8.1.4 Attribute costs to the cost objects 83
8.1.5 Validate and confirm the results of the 84 11.1 Introduction 106
costing exercise
8.1.6 Create a summary and share the results 84 11.2 Disseminating the NSOAP 107

8.2 Participants in the costing process 84 11.3 Operationalizing the NSOAP 108

8.3 Tools available to guide the costing process 84 11.4 Resources needed for NSOAP 109
implementation

9. ORGANIZATIONAL STRUCTURES 87 11.5 Establishing leadership and governance 110

structure for the NSOAP implementation
AND GOVERNANCE
11.6 Initiation of NSOAP implementation - Pilot 112
9.1 National-level organization and governance 88
11.7 Feedback on implementation progress 112
9.2 Regional- and district-level organization 89 and results
and governance
11.8 Conclusion 112
9.3 Facility-level organization and governance 90

9.4 Training around leadership and governance 92

12. REFERENCE LIST 115
9.5 Conclusion 93

UNITAR & HARVARD MEDICAL SCHOOL iii

OUR

Acknowledgements
This publication is the result of a collaboration between the
Program in Global Surgery and Social Change at Harvard
Medical School and the United Nations Institute for Training
and Research.

We would like to thank the contributors and authors who have

made this publication possible.

We would also like to thank the following people for writing

support and editorial expertise:

Barnabas Alayande
Adam Ammar
Alexandra Buda
Gabrielle Cahill
Kashmira Chawla
Deena El Gabri
Belain Eyob
Deen Garba
Sebastian Hofbauer
Anusha Jayaram
Rashi Jhunjhunwala
Tarinee Kucchal
Anna Nicholson
Isioma Okolo
Manon Pigeolet
Rennie Qin
Myron Rolle
Makela Stankey
Dominique Vervoort
Anchelo Vital

The contents of this manual came from the proceedings of

the National Surgical, Obstetric and Anaesthesia Planning
Workshop that took in Dubai, UAE, 2018 and the National
Surgical, Obstetrics and Anesthesia Planning Conference for
WHO Regional Officers, High-Level Authorities, and Funders,
Dubai, UAE, 2019 with support from the Harvard Medical School
Center for Global Health Delivery – Dubai.

The PGSSC would also like to thank Rhonda Stryker, William

Johnston and the Kletjian Foundation for their support.

iv UNITAR & PGSSC

 NATIONAL SURGICAL, OBSTETRIC AND ANAESTHESIA PLANNING
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Contributors
EDITORS*
Katherine Albutt, MD, MPH, Paul Farmer Global Haitham Shoman, MD, DIC, MPH, SM, Paul Farmer
Surgery Research Fellow, Program in Global Surgery Global Surgery Research Fellow, Program in Global
and Social Change, Department of Global Health Surgery and Social Change, Department of Global
and Social Medicine, Harvard Medical School; Health and Social Medicine, Harvard Medical School,
Department of Surgery, Massachusetts General Boston, MA, USA. Vanier Scholar, Canadian Institutes
Hospital, Boston, MA, USA of Health Research – PhD at McGill University,
Montreal, Canada
Isabelle Citron, BmBCh, MPH, Paul Farmer Global
Surgery Research Fellow, Program in Global Surgery Kristin Sonderman, MD, MPH, Paul Farmer Global
and Social Change, Department of Global Health Surgery Research Fellow, Program in Global Surgery
and Social Medicine, Harvard Medical School, Boston, and Social Change, Department of Global Health
MA, USA and Social Medicine, Harvard Medical School;
Department of Surgery, Brigham and Women’s
Walter Johnson, MD, MBA, MPH, Lead (2015-2019), Hospital, Boston, MA, USA
Emergency and Essential Surgical Care Program,
World Health Organization, Geneva, Switzerland.
Department of Neurosurgery, Loma Linda University,
Loma Linda, CA, USA REVIEWERS*
John G. Meara, MD, DMD, MBA, Kletjian Professor Adeline Boatin, MD, MPH, Assistant Professor of
and Director, Program in Global Surgery and Social Obstetrics and Gynecology, Harvard Medical School
Change, Harvard Medical School; Plastic Surgeon-in- and Department of Obstetrics and Gynecology,
Chief, Boston Children’s Hospital, Boston, MA, USA Massachusetts General Hospital

Alexander W. Peters, MD, MPH, Paul Farmer Global Kathryn Chu, MD, MPH, FACS, FASCRS, Professor of
Surgery Research Fellow, Program in Global Surgery Global Surgery - Director, Centre for Global Surgery,
and Social Change, Department of Global Health and Stellenbosch University, South Africa
Social Medicine, Harvard Medical School, Boston, MA,
USA; Department of Surgery, Weill Cornell Medical Dan Deckelbaum, MD, CM, FRCSC, MPH, Co-director,
College, New York, NY USA Centre for Global Surgery, Assistant Professor,
Division of trauma surgery, McGill University Health
Lina Roa, MD, MPH, Paul Farmer Global Surgery Center, Montreal, Canada
Research Fellow and Lecturer, Program in Global
Surgery and Social Change, Department of Global Anita Gadgil, MBBS, MS, DNB (surg), Head,
Health and Social Medicine, Harvard Medical Department of Surgery and WHO Collaboration
School, Boston, MA, USA; Department of Obstetrics Center, (WHOCC) for Research in Surgical Care
& Gynecology, University of Alberta, Edmonton, Delivery in LMICs, Bhabha Atomic Research Centre
Canada Hospital, Mumbai, India

* Editors and reviewers are listed in alphabetical order by surname

2020 EDITION v
Gabriel Y.K. Ganyaglo, MB ChB, Obstetrician Urogy- Kenan Yusif-Zade, (Col), MD, PhD, MBA, FACS,
naecologist, Korle Bu Teaching Hospital, Accra, Ghana Professor, General and Military Surgery | Head
of Military Hospital, State Border Service, Baku,
Geoffrey Ibbotson, MSc, MD, FRCSC, FACS, Senior Azerbaijan
Consultant / General Surgeon, Executive Lead, Global
Surgery Foundation. United Nations Institute for
Training and Research (UNITAR)
CONTRIBUTING AUTHORS
Neema Kaseje, MD, MPH, DrPHc, London School of
Hygiene and Tropical Medicine, London, UK Chapter 1. Introduction

Salome Maswime, PhD, Head of Global Surgery, John G. Meara, MD, DMD, MBA, Kletjian Professor
Department of Surgery, Faculty of Health Sciences, and Director, Program in Global Surgery and Social
University of Cape Town, Associate Professor Change, Harvard Medical School; Plastic Surgeon-in-
Obstetrics and Gynaecologist, President of SACSS, Chief, Boston Children’s Hospital, Boston, MA, USA
Capte Town, South Africa
Walter Johnson, MD, MBA, MPH, Lead (2015-2019),
Elizabeth Jane McLeod, MD, MPH, FRACS, Royal Emergency and Essential Surgical Care Program,
Australasian College of Surgeons (RACS) World Health Organization, Geneva, Switzerland.
Department of Neurosurgery, Loma Linda University,
Martin Ekeke Monono, MD, FRCS(Ed), Consultant Loma Linda, CA, USA
ENT Surgeon, Wellstar Imaging and Diagnostic
Centre, Miniprix Bastos, Yaounde, Cameroon
Chapter 2. Developing a case for
Lauri Romanzi, MD MScPH, Lecturer, Department of prioritizing and planning SOA care
Global Health and Social Medicine, Harvard Medical
School, Boston, USA Kathryn Taylor, MD, Program in Global Surgery and
Social Change, Department of Global Health and
Andres Rubiano, MD, Professor of Neurosciences Social Medicine, Harvard Medical School, Boston,
and Neurosurgery, Universidad El Bosque, Bogota, MA, USA
Colombia
Isabelle Citron, BmBCh, MPH, Paul Farmer Global
Lubna Samad, MBBS, MRCS, FCPS, Director Center Surgery Research Fellow, Program in Global Surgery
for Surgery and Acute Care, Global Health Directorate, and Social Change, Department of Global Health
Indus Health Network, Karachi, Pakistan and Social Medicine, Harvard Medical School, Boston,
MA, USA
Mark Shrime, MD, MPH, PhD, FACS, Director, Center
for Global Surgery Evaluation, Massachusetts Eye Kristin Sonderman, MD, MPH, Paul Farmer Global
and Ear Infirmary, Harvard Medical School, Boston, Surgery Research Fellow, Program in Global Surgery
MA, USA and Social Change, Department of Global Health
and Social Medicine, Harvard Medical School;
David Watters, AM, OBE, BScHons, MB ChM, Department of Surgery, Brigham and Women’s
FRCSEd, FRACS, University Hospital Geelong, Hospital, Boston, MA, USA
Barwon Health - Alfred Deakin Professor, Deakin
University, Melbourne, Australia Swagoto Mukhopadhyay, MD, MPH, Paul Farmer
Global Surgery Research Fellow, Program in Global
Surgery and Social Change, Department of Global
Health and Social Medicine, Harvard Medical School,
Boston, MA, USA

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Adrian W. Gelb, MBChB, FRCPC, FRCA, Secretary, Boston, MA, USA. Vanier Scholar, Canadian Institutes
World Federation of Societies of Anaesthesiologists; of Health Research – PhD at McGill University,
Professor, Department of Anesthesia & Perioperative Montreal, Canada
Care, University of California San Francisco, CA, USA
Yihan Lin, MD, MPH, Paul Farmer Global Surgery
Barbara Levy, MD, Clinical Professor of Obstetrics and Research Fellow, Program in Global Surgery and
Gynecology, George Washington University School of Social Change, Department of Global Health and
Medicine and Health Sciences, Washington DC, USA Social Medicine, Harvard Medical School; Depart-
ment of Surgery, University of Colorado Hospital,
Emmanuel Makasa, MD, MPH Global Surgery Con- Aurora, CO, USA
sultant and Director – Wits Centre of Surgical Care for
Primary Health & Sustainable Development, Faculty Mzaza A. M. Nthele, MD, Director of Clinical Care
of Health Sciences, University of Witwatersrand, RSA and Diagnostic Services, Ministry of Health, Lusaka,
Zambia
John G. Meara, MD, DMD, MBA, Kletjian Professor
and Director, Program in Global Surgery and Social
Change, Harvard Medical School; Plastic Surgeon-in- Chapter 4. Situation analysis and
Chief, Boston Children’s Hospital, Boston, MA, USA baselining

Walter Johnson, MD, MBA, MPH, Lead (2015-2019), Katherine Albutt, MD, MPH, Paul Farmer Global
Emergency and Essential Surgical Care Program, Surgery Research Fellow, Program in Global Surgery
World Health Organization, Geneva, Switzerland. and Social Change, Department of Global Health
Department of Neurosurgery, Loma Linda University, and Social Medicine, Harvard Medical School;
Loma Linda, CA, USA Department of Surgery, Massachusetts General
Hospital, Boston, MA, USA

Chapter 3. The SOA planning process Desmond Jumbam, MSGH, Health Policy Analyst,
Program in Global Surgery and Social Change,
Kristin Sonderman, MD, MPH, Paul Farmer Global Department of Global Health and Social Medicine,
Surgery Research Fellow, Program in Global Surgery Harvard Medical School; Department of Plastic
and Social Change, Department of Global Health and Oral Surgery, Boston Children’s Hospital,
and Social Medicine, Harvard Medical School; Boston, MA, USA
Department of Surgery, Brigham and Women’s
Hospital, Boston, MA, USA Kathryn Taylor, MD, Program in Global Surgery and
Social Change, Department of Global Health and
Isabelle Citron, BmBCh, MPH, Paul Farmer Global Social Medicine, Harvard Medical School, Boston,
Surgery Research Fellow, Program in Global Surgery MA, USA
and Social Change, Department of Global Health
and Social Medicine, Harvard Medical School, Boston, Emmanuel Makasa, MD, MPH Global Surgery
MA, USA Consultant and Director – Wits Centre of Surgical Care
for Primary Health & Sustainable Development, Faculty
Swagoto Mukhopadhyay, MD, MPH, Paul Farmer of Health Sciences, University of Witwatersrand, RSA
Global Surgery Research Fellow, Program in Global
Surgery and Social Change, Department of Global Jose Miguel Guzman, PhD, Technical Leader in
Health and Social Medicine, Harvard Medical School, International Development and Population Change.
Boston, MA, USA Founder of the blog: NoBrainerData.com

Haitham Shoman, MD, DIC, MPH, SM, Paul Farmer Sabrina Juran, PhD, Faculty, Program in Global
Global Surgery Research Fellow, Program in Global Surgery and Social Change, Department of Global
Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School,
Health and Social Medicine, Harvard Medical School, Boston, MA, USA

2020 EDITION vii

Chapter 5. Stakeholder engagement
and priority-setting

Brittany Powell, MD, Program in Global Surgery and Larry Akoko, MD, Senior Lecturer, Department of
Social Change, Department of Global Health and Surgery, Muhimbili University of Health and Allied
Social Medicine, Harvard Medical School, Boston, Science and President Elect, Tanzania Surgical
MA, USA; Stanford University School of Medicine, Association, Dar es Salaam, United Republic of
Palo Alto, CA, USA Tanzania

Isabelle Citron, BmBCh, MPH, Paul Farmer Global Edwin R. Lugazia, MD, MMed, FCTA, MBA, Consultant
Surgery Research Fellow, Program in Global Surgery Cardiothoracic Anaesthesiologist and Head of
and Social Change, Department of Global Health Anaesthesiology Department, Muhimbili University
and Social Medicine, Harvard Medical School, Boston, of Health and Allied Sciences School of Medicine, Dar
MA, USA es Salaam, United Republic of Tanzania

Kristin Sonderman, MD, MPH, Paul Farmer Global Isabelle Citron, BmBCh, MPH, Paul Farmer Global
Surgery Research Fellow, Program in Global Surgery Surgery Research Fellow, Program in Global Surgery
and Social Change, Department of Global Health and Social Change, Department of Global Health
and Social Medicine, Harvard Medical School; and Social Medicine, Harvard Medical School,
Department of Surgery, Brigham and Women’s Boston, MA, USA
Hospital, Boston, MA, USA

Sarah Maongezi, MD, National Coordinator for Chapter 7. Monitoring and evaluation
Cancer and Injuries, Ministry of Health, Community
Development, Gender, Elderly & Children, Dodoma, Katherine R. Iverson, MD, MPH, Program in Global
United Republic of Tanzania Surgery and Social Change, Department of Global
Health and Social Medicine, Harvard Medical School,
Elliot Marseille, DrPH, MPP, President, Health Boston, MA, USA; Department of Surgery, University
Strategies International, Oakland, CA of California–Davis, Sacramento, CA, USA

Robert Riviello, MD, MPH, Director of Global Surgery Atlibachew Teshome, MD, General Manager,
Program and Associate Surgeon, Division of Trauma, Damota special Dental clinic, Addis Ababa, Ethiopia
Burn, Surgical and Critical Care, Brigham and
Women’s Hospital–Center for Surgery and Public Samson Esseye, MD, FCS (ECA), Senior Technical
Health; Associate Professor of Surgery and of Global Advisor, Jhpiego, Addis Ababa, Ethiopia
Health and Social Medicine, Program in Global
Surgery and Social Change, Department of Global Abraham Mengistu, MD, MPH, Project Director of
Health and Social Medicine, Harvard Medical School, Safe Surgery Project at Jhpiego
Boston, MA, USA
Abebe Bekele, MD, FCS, FACS, Professor of Surgery,
Dean of the University of Global Health Equity, Kigali,
Chapter 6. Drafting and validating the Rwanda
plan
Kaya Garringer, MS, Safe Surgery 2020; Program in
Desmond Jumbam, MSGH, Health Policy Analyst, Global Surgery and Social Change, Department of
Program in Global Surgery and Social Change, Global Health and Social Medicine, Harvard Medical
Department of Global Health and Social Medicine, School, Boston, MA, USA
Harvard Medical School; Department of Plastic and
Oral Surgery, Boston Children’s Hospital, Boston, Olivia Ahearn, MS, Safe Surgery 2020; Program in
MA, USA Global Surgery and Social Change, Department of
Global Health and Social Medicine, Harvard Medical
School, Boston, MA, USA

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Isabelle Citron, BmBCh, MPH, Paul Farmer Global Katherine R. Iverson, MD, MPH, Program in Global
Surgery Research Fellow, Program in Global Surgery Surgery and Social Change, Department of Global
and Social Change, Department of Global Health Health and Social Medicine, Harvard Medical School,
and Social Medicine, Harvard Medical School, Boston, Boston, MA, USA; Department of Surgery, University
MA, USA of California–Davis, Sacramento, CA, USA

Boniface Nguhuni, MD, MSc, Division of Health, Social

Chapter 8. Costing and budgeting Welfare and Nutrition Services, President’s Office–
Regional Administration and Local Government,
James Dahm, MD, Paul Farmer Global Surgery Dodoma, United Republic of Tanzania
Research Associate, Program in Global Surgery and
Social Change, Department of Global Health and Daniel Burssa, MD, MPH, Special Advisor to the
Social Medicine, Harvard Medical School, Boston, Minister, Federal Ministry of Health, Addis Ababa,
MA, USA Ethiopia

Swagoto Mukhopadhyay, MD, MPH, Paul Farmer

Global Surgery Research Fellow, Program in Global Chapter 10. Financing
Surgery and Social Change, Department of Global
Health and Social Medicine, Harvard Medical School, Ché L. Reddy, MBChB, MPH, Paul Farmer Global
Boston, MA, USA Surgery Research Fellow, Program in Global Surgery
and Social Change, Department of Global Health
Yihan Lin, MD, MPH, Paul Farmer Global Surgery and Social Medicine, Harvard Medical School, Boston,
Research Fellow, Program in Global Surgery and MA, USA
Social Change, Department of Global Health
and Social Medicine, Harvard Medical School; Desmond Jumbam, MSGH, Health Policy Analyst,
Department of Surgery, University of Colorado Program in Global Surgery and Social Change,
Hospital, Aurora, CO, USA Department of Global Health and Social Medicine,
Harvard Medical School; Department of Plastic and
John S. Kachimba, BSc, MBChB, MMed, FCS(ECSA), Oral Surgery, Boston Children’s Hospital, Boston,
FCSurol(ECSA), Senior Medical Superintendent and MA, USA
Consultant Urological Surgeon, Livingstone Central
Hospital, Livingstone, Zambia Rifat Atun, MBBS, MBA, FRCP, FRCGP, FFPH,
Professor of Global Health Systems, Department of
Kennedy Lishimpi, BSc, MB ChB, MMed (Paeds), FC Global Health & Population, Department of Health
Rad Onc (SA), Director and National Coordinator of Policy & Management, Harvard T.H. Chan School
Cancer Control, Ministry of Health, Lusaka, Zambia of Public Health, Department of Global Health and
Social Medicine, Harvard Medical School, Boston,
MA, USA
Chapter 9. Organizational structures
and governance Kee B. Park, MD, MPH, Lecturer, Program in Global
Surgery and Social Change, Department of Global
Isabelle Citron, BmBCh, MPH, Paul Farmer Global Health and Social Medicine, Harvard Medical School,
Surgery Research Fellow, Program in Global Surgery Boston, MA, USA
and Social Change, Department of Global Health
and Social Medicine, Harvard Medical School, John G. Meara, MD, DMD, MBA, Kletjian Professor
Boston, MA, USA and Director, Program in Global Surgery and Social
Change, Harvard Medical School; Plastic Surgeon-in-
Chief, Boston Children’s Hospital, Boston, MA, USA

2020 EDITION ix
Walter Johnson, MD, MBA, MPH, Lead (2015-2019), Ché L. Reddy, MBChB, MPH, Paul Farmer Global
Emergency and Essential Surgical Care Program, Surgery Research Fellow, Program in Global Surgery
World Health Organization, Geneva, Switzerland. and Social Change, Department of Global Health
Department of Neurosurgery, Loma Linda University, and Social Medicine, Harvard Medical School, Boston,
Loma Linda, CA, USA MA, USA

Lina Roa, MD, MPH, Paul Farmer Global Surgery

Chapter 11. Implementation Research Fellow and Lecturer, Program in Global
Surgery and Social Change, Department of Global
Desmond Jumbam, MSGH, Health Policy Analyst, Health and Social Medicine, Harvard Medical
Program in Global Surgery and Social Change, School, Boston, MA, USA; Department of Obstetrics
Department of Global Health and Social Medicine, & Gynecology, University of Alberta, Edmonton,
Harvard Medical School; Department of Plastic and Canada
Oral Surgery, Boston Children’s Hospital, Boston,
MA, USA Walter Johnson, MD, MBA, MPH, Lead (2015-2019),
Emergency and Essential Surgical Care Program,
Sarah Maongezi, MD, National Coordinator for World Health Organization, Geneva, Switzerland.
Cancer and Injuries, Ministry of Health, Community Department of Neurosurgery, Loma Linda University,
Development, Gender, Elderly & Children, Dodoma, Loma Linda, CA, USA
United Republic of Tanzania

Emmanuel Makasa, MD, MPH Global Surgery

Consultant and Director – Wits Centre of Surgical
Care for Primary Health & Sustainable Development,
Faculty of Health Sciences, University of
Witwatersrand, RSA

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UN Photo/SCH

2020 EDITION xi
 Abbreviations
CEA Cost–effectiveness analysis
CEmONC Comprehensive emergency maternal, obstetric and neonatal care
DALY Disability-adjusted life year
DCP-3 Disease Control Priorities, third edition
DHS Demographic and Health Survey
GDP Gross domestic product
HAT Hospital Assessment Tool
HHFA Harmonized Health Facilities Assessment
HIS Health information system
HMIS Health sector management and information system
HPMI Hospital performance monitoring and improvement
KPI Key performance indicator
LCoGS Lancet Commission on Global Surgery
LMIC Low- and middle-income country
M&E Monitoring and evaluation
MoF Ministry of finance
MoH Ministry of health
MST Multidisciplinary surgical team
MTEF Medium-term expenditure framework
NCD Noncommunicable disease
NGO Nongovernmental organization
NHSP National health strategic plan
NSOAP National Surgical, Obstetric and Anaesthesia Plan
OR Operating room
PFM Public financial management
RACS Royal Australasian College of Surgeons
RHB Regional health bureau
RMNCH Reproductive, maternal, newborn and child health
SaLTS Saving Lives Through Safe Surgery
SAT Surgical Assessment Tool
SDG Sustainable Development Goal
SOA Surgical, obstetric and anaesthesia
SWOT Strengths, weaknesses, opportunities and threats
TWG Technical working group
UHC Universal health coverage
UN United Nations
WDI World Development Indicator
WHO World Health Organization

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LIST OF FIGURES

Fig. 2.1 Need, impact and cost of surgery for cancer versus other therapies
Fig. 3.1 Roadmap for Pakistan’s Surgical Care Strengthening: from National Vision to Provincial Plans
Fig. 3.2 Steps for the development of an NSOAP
Fig. 3.3 Integration of NSOAPs into national health policy
Fig. 5.1 Example of discussion framework for the infrastructure domain
Fig. 6.1 Mind map of stakeholder priorities and themes around information management
Fig. 6.2 Organizing an NSOAP situation analysis around building blocks of health systems
Fig. 7.1 Surgical KPIs in Ethiopia
Fig. 7.2 Data flow for KPIs in Ethiopia
Fig. 9.2 Ethiopia’s SaLTS initiative leadership structure

LIST OF TABLES
Table 4.1 Situation assessment strategies
Table 4.2 Example SWOT analysis of NSOAP service delivery in Zambia
Table 4.3 LCoGS six core surgical indicators
Table 5.1 Major stakeholder groups to consider involving in the planning process
Table 5.2 Essential surgical procedures recommended for each setting
Table 6.1 Example of an NSOAP goal to increase surgical volume nationally
Table 7.1 LCoGS indicator group 1: preparedness for surgery and anaesthesia care
Table 7.2 LCoGS indicator group 2: delivery of surgical and anaesthesia care
Table 7.3 LCoGS indicator group 3: financial effect of surgical and anaesthesia care
Table 8.1 Sample items that may need to be costed
Table 9.1 NSOAP governance at multiple levels
Table 10.1 Fiscal space approach to health system financing
Table 10.2. Stakeholders to consider when developing a resource mobilization plan

LIST OF BOXES
Box 2.1 Surgical terminology
Box 2.2 Status of surgical care worldwide
Box 2.3 SDG 3 targets directly related to SOA care
Box 3.1 Zambia’s NSOAP planning process
Box 3.2 Pakistan’s NSOAP planning process
Box 3.3 The SADC NSOAP planning process
Box 4.1 Preliminary list of data for priority-setting
Box 4.2 Case Example: Zambia DHS survey surgery pilot project questions
Box 4.3 World Bank and WDIs relating to surgery
Box 4.4 Collaborative data collection on global surgery indicators in the Asia-Pacific region
Box 5.1 Stakeholder engagement: case study from the United Republic of Tanzania
Box 6.1 Sample outline for NSOAP
Box 7.1 M&E: case study from Ethiopia
Box 9.1 Ethiopia’s commitment to strong governance
Box 10.1 Innovative financing - Global Financing Facility
Box 11.1 NSOAP dissemination in Zambia
Box 11.2 Summary: NSOAP operational planning
Box 11.3: Establishing an NSOAP governance unit: the Tanzania case

2020 EDITION xiii

Forewords
I am honored to support the publication of this
important manual that will guide the process of
countries developing their own surgical, obstetric
and anaesthesia plans. During the final preparations
for its publishing, the world was plunged into the
chaos and uncertainty of the COVID-19 pandemic.
Through this pandemic, the world has clearly seen
that even the strongest healthcare systems in high
income countries have been severely challenged
and pushed beyond their capacity. How much more
will countries with marginal health services struggle
under the strain of dealing with pandemics?

Strong and resilient healthcare systems are essential

for countries to maintain healthy populations and
economic stability during times of uncertainty. The
importance of Universal Health Coverage (UHC) and
other important health related objectives outlined in
the UN Sustainable Development Goals (SDGs) are
now, more than ever before, being clearly recognized
as preeminent tools for maintaining world stability.
More specifically, it has been shown that surgical,
obstetric and anaesthesia care is the cornerstone for
NIKHIL SETH
ensuring strong, resilient and sustainable healthcare
United Nations Assistant Secretary-General, systems. Despite this reality, over 5 billion people
UNITAR Executive Director and more than 90% of the world’s poor lack access to
basic surgical care.

The world has made a commitment to achieving the

SDGs by 2030. The provision of safe and affordable
surgical care is inextricably linked to many of
these goals and is a key factor in their successful
achievement. In particular, goals touched by surgical
care provision include: SDG 1 - ending poverty; SDG
3 - ensuring good health for all; SDG 5 - achieving
gender equality; SDG 8 - promoting economic
growth; SDG 9 - building resilient infrastructure and
fostering innovation SDG 10 - reducing inequalities in
and among countries; SDG 16 - promoting inclusive
societies and effective and accountable institutions,
and SDG 17 - strengthening partnerships. In particular,
successfully achieving the majority of the SDG 3
components is closely linked to each country’s ability
to increase access to surgical care, especially for the
poor and marginalized.

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Unfortunately, surgical care has largely been absent I invite all of you reading these words to set your
from the global health dialogue despite playing mind on the targets in front of us, to be optimistic,
an indispensable role in achieving the SDGs and and to use this publication as a tool to support your
Universal Health Coverage. The ramifications are important work.
profound: the lost economic output due to poor
access to safe and affordable surgical care will
cost low- and middle-income countries (LMICs) References
an estimated $12.3 trillion USD by the year 2030
unless access to surgical, obstetric and anesthesia https://tinyurl.com/yaj6belf
care is improved. While significant investment will
be required to change this economic and human https://tinyurl.com/yajblgul
tragedy, we know that great progress can be made
in global health. https://tinyurl.com/y9woe2wf

We need only to look at the impressive achievements

the world had made over the last decade in
several areas. Through the coordinated efforts
of stakeholders around the world, the maternal
mortality rate has decreased by 38% since the year
2000. During the same time period, infant mortality
has also been reduced by 44%. However, we will
not finish the last mile for both maternal and child
health until access to safe surgical, obstetric and
anaesthesia care is strengthened.

We at UNITAR, along with all the contributors, are

pleased to publish the NSOAP Manual with its goal
to help countries increase their capacity to deliver
safe and affordable emergency and essential
surgical, obstetric and anaesthesia services. We feel
that – with the adequate support – this publication
can become a key resource in assisting countries
integrate surgery, obstetric and anesthesia care
delivery into their national health strategies.

If the COVID-19 pandemic has taught us anything,

it is that investments in strong and resilient health
systems are a necessity. Without that, no country
can be prepared for the next health crisis. In the
2030 Agenda for Sustainable Development, the
Governments of this world pledged to endeavour
to reach the furthest behind first. It is these very
countries that need assistance in upscaling surgical
services the most, as the cornerstone for building
strong, resilient and sustainable healthcare systems.

2020 EDITION xv
 Development and health system strengthening are
not where this manual or global surgery’s utility ends.
The recent COVID crisis has focused our attention
acutely on pandemic preparedness and health
security. To many people, global health development
and global health security are “Venn diagrams”
that are seemingly separate, with separate funding
streams and separate communities of interest, but
in reality - or in an ideal reality - nothing should
be further from the truth. Strong health systems,
health equity, and health security are interlinked
and co-dependent. In my April 2020 article in the
New Yorker - “It’s not too late to go on the offensive
against the coronavirus” - I called out five elements
in the battle against this foe. The first four, social
distancing, contact tracing and isolation, are the first
line in the battle against all infectious pandemics.
The fifth - treatment - does not belong exclusively
to pandemics. Treatment calls upon a surgical
ecosystem that includes care providers, operating
rooms, anesthesia machines, consumables and
medications; all of which require strong health
JIM YONG KIM
systems BEFORE a pandemic strikes.
12th President of the World Bank
Investing in surgical capacity strengthens health
systems by ensuring timely, affordable, and safe
surgical and anesthesia care; it is truly foundational
In my opening address for the Lancet Commission on for the delivery of health care under ordinary
Global Surgery (LCoGS) in January 2014 I reminded circumstances. And, as we saw in New York City
the commissioners that “surgery is an indivisible, and beyond, existing surgical capacity also played
indispensable part of health care” and challenged a pivotal role in extraordinary circumstances, as it
them to create a commission report that not only was readily repurposed to rapidly expand Covid-19
called out the challenges and shortcomings of treatment capacity. In my opinion, there has never
global surgery at the time, but more importantly set been a more critical time to reimagine and rebuild
forth a vision for a future in which surgical care was surgical systems to deliver on a promise of universal
an integral component of universal health coverage health coverage, health equity and health security.
(UHC). This challenge was bolstered by the WHO
in May of 2015 when the World Health Assembly
resolution 68.15 was passed calling for emergency References
and essential surgery’s inclusion in UHC. Both the
LCoGS and the WHA Resolution 68.15 called for https://tinyurl.com/ya5bxy4y
member states to include surgical care in national
health planning initiatives and in the last 5 years https://tinyurl.com/yaqbsjw2
the global surgery community has taken this call
to action seriously. This National Surgical, Obstetric https://tinyurl.com/y8d6cz22
and Anesthesia Planning Manual published by
UNITAR provides a thorough, yet flexible framework https://tinyurl.com/ycqrhlh8
for member states to use in their national planning
efforts that allows for contextual, cultural, economic
and demographic realities to guide priority setting.
This Manual is an important adjunct for the global
health development community and member
states alike in working towards UHC.

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CHAPTER 1

Introduction/
Preface

2020 EDITION 1
C
linical conditions requiring surgical,
obstetric and anaesthesia (SOA) services
amount to 30% of the global disease
burden, yet over 70% of the world’s population
cannot access safe, timely and affordable SOA
care when they need it (1). In many corners
of the globe, in the words of Paul Farmer and
Jim Kim, surgery has remained the “neglected
stepchild of global health” (2). Nevertheless, the
year 2015 was a landmark year for global surgery,
drawing international attention to the scope and
seriousness of the surgical disease burden.

Two seminal publications were released in 2015

that describe specific interventions essential for
the advancement of surgery in low- and middle-
income countries (LMICs). Volume 1 of the nine-
volume series Disease Control Priorities, 3rd Edition
(DCP-3) focuses on essential surgical care (3) and
identifies 44 surgical procedures that address
substantial needs as well as being cost-effective
and feasible to implement in LMICs. The same
year, the Lancet Commission on Global Surgery
(LCoGS) released Global Surgery 2030: Evidence
and Solutions for Achieving Health, Welfare, and
Economic Development (1), which provides an
overview of the state of surgical care in LMICs and
sets a framework of recommendations, indicators
and targets to promote universal access to safe
and affordable surgical and anaesthesia care. The
unanimous passage of the World Health Assembly
resolution WHA68.15 – on strengthening emergency through the Sustainable Development Goals (SDGs)
and essential surgical care and anaesthesia as a adopted by the United Nations (UN) in 2015. While
component of universal health coverage (UHC) – in the UN’s previous Millennium Development Goals
2015 (4) provided the political mandate to accomplish had only three targets pertaining to surgical care,
the recommendations set forth in the DCP-3 and within SDG3 “Good Health and Well-being”, four of
LCoGS publications. The recommendations from the targets (reducing maternal, neonatal and under
these three documents range from scale up of 5 mortality, reducing premature deaths from non-
the most cost-effective surgical procedures, to the communicable diseases, and reducing deaths from
development and monitoring of surgical capacity injury) will never be achieved without the scale up of
using specific indicators, to the creation of a National surgical services. Furthermore, eight of the thirteen
Surgical, Obstetric and Anaesthesia Plan (NSOAP) in sustainable development goals are related to SOA
each country. Further political momentum came care (5).

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Despite the increased awareness and discussion

regarding the provision of surgical care in LMICs,
there are still multiple obstacles faced in translating
theory and existing knowledge into the provision of
safe, affordable and timely surgery to those who need
it. This manual acts as a guide to the components
necessary to create a country specific NSOAP, drawing
on the expertise and lessons learnt from countries
and implementers around the world. From situation
analysis to stakeholder engagement, from drafting
Since 2015, unprecedented interest has been to monitoring and evaluation, and from costing to
generated within multinational organizations, governance, this publication provides a roadmap
governments, ministries, professional societies for national governments and ministries, funders,
and clinicians to increase access to SOA services, implementing partners and others seeking to create
with stakeholders driving changes in policy and and implement an NSOAP that is integrated within
programming surrounding surgical care. In existing and future national health policy, strategy
many countries, these efforts are culminating in or plans; an NSOAP must never be a standalone
the development of National Surgical, Obstetric document or vertical plan. We hope that this
and Anaesthesia Plans (NSOAPs) that are fully publication serves as a useful guide for countries to
embedded into a country’s national health policy, adapt as they begin to address the gap in the provision
strategy or plan, which is critical to ensuring of safe, timely and affordable SOA care around the
countrywide implementation and scale. globe through the development of NSOAPs.

2020 EDITION 3
YOUR

Notes

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CHAPTER 2

Developing a case
for prioritizing
and planning
SOA care

2020 EDITION 5
P
romoting surgery, obstetric, and anaesthesia allow for better coordination and efficiency of
(SOA) care as an international priority will planning. Anaesthesiology is dedicated to the total
require significant buy-in from a cross- care of a patient before, during and after surgery; it
section of political and social leaders. Gaining buy- is also critical for resuscitation, pain management
in involves building a compelling, data-driven case and intensive care. Safe surgery and obstetrics rely
about how SOA care contributes to the health and on safe anaesthesia, so improved anaesthesia care is
economic well-being of a country or region. This a key factor in strengthening surgical systems. The
chapter provides guidance for developing the case for limited availability of safe anaesthesia frequently
prioritizing and planning around SOA care. The first constrains the volume of safe surgical and obstetric
section provides a situational analysis of the current care in LMICs and has serious implications on
state of SOA care, describing the global burden of outcomes (6–9). Similarly, obstetric care is also critical
surgical disease, surgical care delivery capacity and for a strong surgical system. Obstetric surgeries,
the prioritization of SOA care on the international including caesarean sections and treatment of
agenda. The second section describes health-related postpartum haemorrhage, are lifesaving for mothers
and economic arguments for urgently changing the and new-borns; caesarean sections are the most
status quo, which will be necessary if countries are to common surgery performed in LMICs. Furthermore,
achieve international targets such as the SDGs. The the complex of infrastructure, equipment, specialist
third section makes the case that strategic planning skills and allied health professional support needed
is critical for affecting positive change in the provision for comprehensive emergency and obstetric and
of SOA care. neonatal care (CEmONC) overlaps almost entirely
with the requirements for surgical care.
Because SOA care form an indivisible continuum
of service delivery, these three components are
considered together throughout this manual to

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2.1 THE CURRENT STATE

OF SOA CARE
BOX 2.1
Surgery is a cross-cutting intervention that is critical
for treating a breadth of conditions, including
obstructed labour, injuries, cancer and other SURGICAL TERMINOLOGY
noncommunicable disease (NCD). However, surgical
Surgically treatable condition: any condition
care has been widely excluded from national and in which surgical care can potentially improve
international health agendas, largely because the outcome.
surgery’s significance in treating some of the
world’s most pressing public health problems is Surgical care: operative and non-operative
underappreciated. This may be due to the prevalent interventions directed at reducing the
but mistakenly narrow conception of surgery as disability or premature death associated with
being limited to complex surgical procedures and a surgically treatable condition, including
are considered non-essential. In fact, surgical care is obstetric conditions; surgical care includes
the preoperative assessment of patients,
a much broader concept that spans “operative and
intraoperative care including anaesthesia and
non-operative interventions directed at reducing complete postoperative care.
the disability resulting from surgically treatable
conditions” (10). Surgical interventions can reduce Surgical procedure: the suturing, incision,
disability caused by a wide range of conditions, excision or manipulation of tissue; or other
including trauma and congenital abnormalities. invasive procedure that usually requires local,
For example, surgery can be involved in airway regional or general anaesthesia.
stabilization for a trauma patient or in the non-
operative management of head trauma (10). Box
2.1 provides an overview of key terminology related
to surgery (10). This section surveys the global
landscape of SOA care: the epidemiological burden of 2.1.1.1 Maternal and newborn health
surgical disease; critical factors affecting access and
capacity for SOA care (including human resources, Safe surgical care is a cornerstone of maternal and
infrastructure, impoverishment, quality of care and newborn care. It is estimated that access to basic
anaesthesia capacity); and the current funding and surgical care could prevent an estimated 233.658
prioritization of surgery on the international agenda. maternal and newborn deaths per year and 20
million maternal and newborn DALYs each year (11).
Even when high-quality antenatal care is provided
2.1.1 Epidemiological burden to pregnant women, which can significantly reduce
of surgical disease maternal disease, the World Health Organization
(WHO) estimates that between 10% and 15% of
Between 28% and 32% of the burden of disease in pregnancies will require caesarean sections to
LMICs is attributable to diseases that are amenable avoid death and disability in the mother and child;
to surgical care, representing 401 million disability- caesarean section rates of up to 19% have been
adjusted life years (DALYs)1 lost each year – almost shown to be beneficial (13,14). Adequate access to
double the total combined DALYs for malaria, caesarean sections for obstructed labour can prevent
tuberculosis and HIV (214 million DALYs per year) (11,12). long-term disabilities, such as obstetric fistula, which
Scaling up basic surgical services alone could prevent affects between 50.000 and 100.000 women per
an estimated 3.2% of all deaths in LMICs and reduce year worldwide (15). Although worldwide data are
the total number of DALYs by 3.5%1 (12). This section lacking, it is thought that 0.20–10.5 per 1000 deliveries
provides an overview of the epidemiological burden worldwide require a peripartum hysterectomy to
of surgical disease related to maternal and newborn avoid or treat life-threatening haemorrhage (16).
health, NCDs, trauma and paediatric populations. Between 8% and 11% of maternal deaths result

1
DALYs are the most widely used metric for quantifying the burden of disease.

2020 EDITION 7
from abortion, miscarriage and ectopic pregnancy; stroke. Surgery is an integral part of the treatment
although medical treatments are available for of NCDs, such as blindness, amputation or other
simple cases, complex cases carry a higher risk of complications related to diabetes. According to
death and often require surgery (17). Expansion of GLOBOCAN2 incidence estimates, cancer is the
safe anaesthesia is also crucial for maternal health second leading cause of death globally – causing
care: 3.5% of all maternal mortality and 13.5% of more than 9.8 million deaths worldwide in 2018 with
deaths after caesarean section are attributable to estimates that this number will rise to 30 million by
poor anaesthesia care (18) 2030 – and more than 60% of cancer cases require
treatment with surgery. The mortality rate is greater
than 70% among diagnosed cancer cases in sub-
.2.1.1.2 Noncommunicable diseases Saharan Africa (20). Compared to radiotherapy and
systemic therapy, surgery for solid tumour cancers
NCDs represent the largest and fastest growing addresses the greatest need, with the highest impact
disease category worldwide. According to WHO and at the lowest cost (21) (see Fig. 2.1). Investment in
estimates, around 40 million (71.3%) of the 57 screening and vaccination for cancers, particularly
million global deaths in 2016 were attributable to breast and cervical cancer (for example, the human
NCDs (19). Only a proportion of the NCD burden is papillomavirus vaccine) is increasing, but there has
classified as preventable, which amplifies the need not been concurrent investment to expand surgical
for better strategies to treat NCDs when they occur. capacity and access to treat the cancer cases that
Surgery is critical for treating almost all common will be additionally detected through screening.
NCDs, including cancers, cardiovascular disease and

Fig. 2.1 Need, impact and cost of surgery for cancer versus other therapies

SURGERY RADIOTHERAPY SYSTEMIC THERAPY

Need 60-85% 20-50% 40-90%

Impact 30-70% 5-20% Variable - 0-20%

Overal Survival Gain Overal Survival Gain Overal Survival Gain
(Solid)

Cost LOW MODERATE VARIABLE

Sources: Figure credit to André Ilbawi, Technical Officer, World Health Organization, Geneva, Switzerland; data from WHO (21,22).

2
The International Agency for Research on Cancer’s GLOBOCAN database provides contemporary estimates of the incidence, mortality and
prevalence of 28 types of cancer in 184 countries worldwide.

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Cardiovascular disease is the leading cause of are a cause of social segregation/discrimination and
death and mortality worldwide, with 17.86 million also only correctable by surgery. LMICs bear more
attributable deaths in 2016 (19). Although prevention than 70% of the global burden of burns, with two
is the best way to control this disease, a large and thirds of burns occurring in Africa and Southeast
increasing volume of patients will inevitably require Asia. More than 95% of fire-related burns and 90% of
open or minimally invasive surgical care, such as fire-related deaths also occur in LMICs (28). Improved
coronary artery stenting, bypass grafting, valve outcomes from burns is possible through effective
surgery and cardiac transplantation. In addition to burn prevention strategies, coupled with safe,
its effects on the heart, cardiovascular disease has a affordable and effective emergency and essential
profound effect on the brain. Globally, 70% of strokes surgical burn care. An estimated 12.1% of preventable
occur in LMICs and the incidence is continuing to rise deaths from burns are avoidable with the provision
rapidly. In low-income countries, compared with high of basic surgical care (10).
income countries populations have an increased
propensity for haemorrhagic stroke; these strokes
are more likely to be amenable to neurosurgical care 2.1.1.4 Paediatric populations
to reduce death and disability (23).
Over one and a half billion children among the
estimated five billion people worldwide lack access
2.1.1.3 Trauma to safe, affordable SOA care (29). According to
the World Bank Group, an average of 43% of the
Injuries represent the largest burden, estimated at population is aged 15 years or less in countries in sub-
68%, of avertable surgical deaths (1). Although injuries Saharan Africa; the proportion is as much as 50% in
occur due to a wide range of trauma, such as falls, some of those countries (30).
burns, occupational accidents and interpersonal
violence, the greatest burden of mortality and Surgery in the paediatric population covers some
morbidity is attributable to road traffic injuries. Road conditions that are common to adults and children
traffic injuries are the leading cause of mortality in – such as trauma and appendicitis. However, many
people aged 15–29, and causes 1.25 million deaths diseases specific to the children also require surgery,
per year – 90% of which occur in LMICs (24). In most such as neoplasms, and congenital anomalies such
countries, road accidents cost around 3% of the gross as club foot, orofacial clefts, heart and gastrointestinal
domestic product (GDP). A coordinated effort to conditions. Small children, particularly neonates,
improve the impact of road trauma is being led by carry a significantly higher risk in surgical care
the UN Road Safety Collaboration, which is working due to their small size and low blood volume. This
to prevent road accidents as well as improving makes it challenging for non-specialist surgery and
trauma care for patients following accidents. The anaesthesia providers to care for this population
SDGs have a specific target aiming to reduce the group. Untreated, many congenital conditions are
number of deaths from road traffic accidents by fatal, and many paediatric conditions carry the risk
50% by 2030. A functional trauma network, including of lifelong disability and impart a disproportional
a robust prehospital system and surgical team are effect on economic productivity. Surgical correction
crucial for improving outcomes for trauma patients. of these conditions averts a significant number of
Surgical intervention is life-saving in many trauma Disability-Adjusted Life Years (DALYs) due to long
cases and for many non-operative trauma cases, life expectancy following surgery. According to the
comprehensive surgical care is needed to assess, limited data available from LMICs, surgical conditions
stabilize and rehabilitate patients (25,26). account for 6-15% of paediatric admissions in sub-
Saharan Africa (11,31,32). In a survey of children aged
According to 2004 estimates, more than 30 000 0–18 years in four LMICs, 11-28% of the sample had
new burns occur globally each day, representing a surgical need (31). Another study found that 85%
more than 11 million burns per year (27). Although of children may require surgical care by the age of
most burns are non-fatal, they have high morbidity 15 years (11,32). The injury mortality rate for children
rates: the lack of effective preventive measures, aged 1–4 years in sub-Saharan Africa is 183.6 per
compounded by poor access to acute burn 100 000, compared with less than nine per 100 000
management, make burn-related disabilities and in Organisation for Economic Co-operation and
disfigurements very common. These disfigurements Development countries (32).

2020 EDITION 9
 BOX 2.2

2.1.2 Access and capacity

STATUS OF SURGICAL CARE
WORLDWIDE
2.1.2.1 Access
In 2015, the LCoGS developed five key
Five billion people around the world lack access to messages about the status of surgical care
safe, timely and affordable SOA care with access is worldwide.
poorest in LMICs. Capacity for high-quality SOA
care is lacking in most LMICs, with an estimated 143 • An estimated 5 billion people lack access to
million additional procedures needed in LMICs each safe, affordable surgical and anaesthesia
year to save lives and prevent disability. Currently, care when needed.
• An estimated 143 million additional surgical
only 6% procedures performed annually occur in the
procedures are needed each year to save
poorest countries, home to one third of the world’s
lives and prevent disability.
poorest populations (1). The need for additional • An estimated 33 million individuals face
surgical procedures is greatest in south Asia and in catastrophic health expenditure due to
eastern, western and central sub-Saharan Africa. payment for surgery and anaesthesia each
Issues exist across the entire health systems in these year.
regions, starting with low surgical capacity at the • Investment in surgical and anaesthesia
first and district levels. When appropriately staffed care is affordable, saves lives and promotes
and equipped, first-level hospitals should be able economic growth.
• Surgery is an indivisible, indispensable part
to provide 80–90% of basic surgery procedures (10).
of health care.
To capture capacity for performing basic surgery,
three procedures have been chosen as “Bellwether”
procedures to act as a proxy measure for the ability of
a hospital to carry out basic surgery, anaesthesia and
obstetric care (1). These are laparotomy, caesarean
section and fixation of an open fracture. However, 2.1.2.2 Human resources
large global studies have shown that at first-level
hospitals, only 64% could provide a caesarean delivery, Multiple clinical and non-clinical staff cadres are
58% could provide a laparotomy and only 40% could required to provide comprehensive surgical service
provide surgical treatment for an open fracture. delivery. These include community health workers,
The lack of provision at the first and district-level hospital managers, operating theatre technicians,
hospitals leads to excessive referrals to tertiary care. surgeons, anaesthesiologists and obstetricians
In addition to delaying treatment and exacerbating (who may already be trained or still be in training),
catastrophic expenditure, these referrals also place generalist physicians, associate clinicians providing
an undue burden on tertiary level hospitals, which surgical and anaesthesia care, mid-wives, educators,
often operate at 200–300% capacity (1). rehabilitation specialists, including physiotherapists,
occupational therapists, speech therapists amongst
The lack of SOA care provision at the first level is others, and diagnosticians in laboratory, pathology
multifactorial, with contributing factors ranging and radiology sciences. Many countries face
from inadequate human resources and staffing, significant workforce deficits in all these areas, with
poor infrastructure and equipment, and limited shortages compounded by poor distribution of
management and leadership capacity. In 2015, staff. According to WHO’s global surgical workforce
collaborators from 110 countries came together database, in low-income countries the average
under the auspices of LCoGS. The LCoGS identified number of specialist SOA providers is just 0.7 per 100
five key messages to describe the current global 000 population. In LMICs, the average of 5.5 per 100
surgical capacity and to underscore the human 000 is still well below the target of 20–40 per 100 000
and economic consequences of the unmet surgical recommended for an adequate health system (1).
burden of disease (see Box 2.2) (1). Based on UN World Population Prospects to 2030,
an estimated 2.28 million additional specialist SOA
providers will be needed worldwide to reach the
target of 20–40 specialist SOA providers per 100 000
population by 2030 (33).

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2.1.2.3 Infrastructure

WHO’s situational analysis tool was used to survey mortality or surgical site infections (35). Multiple
800 facilities in LMICs, revealing common problems studies have shown that postoperative mortality in
with the very basic infrastructure required to LMICs exceeds that of high-income countries (36).
provide surgery. Among the facilities surveyed, A study by Biccard et al. found that mortality rates
challenges to providing surgical care included lack across 25 African countries are twice the global
of electricity (31%), running water (22%), oxygen average when compared with high-income cohorts,
(24%) and postoperative care space (47%). A survey despite the African patients being younger and
of 88 countries found that the average number of having fewer co-morbidities (37).
operating rooms was 5.5 per 100 000 population,
which will need to nearly double to 9.8 per 100 000
to meet the projected growth in surgical demand 2.1.2.6 Anaesthesia capacity
(34). In addition to basic infrastructure needs,
facilities urgently need context-appropriate surgical A lack of access to anaesthesia is often the limiting
equipment; several essential equipment lists have factor in the quantity and complexity of surgical
been proposed to help meet those needs. In terms of care delivered (6–8). Although anaesthesia-related
anaesthesia specifically, WHO’s Situational Analysis mortality has fallen steadily to around one death
Tool database reports that 55% of district hospitals per 200 000 in high-income countries, evidence
surveyed across eight African countries did not have indicates that anaesthesia-related mortality rates
an anaesthesia machine and 70% of operating rooms remain much higher in some LMICs (6). A systematic
in parts of sub-Saharan Africa lack pulse oximetry; review of perioperative mortality showed that
and lack of laryngoscopes was widely reported (1). anaesthesia-related mortality rates in Thailand are
as high as one per 1754 – more than 100 times the
international average for high-income countries. Of
2.1.2.4 Impoverishment SOA specialists, the anaesthesia workforce remains
the most deficient; a 2015 survey by the World
Financial barriers affect patients seeking surgical Federation of Societies of Anaesthesiologists found
care in two ways. Firstly, financial barriers can that 77 countries worldwide reported a density of
prevent patients from seeking care at all. Secondly, physician anaesthesia providers of less than five per
many patients who can access and receive care 100 000 (38). Even when non-physician anaesthesia
are left catastrophically impoverished by the costs providers are taken into account, 70 countries
of care and are left to suffer the health and social reported a total anaesthesia provider density of less
consequences of poverty. This problem is widespread, than five per 100 000 (38).
with 33 million individuals facing catastrophic
expenditure each year that is secondary to out-of-
pocket payments for surgery and anaesthesia care 2.1.3 Current funding and prioritization
(12). This number increases to 81 million people of surgery on the international agenda
when indirect expenses are included, such as lost
wages, travel expenses, food expenses. Again, this A 2008 editorial by Paul Farmer and Jim Kim
risk is greatest for people in LMICs, as well as for the described surgery as the “neglected stepchild of
poorest, most vulnerable people within any country. global health” (2). In 2011, correspondence in the
Lancet noted that surgery was not mentioned
once during the high-level meeting on NCDs at
2.1.2.5 Quality of care the UN (39). A 2015 study of national health plans
in sub-Saharan Africa reported that 63% of plans
As well as stark inequalities in access to surgical care, had less than five mentions of surgery and 33% had
inequalities also exist in the quality and safety of the no targets relevant to surgery (40). In comparison,
SOA care received by patients. Data on quality of over 95% of the national health plans specifically
surgical care is notably sparse and heterogeneous, report the prevalence of HIV, tuberculosis, infant
with most studies being small and focused on just mortality and maternal mortality, with associated
a single aspect of quality such as post-operative targets for each. A study of funding flows from 160

2020 EDITION 11
charitable organizations showed that expenses and essential surgery and anaesthesia care were
focused on surgical conditions totalled US$ 3.1 officially included as part of the recommended
billion – or 11% of total charitable global health UHC package through the unanimous passing of
spending – despite surgical conditions representing resolution WHA68.15 by the World Health Assembly.
28–32% of the burden of disease (41). Additionally, The same year saw the publication of LCoGS and the
funding for surgery was usually siloed into vertical, inclusion of Essential Surgery as the first volume of
disease-specific interventions, most commonly for DCP-3. These strides forward have led to a growing
ophthalmological or cleft-related procedures. The and increasingly cohesive movement around SOA
total development assistance for strengthening of care. As of 2018, four African countries had created
surgical systems is not well tracked. and invested in strategic plans specifically for the
improvement of their SOA systems.
Since 2015, a significant momentum has been
generated around advancing the case for surgery as
a public health measure and for the inclusion of SOA
into health systems planning. In 2015, emergency

2.2 WHY SOA CARE MUST BE PRIORITIZED

The previous section described the global burden of surgical disease, factors underlying access to and
capacity for SOA care and the escalating prioritization of surgery on the international agenda. This section
explores the central role of SOA care in health systems and why surgical care must be prioritized for
countries to reach their economic and health targets. The section is framed by three key arguments for
improving access and quality of SOA services.

Improved SOA care is Improved SOA care will Expansion of SOA care is a
required to meet the improve health and well- cost-effective intervention
many of the SDG targets, being which will enable to to improve the health
in particular SDG 3 of achievement of other SDGs. of a population through
promoting health and strengthened health
well-being for all at all ages systems and improved
and SDG 3.8 which aims health outcomes.
to attain Universal Health
Coverage by 2030.

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2.2.1 SOA care is required to meet

the SDGs

The integration of surgery into national health

agendas is crucial for meeting the SDGs, which were
adopted by world leaders as a unified vision for the
future of health, prosperity and development by 2030.
Improved SOA care can contribute to supporting
almost all of the SDGs through its role in poverty
reduction and in improved health and productivity.
However, six of the SDGs are highly dependent upon
improving SOA care: SDGs related to good health
and well-being (SDG 3); SDGs related to gender
equality (SDG 5); and SDGs related to economic
improvement, including an end to poverty (SDG 1),
decent work and economic growth (SDG 8), reduced
inequalities (SDG 10) and creating the partnerships
necessary to make this a reality (SDG 17).

2.2.1.1 Good health and well-being

Target 3.8 on universal health coverage is particularly

important because it provides the necessary
prerequisites, including scaling up of SOA, for the
attainment of the other targets of this goal.

Scaling up SOA care will be crucial to improving

the maternal mortality ratio to less than 70 per 100
000 population (SDG 3.1) and reducing the perinatal
mortality rate to as low as 12 per 1000 live births (SDG
3.2). Robust evidence demonstrates that access
to safe CEmONC reduces maternal and perinatal
mortality (13,14,43,44). Around 8% of maternal deaths
result from obstructed labour and many of those
who survive obstructed labour suffer disability, such
as obstetric fistula.
Given that a considerable proportion (28–32%) of
the global burden of disease requires surgical care, The recommendation for a population-level caesarean
SDG3 on good health and well-being cannot be section rate of 10% of live births is equivalent to rate
achieved without addressing this burden, especially up to which caesarean sections have been shown to
in LMICs (42). Within SDG 3 there are nine targets decrease maternal mortality (when adjusted for social
specifically related to SOA care (see Box 2.3); SOA factors) (13). A study by Molina et al. analysed 22.9 million
care is absolutely essential to fulfilling four of these caesarean sections and determined that a national
targets: 3.1 (reduce maternal mortality), 3.2 (reduce caesarean section rate of up to 19% was correlated with
infant and under-5 mortality), 3.4 (reduce premature a lower neonatal mortality rate however worldwide
deaths from NCDs) and 3.6 (reduce the number of 10% is considered optimal (13,14). Safe emergency
deaths and disabilities from road traffic accidents). caesarean sections require a strong health system with

2020 EDITION 13
specialist SOA staff. Safe anaesthesia is a crucial part cardiovascular disease through minimally invasive or
of obstetric care. Poor quality care is identified as the open cardiac and vascular techniques. Neurosurgical
cause of 3.5% of deaths due to obstetric complications capacity is also required to reduce the morbidity
and 13.8% of post-caesarean section deaths (18) associated with stroke.
(18). Surgical care is also critical for safe treatment of
retained products of conception, ectopic pregnancies, Another explicit goal of the SDGs is to reduce by
repair of obstetric fistulae, cervical cancer and other one half the global deaths and injuries from road
gynaecological cancers. traffic accidents (SDG 3.6). Comprehensive SOA
care, along with strong pre-hospital and emergency
SDG 3.4 aims to reduce by one third the premature care systems, are required for the treatment trauma
mortality rate attributed to non-communicable patients, and many of those who do not require
diseases. As mentioned previously, a high proportion, intervention in the operating room will need surgery
including 60% of all cancers, will require surgery and and anaesthesia services for accurate assessment
a strong perioperative surgical system. Additionally, and stabilization.
surgical services are required for the treatment of

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BOX 2.3

SDG TARGETS DIRECTLY RELATED TO SOA CARE

Target 3.1.1
By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
per year.

Target 3.2.1
By 2030, end preventable deaths of children aged 5 years or less with all countries aiming
to reduce under-5 mortality to at least as low as 25 per 1000 live births per year.

Target 3.2.2
By 2030, end preventable deaths of new-borns, with all countries aiming to reduce
neonatal mortality to at least as low as 12 per 1000 live births per year.

Target 3.3.1
Reduce the number of new HIV infections per 1000 uninfected population by sex, age and
key populations.

Target 3.4.1
By 2030, reduce by one third premature mortality rate attributed to cardiovascular
disease, cancer, diabetes or chronic respiratory disease.

Target 3.6.1
By 2020, halve the number of global deaths and injuries from road traffic accidents.

Target 3.7
By 2030, ensure universal access to sexual and reproductive health care services, including
for family planning, information and education, and the integration of reproductive health
into national strategies and programmes.

Target 3.8.1
By 2030, achieve UHC including financial risk protection, access to quality essential health
care services, and access to safe, effective, quality and affordable essential medicines and
vaccines for all. Coverage of essential health services is defined as the average coverage
of essential services based on tracer interventions that include reproductive, maternal,
new-born and child health (RMNCH), infectious diseases, NCDs and service capacity and
access, among the general and the most disadvantaged population.

Target 3.B
Support the research and development of vaccines and medicines for the communicable
and NCDs that primarily affect developing countries, provide access to affordable
essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS
Agreement and Public Health.

Target 3.C
Substantially increase health financing and the recruitment, development, training and
retention of the health workforce in developing countries, especially in least developed
countries and small island developing states; measured by health worker density and
distribution.
2.2.1.2 Gender equality 2.2.1.3 No poverty, decent work and economic
growth, and reduced inequalities

SDG 5, Gender equality will never be achieved as Across 128 countries that account for 90% of the
long as mothers and neonates continue to die in global population, the estimated value lost due to
the absence of life-saving surgery. In addition to untreated conditions requiring surgery is US$ 20.7
saving mothers’ lives and avoiding disability from trillion, or 1.3% of the projected economic output
childbirth (for example, obstetric fistula), surgical of the global economy (1). These economic losses
care plays a significant role in empowering women exceed by 50-fold the estimated US$ 350 billion that
to make decisions about their reproductive future, would be required to scale up SOA care in LMICs at
through options for safe sterilization and abortion an aspirational rate by 2030. More than half of these
care. Surgical care is also critical for successful economic losses will occur in LMICs, which is an
sexual, urological and reproductive function in unacceptable financial inequality.
women who have been affected by female genital
mutilation. Gender equality is also required for the Each year, 33 million individuals face catastrophic
attainment of SDG 4 which is to provide quality health expenditure due to personal (out-of-
education by empowering women and girls with pocket) payment for surgery and anaesthesia
their reproductive rights. Gender Equality is also key care. The burden of untreated surgical disease
to attaining SDG 10, the reduction of inequality. disproportionately affects rural, impoverished and
marginalized populations. The lack of SOA services or
poor-quality care can lead to chronic disability, death
and loss of economic productivity for individual
families and for communities as a whole. A survey
of patients undergoing cataract surgery in Pakistan
found that 85% of men and 57% of women who had
lost their jobs as a result of blindness regained those
jobs after cataract surgery; in the first year alone,
their regained vision generated 1500% of the cost of
the surgery in increased economic productivity (45).

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2.2.2 SOA care is required to reach 2.2.3 Surgery is cost-effective

goals of UHC and primary health care
coverage by 2030 Despite the perception that surgical care is complex
and cost-prohibitive, surgery has been shown to
Emergency and essential surgery and anaesthesia be highly cost-effective (47). The cost of scaling up
care are integral components of UHC, following the surgical services to address the surgical burden of
unanimous passing of resolution WHA68.15 in 2015. disease in LMICs is 50-fold less than the estimated
UHC is defined by WHO as “ensuring that all people losses that are attributable to untreated conditions
have access to needed promotive, preventive, requiring surgery (34). The estimated cost to scale
curative and rehabilitative health services, of up delivery of the identified essential surgical
sufficient quality to be effective, while also ensuring procedures at first-level hospitals worldwide is US$
that people do not suffer financial hardship when 3 billion annually, with a benefit-to-cost ratio of 10:1.
paying for these services”. The World Bank and WHO Surgical care is unequivocally one of the most cost-
define targets for worldwide coverage as 80% of all effective public health interventions, comparable to
essential health services and 100% protection from oral rehydration therapy, vitamin A supplementation
out-of-pocket expenses by 2030. Given that five and antiretroviral therapy for HIV (3,47,48). Some of
billion people currently lack access to safe, timely the most cost-effective interventions may be those
and affordable SOA care, meeting the targets for in paediatric surgery, which provide lifelong disability
UHC will require a 250% increase in access to SOA aversion and societal benefit (49).
care by 2030.

District-level hospitals should be able to deal with

80–90% of essential surgical conditions, therefore
SOA care should also be supported in all efforts
to improve primary health care. In recognition of
this, “improvement of surgical care at the district
hospital” was identified as one of the most effective
ways to advance global welfare in the Copenhagen
consensus, which included five economic Nobel
laureates (46).

SOA care requires many elements of the health

system to function well. In addition to the ecosystem
within the operating theatre and capacity for
postoperative rehabilitation, additional elements
include community education, prehospital care,
emergency department care, robust supply chains
of consumables, and laboratory services. Many of
these services are shared, so building SOA care
capacities can also improve the functions of multiple
other elements in the hospital. For example, a secure
supply of antibiotics for surgery helps to reduce
postoperative sepsis in surgical patients, but it will
also help reduce under-5 mortality from pneumonia.
Similarly, improved anaesthesia and critical care
capacity can help expand the volume and complexity
of surgical care, but it will also provide life-saving care
for critically unwell medical patients.

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2.3 WHY ENGAGE IN NATIONAL
SOA PLANNING?
In a seminal paper in 2007, Shiffman identified four 2.3.2 Ideas: Building a cohesive vision
areas required to transform a public health issue into
a priority (50). The process of developing an NSOAP engages
multidisciplinary stakeholders from government,
• Actor power: the strength of the individuals and civil society, private and all other sectors to collectively
organizations concerned with the issue. agree upon priorities of a country-specific plan within
• Ideas: the ways in which those involved with the the context of government priorities. These priorities
issue understand and portray it. can then be translated into concrete, implementable
• Political contexts: the environments in which actions with an associated accountability structure
actors operate. – through rigorous, clearly defined monitoring and
• Issue characteristics: the scale of the issue and evaluation – to ensure these goals are met. A shared
strength of the data to support it. vision between NSOAP planners and those who
control resources, helps bring clarity to the issue
Each of these areas are pre-requisites for generating and drives the prioritization of NSOAPs. Further,
the political will to create of national, subnational or the consultative, consensus-building process of
regional SOA plans. Once developed, the NSOAPs developing the plan gives a voice to stakeholders,
in contribute to strengthening each of these four such as frontline health workers, who are often
areas and continuing to keep SOA care as priority excluded from this type of national-level discourse.
on the health agenda. Additional benefits derived The NSOAP process ensures that priorities are set
from NSOAPs are the capacities to promote more locally and strategically, rather than being driven
efficient use of resources and to act as a platform for by external forces which may safeguard against
investment. political turnover or changes in priorities. The plan
emerges from a consensus of the stakeholders who
will ultimately be the implementers, increasing the
2.3.1 Actor power: Visibility and likelihood of support and motivation to implement
stakeholder engagement the plan.

The process of developing an NSOAP promotes

visibility around SOA care. The consultative process 2.3.3 Political contexts: Integration and
of NSOAP development sensitizes communities, accountability
institutions and civil society actors to SOA issues.
Because these stakeholders will eventually be NSOAPs facilitate the integration of SOA care into
responsible for implementing the NSOAP, the the national health strategy and planning. Since SOA
process begins by mobilizing stakeholders, building care is closely aligned with many existing targets,
awareness and garnering the political will to affect including the SDGs and UHC, and the NSOAP
change. The process of mobilizing stakeholders provides a platform to inform how improving SOA
also allows for identifying the leaders or champions care is an integral component for meeting these
who will drive the efforts during the development goals. Once it is signed, the NSOAP also creates a
phase and – most importantly – during the critical mechanism for stakeholders to hold implementers
implementation phase. accountable for the reforms that have been promised,
which can be maintained through the NSOAP’s
objective monitoring and evaluation targets.

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2.3.4 Features of the problem: Making a 2.3.6 Platform for investment

case through data
NSOAPs can lead to more efficient distribution of
As part of the NSOAP process, country-specific data resources by improving the coordination of national
are gathered during the situational analysis. The data and international investments that are used to
can help to make clear, evidence-driven, context- finance the implementation of the plan. More
specific arguments about the urgent need to improve efficient and transparent use of domestic resources
access to quality SOA care. This process also allows for will be critical for meeting the projected US$ 350
robust gap analysis and for building group consensus billion investment gap that is required to scale
about how to deliver optimal solutions within the surgical services to meet the SDGs (34). Further, the
local contexts. The NSOAP monitoring and evaluation combination of well-articulated plans and rationales
framework provides updated data that can be used with prioritized, costed implementation strategies
to strengthen advocacy around the issue. and related time-bound targets can serve as an
attractive platform form investment.

2.3.5 Efficiency

Through improved coordination among government

programmes and partners from the private sector
and civil society, NSOAPs can promote greater
efficiency in the allocation of existing resources.
Coordination ensures that no single domain of the
plan is developed in isolation – for example, building
new operating rooms without considering how they
will be staffed or equipped. Coordination between
representatives of all sectors also avoids duplication
of efforts; this is especially important given that
efforts to strengthen SOA care overlap with efforts
to improve disease-specific care (and vice versa). In
another efficiency-related benefit, national surgical
planning can provide an organizing framework to
convene political, technical and financial support
from national and international bodies.

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YOUR

Notes

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CHAPTER 3

The SOA
planning
process

2020 EDITION 21
C
hapter 2 described how an NSOAP can NSOAPs are designed to facilitate direction and
help strengthen surgical systems as coordination for provision of SOA services. In most
well as health systems as a whole. This cases, strategic plans are just the beginning of a
chapter offers a step-by-step guide for developing national effort to improve a health system. To execute
an NSOAP. The steps are intended to serve as a the NSOAP, each activity will typically require more
guide and should be adapted to the local context. exhaustive planning than the main NSOAP will
They do not necessarily need to be completed in allow – for example, setting exact month-to-month
the order presented here. Some countries may timelines and adjusting scale based on the budget.
choose to take a regional approach to national Each activity also needs to be responsive to what
SOA planning, while other countries may prefer to has and has not been successfully implemented by
test programmes and generate evidence prior to each milestone. Setting a clear timeline for NSOAP
policy setting and scale up. This manual focuses on development activities helps to prevent the process
a top-down approach to improving SOA care, but from becoming too drawn out, because fatigue
there are many equally important and successful and loss of momentum can threaten the successful
bottom-up programmes contributing to worldwide completion of the plan. Multiple countries have
NSOAP efforts. For examples of other frameworks completed an NSOAP including Zambia (see Box 3.1),
for surgical health systems strengthening, please Ethiopia, United Republic of Tanzania, Rwanda and
refer to WHO’s publication Surgical Care Systems Nigeria, with over a dozen countries in the progress
Strengthening (51). of completion.

Subsequent chapters will add detail to each

step, highlight potential challenges and provide 3.1.1 NSOAP models
recommendations to assist in the NSOAP process.
Each country is unique in terms of its governance,
management structure and MoH functionality. The
NSOAP is specifically designed to be fully embedded
3.1 GENERAL PRINCIPLES OF (or incorporated) into the national health policy,
PLANNING strategy and plan. Based on the countries that are
developing NSOAPs to date, three distinct models
A successful NSOAP needs champions. Ideally, a have emerged.
champion is a person who understands the process,
who has expertise in SOA, who is passionate about
establishing an NSOAP and who has the respect and 3.1.1.1 Centralized Model
influence to guide initial efforts. A champion can play
an integral role at each step of the NSOAP process In the centralized model, the NSOAP process of policy
by providing leadership, motivation and direction. A development is led by centralized efforts from the
country’s ministry of health (MoH) will be the primary MoH and the implementation processes are driven
driver of the NSOAP, but in many countries, the MoH through central agencies such as the MoH and
may not be familiar with the concept. A champion Ministries of Finance. In this model, the MoH leads
can help to introduce the concept and strategy of the process and is the champion that coordinates
the NSOAP in order to encourage MoH buy-in for the the development of the NSOAP, working closely with
process. Depending on the setting, it can be helpful stakeholders and gaining consensus from academic
to create an NSOAP lead team made up of a small institutions, NGOs, public and private agencies,
group of individuals – including champions, MoH professional societies and international organizations
representatives and SOA society representatives – including donors and organizations operating in the
who can serve together as the leaders throughout country. The MoH also gathers necessary information,
the process. An additional consideration is whether conducts the necessary assessments and finally the
to engage external consultants to assist with the development and launch of the NSOAP. The MoH
NSOAP process. Consultants may provide expertise in coordination with these stakeholders, sets out a
in areas such as monitoring and evaluation, as well national plan that aligns with government priorities
as administrative support. and its national health policy, strategy and plan. It

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is essential to explore factors such as the political, 3.1.1.2 Decentralized model

economic and geosocial ecosystems that define
a country’s context before embarking on such a Countries that have a devolved health system
plan. The country context will influence the health structure where the authority is shared between the
system development process in order to develop federal government and its states, federal units or
and NSOAP fitting its circumstances. Countries that provinces, might be better suited to a decentralized
have pursued a centralised model include Zambia, model. In this model, the role of health policy
Tanzania, Ethiopia, Nigeria and Rwanda. planning and implementation is devolved into each
state or provincial governments; states or provinces
have autonomy in planning and resource allocation
for essential health services. Thus, each takes the
BOX 3.1
responsibility in the provision of preventive and
curative services for their respective state or province
health needs. The states or provinces might hold
ZAMBIA’S NSOAP responsibilities ranging from framing local rules or
PLANNING PROCESS regulations, developing standards for drugs quality
control, patient safety to education and training
Following the 68th World Health Assembly,
of health care professionals. The NSOAP process
Zambia embarked on the creation of an
NSOAP using the Lancet Commission can be adapted and customized to match this
framework and presented the completed configuration. In this model, the role of the federal
plan in May 2017. The process began in 2016, MoH might be limited to providing national-level
with the recognition of the need for an policy guidelines, overseeing health regulation,
NSOAP by key stakeholders including Dr national disease surveillance, providing a template
Emmanuel Makasa, Counsellor of Health or a generic plan that can be adapted by the state or
for the Permanent Mission of the Republic province, coordinate efforts to identify priorities and
of Zambia to the United Nations, Dr Peter guide decision making and liaise with international
Mwaba, Permanent Secretary in the MoH of
partners. An example of a decentralized model is
Zambia, and Dr Kennedy Lishimpi (Director
of Clinical Care and Diagnostic Services). With Pakistan’s NSOAP. Pakistan has a health governance
full support from Zambia’s MoH, a larger structure where the role of policy implementation is
group of stakeholders relevant to surgical devolved to the provincial governments making it
system strengthening was assembled to a federal-provincial model. In this case, the NSOAP
work on the plan. The six surgical indicators process has been adapted to match the country’s
for Zambia were identified by utilizing structure and operational dynamics.
Zambia’s health management information
system with support from the Institute for
Health Metrics and Evaluation. Stakeholders
were then divided into three committees to
focus on different domains, including service
delivery and infrastructure, workforce and
information management and financing.
Implementation of the NSOAP is underway
and has already increased capacity for
training surgical and anaesthesia providers,
increased the number of theatre nursing staff
being trained, and improved the distribution
of trained personnel across the country. For
more detail on Zambia’s NSOAP process, see
Mukhopadhyay et al (52).

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 BOX 3.2

PAKISTAN’S NSOAP PLANNING PROCESS

Pakistan’s federal-provincial model has driven the NSOAP process to be adapted and customized in line
with the country’s health governance structure and operational dynamics. Pakistan’s Ministry of National
Health Services, Regulation and Coordination (MoNHSR&C) led the development of the National Vision for
Surgical Care 2025 (NVSC2025), which supplements the current National Health Vision (NHV) 2016-2025.
Developed by the MoNHSR&C in collaboration with the provincial departments of health, NHV 2016-2025
provides a strategic direction for Pakistan’s health priorities. Since surgical care was not explicitly stated as
a health priority, NVSC2025 aims to fill that gap.

The MoNHSR&C and Indus Health Network jointly hosted a national stakeholders conference in Islamabad
in November 2018. The participants included relevant stakeholders from federal government, provincial
health departments, professional societies, public and private sector specialists, national and international
academic institutions and organizations. A consensus statement was drafted at this forum, which provided
a framework for the developed NVSC document. The MoNHSR&C has established a steering committee to
provide oversight for the process, and a technical working group (TWG) that is responsible for conducting
a situation analysis based on which the NVSC document has been drafted. In this regard, the TWG held a
series of consultative workshops in each provincial capital in February - March 2019, to introduce the process
to each provincial government and an additional tier of local stakeholders. The NVSC2025 document has
been submitted to the MoNHSR&C for final review, approval and dissemination.

The NVSC2025 document provides a guideline for each provincial Department of Health to develop a
Provincial Surgical, Obstetric and Anaesthesia Plan (PSOAP) that is customized to address the specific
surgical needs of each province’s population. The process in Pakistan has adapted the NSOAP framework in
two distinct but interlinked phases that align well with the country’s devolved system of government. The
initial ministerial and stakeholder involvement was conducted in parallel with a detailed gap assessment
in Pakistan to develop NVSC2025. These steps have been replicated at a provincial level, following which
drafting of customized PSOAPs will be initiated, including defining M&E, governance and costing
components in line with each province’s needs and resources.

Even though this process is a longer one with multiple tiers of stakeholder involvement, it is well adapted
to the country’s system of government. Keeping in mind the large population that this intervention aims
to serve, it is expected that ownership and implementation at a provincial level will lead to better eventual
outcomes.

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Figure 3.1 Roadmap for Pakistan’s Surgical Care Strengthening: from National Vision to Provincial Plans

National Provincial Stakeholder’s

MoNHSR&C Stakeholder’s Engagement Development of
Consultations Conference Workshops PSOAPs

1 2 3 Consensus
Statement 4 5 NVSC 6 7

LoU signed between

MoNHSR&C and IHN

Notification of NSC*

Notification of TWG** NVSC Draft NVSC Lauch -

Integration into NHV

National Steering Committee (NSC)* consisting of representatives from international and national public and private stakeholders to oversee
and coordinate the process being the decision maker.
Technical Working Group (TWG)** consisting of international and national partners to conduct research, provide technical support throughout
the process and draft documents.
Ministry of National Health Services, Regulation and Coordination (MoNHSR&C); Letter of Understanding (LoU); Indus Health Network (IHN).
National Vision for Surgical Care (NVSC); National Health Vision (NHV); Provincial Surgical, Obstetric and Anaesthesia Plan (PSOAP).

Figure credit to: Syeda Mahnoor Rizvi – Indus Hospital, Karachi, Pakistan

3.1.1.3 Regional Model

The regional model is one that has recently emerged scientific and technical development in surgical
as an innovative approach to NSOAP development. service delivery, especially the setting up of standards
This model leverages and builds upon existing inter- which enable establishment of equivalents in
governmental platforms of countries that share training and compensation across countries.
similar political, geographic and socio-economic This regional model could also work for countries
dynamics. In collaboration, member states will that are already sharing cross-border technical
develop and implement a regional strategic and scientific expertise to build partnerships and
policy to strengthen SOA service delivery, with facilitate rapid expansion of access to surgical care
a shared research and accountability processes in the region. This will also help improve resource
for the cooperating Member States that provides mobilization including finances and efficiencies to
information on the annual progress, performance/ achieve collective goals. A regional NSOAP model
impact, monitoring and evaluation, and updates. could emerge in neighbouring countries that
The regional model offers an innovative collaborative have an intergovernmental organization fostering
platform between those Member States that could collaborative exchanges.
probably formulate similar policy plans and foster

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BOX 3.3

THE SADC NSOAP PLANNING PROCESS

The Southern African Development Community (SADC) is an intergovernmental organization that fosters
socio-economic, political and security cooperation between the 16 Member States of Southern Africa.
The SADC has embarked on a regional strategic approach to NSOAP development with the objective of
strengthening surgical health systems. In November 2018, the Ministers of Health from the 16 SADC Member
States deliberated and adopted a decision to strengthen surgical health care by incorporating NSOAP work
into the SADC Health Protocol while targeting the development and integration of the NSOAP into their
respective national health sector strategic plans by the end of 2019. The SADC region member states are
working together in framing the NSOAP policy development and implementation plans together with the
concomitant implementation research.

3.1.2 WHO support

WHO brings technical expertise to strategic planning WHO country, regional and headquarter offices
processes through country and regional offices at the outset of the NSOAP process. A template
and central headquarters. WHO can work with letter to request WHO assistance is available from
WHO collaborating centres and non-state actors in the Program in Global Surgery and Social Change
official relations with WHO to assist with the surgical (Harvard Medical School, Boston, MA, USA) (53).
health system strengthening process, by working
within the organization through the World Health
Assembly and Executive Board, governing bodies
and the permanent missions of the United Nations 3.2 STEPS FOR DEVELOPING
Office at Geneva. They can play an advisory role AN NSOAP
for priority setting and resource allocation, provide
technical assistance and use their political influence Eight components are important steps in developing
to convene meetings and request assistance from an NSOAP (see Fig. 3.2). Many of these steps can be
other key bodies, such as the African Union or the carried out simultaneously in the planning process,
South African Development Community. Regional rather than sequentially. This section provides an
offices can convene regional committee meetings overview each of the eight components: ministry
for ministers of health, which may include statutory support and ownership; situation analysis and
endorsements that serve as a mandate for countries baseline assessment; stakeholder engagement and
to tackle specific health issues. WHO regional priority-setting; drafting and validation; monitoring
offices also work in international advocacy and they and evaluation; costing and budgeting; governance;
develop technical guidelines and documentation, all and implementation. Each component is explored in
of which can be leveraged to advance the surgical more detail in subsequent chapters.
strengthening process. At the national level, WHO
can provide technical support, including evidence
generation, analysis, costing and monitoring and
evaluation. They can also play a convening role,
helping to engage all major stakeholders including
health ministries, civil society, programmes and
partners. Additionally, bringing country and regional
offices on board in the strategic planning process
and working closely with ministries of health may
help to prioritize SOA care within the broader WHO
international agenda. Planners are advised to contact

2020 EDITION 27
 Fig. 3.2 Steps for the development of an NSOAP

MOH
COMMITMENT
FUNDING
MULTI-
STAKEHOLDER
IMPLEMENTATION
SITUATIONAL
ANALYSIS

GOVERNANCE

MOH PARTICIPATORY
APPROVAL PRIORITY
SETTING
DATA

DRAFTING
COSTING AND
VALIDATION

MONITORING
EVALUATION
GOVERNANCE
STRUCTURES

MoH: Ministry of Health

3.2.1 Ministry support and ownership

Achieving support from the MoH is the first – and process where the NSOAP will be situated within
arguably most important – step in successfully the MoH – for example, within RMNCH, NCDs,
completing an NSOAP. Buy-in, support and Health Care Organization, Clinical Services, Hospital
leadership from the MoH are critical for increasing Medicine, quality or other directorates. Strategically,
the likelihood that the NSOAP is integrated into the this can help to establish continuity of leadership,
national health strategic plan (NHSP) and that the governance and accountability for the NSOAP within
NSOAP will ultimately be implemented. the MoH, especially during periods of government
turnover. Fig. 3.3 illustrates the integration of the
The MoH will have an understanding of the country’s NSOAP into national health policy.
health priorities, the current health care landscape,
financial and resource capacities and the bandwidth
for implementation. Ministries also lead policy
development and drafting and have the most
comprehensive knowledge of current programmes
and priorities that can help to avoid fragmentation
and duplication. It is helpful to identify early in the

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Fig. 3.3 Integration of NSOAPs into national health policy

NATIONAL HEALTH POLICY

HEALTH VISION AND POLICY DIRECTIONS

National Health Strategic Plan

Strategic objectives, health system investments,
and program descriptions

HIV NCD EPI NSOAP RH Child Health Malaria Other

Strategy Strategy Strategy Strategy Strategy Strategy Strategy Strategy

Infrastructure,
Service Information
Products and Workforce Financing Governance
Delivery Management
Technology

IMPLEMENTATION

EPI: epidemiological; NCD: noncommunicable disease; NSOAP: National Surgical, Obstetric and Anaesthesia Plan; RH: reproductive health

3.2.2 Situation analysis and baseline 3.2.3 Stakeholder engagement and

assessment priority-setting

Situation analysis and baseline assessment are The final NSOAP should aim to represent the views
important tools for developing evidence-based policy. and expertise of diverse stakeholders, so it is helpful
Conducting a thorough evaluation of a country’s to convene a broad group of stakeholders in the
surgical system helps to define the baseline state and planning process, including clinical providers, pro-
identify major gaps in care. This can be undertaken fessional and civil societies, academic institutions,
using a range of different methods, including on- funders and implementers. NSOAPs address the
the-ground hospital assessments, literature reviews entire surgical system, which can be divided into
and analysis of established countrywide data. The six major domains to be addressed by different
six surgical indicators recommended by LCoGS and committees of stakeholders: infrastructure, work-
incorporated in the 2015 and 2018 WHO Core 100 force, service delivery, information management,
Health Indicators can serve as a good minimum financing and governance. Adopting a systematic
starting point. Chapter 4 provides more detail approach to addressing each domain can help to
about this step, along with several tools to assist ensure that the plan is complete. Such an approach
in the process of situation analysis and baseline might involve first discussing baseline assessments,
assessment. followed by identifying challenges and prioritizing
proposed solutions, setting priorities and targets
and then proposing a monitoring and evaluation
plan. Specific discussion points pertinent to each
of these domains have been created to help guide
these committee discussions (detailed in Chapter 5).

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3.2.4 Drafting and validation 3.2.7 Governance

The next step is to draft a plan that compiles and The implementation and governance of the
prioritizes the content from the committees’ NSOAP are important to consider throughout the
discussions. The drafting process should be adapted planning process. Good governance is based on
to the local context and aligned with the country’s understanding the organizational structure and
norms and NHSP. Typically, this process includes mechanisms needed to achieve the objectives laid
identifying gaps and challenges from the baseline out in the NSOAP, assigning roles and responsibilities
situation analysis, the goals to be achieved by the to stakeholders and establishing accountability.
NSOAP and the proposed solutions and activities To ensure alignment, it will be useful to frame the
for each of these goals. These solutions can then be governance of the NSOAP within the country’s
prioritized to ensure that the plan is attainable. Major existing governance strategies for the NHSP.
stakeholder groups can then provide feedback on
the draft and the plan can be iterated until consensus
is reached. 3.2.8 Implementation

Given the breadth and complexity of an NSOAP,

3.2.5 Monitoring and evaluation dedicating full-time staff members to NSOAP design
and implementation is ideal (detailed in Chapter 9).
Monitoring and evaluation (M&E) play a crucial role in Establishing accountability for implementing and
demonstrating an NSOAP’s progress, improvement evaluating the NSOAP can be facilitated by creating
and cost–effectiveness, as well as highlighting a clear chain of responsibility from the facility level,
activities or initiatives that are lagging and may through the district and regional levels, to the MoH.
require additional support and attention. More Ensuring that responsible actors at each of those
guidance regarding the M&E component is provided levels have access to the necessary M&E data can
in Chapter 7. help to guide evidence-based decision-making.
Implementation science methodology can be
used to implement evidence-based activities and
3.2.6 Costing and budgeting to demonstrate what is working and what is not
working (and why).
The steps involved in costing an NSOAP include
assembly of available costing information, defining
the objects and quantities required, and finally
determining the base cost of each object and then 3.3 DISSEMINATION
attributing cost to the quantity of objects. This
provides an estimated cost for implementation of the As more countries successfully create NSOAPs,
plan and facilitates informed discussion with direct the plans should be shared at the national and
input from the ministry of finance (MoF) about the international levels. Within a country, it is important
appropriate budgeting for NSOAP implementation. to disseminate the completed NSOAP within
A strategic costed plan may also serve to attract communities, academic medical institutions
appropriate donors and frame discussions with and the public and private health sectors. This
funding bodies and implementation partners, as contributes to common understanding and unified
well as creating more advocacy. Chapter 8 provides execution of the strategic framework set forth by
more detail on costing NSOAPs. the NSOAP for surgical system strengthening. At the
international level, these NSOAPs and leaders in the
planning process can help to guide other countries
and to spur conversation on common barriers and
possible solutions.

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CHAPTER 4

Situation
analysis and
baselining

2020 EDITION 33
L
ittle is known about the unmet need of In 2017, Member States further approved the World
surgical care and the capacity to deliver Health Assembly’s decision WHA70.22, calling upon
surgical services across much of the world. WHO’s Director-General to report every two years
In developing an NSOAP, conducting a situational on progress towards SDG targets related to health,
analysis to establish a baseline are key initial steps including the target of Strengthening Emergency
that provide a framework for setting priorities and and Essential Surgical Care and Anaesthesia
creating initiatives. The WHO defines a health- (detailed in resolution WHA68.15). The WHO African
specific situation analysis as “an assessment of the Group, representing 54 Member States, further
current health situation ... [that] is fundamental to called for the development of a global plan of action
designing and updating national policies, strategies to support implementation of this resolution.
and plans” (54). By integrating a micro and macro
analytical approach, situation analyses provide a In March 2018, more than 120 signatories of the
basis for an integrated appraisal of health dynamics report Global Surgery and Anaesthesia Statistics
and their impacts on poverty, inequality and committed themselves to (55):
development. The process of situation analysis is
analytical, relevant, comprehensive and inherently • Support the establishment of a working group
participatory and inclusive of all relevant stakeholders. of experts on global surgery and anaesthesia
Doing so promotes national capacity-building and statistics, with participants drawn from national
recognizes national ownership and leadership in statistical authorities, ministers, health facilities,
the development of context specific evidence for health service providers, professional societies,
decision making. More efficient evidence-based national and international NGOs, academia,
decision making and policy formulation relies international organizations and the research
on increased capacity for data generation and community
utilization. The knowledge generated through the • Organize the first meeting among the working
process will provide stakeholders with the factual group of experts on global surgery and
knowledge needed to integrate surgical systems anaesthesia statistics in 2018
into policymaking. • Draft preliminary recommendations on global
surgery and anaesthesia statistics as well as a
global surgery statistics manual (both tentatively
set for issuance in 2019)
4.1 DATA IN GLOBAL SURGERY • Present draft recommendations and manual
to the United Nations Statistical Commission
As essential SOA care has come to the forefront of in 2019
the global health agenda, the importance of global
surgery indicators and standardized data collection A working group has since been established and
has been highlighted. The World Health Assembly organized the first expert group meeting in Utstein,
resolution WHA68.15 recognizes and advocates that Norway in June 2019 to draft recommendations on
essential and emergency surgical care become global surgery and anaesthesia statistics.
a part of universal health care with a particular
emphasis on surgical delivery at the district hospital.
Further, the resolution called upon the WHO’s
Director-General to:

• Establish mechanisms to collect emergency

and essential surgical and anaesthesia case
log data
• Devise relevant, meaningful and reliable
measures of access to and safety of surgical
and anaesthesia care
• Collect, assess and report related cost data
on the delivery of emergency and essential
surgical care

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4.2 WHY CONDUCT A SITUATION 4.3 HOW TO CONDUCT A

ANALYSIS? SITUATION ANALYSIS
A situation analysis provides a snapshot of the The WHO, LMICs and some Non-State Actors
strengths and weaknesses of a country’s surgical (academic institutions like the Harvard PGSSC)
system. Performing a situation analysis is important have developed several tools that could be used
for several key reasons: to conduct a Baseline Assessment of Surgical
healthcare services. A situation analysis is usually
• It provides a base of information, data and carried out in four steps:
evidence on the current state of surgical
healthcare in a country/region/district. • Defining what information and data are needed
• It gives a voice and a platform to health • Reviewing existing information and data
sector stakeholders, including the population, • Performing a comprehensive situation
for awareness raising and engagement for assessment
improvement • Conducting a strengths, weaknesses,
• It helps to establish consensus on the status of opportunities and threats (SWOT) analysis
surgery in the country and provides an evidence
base for systematic improvements.
• It allows for an evidence-informed response to 4.3.1 Define what information is needed
actual health system and population needs.
• It serves as a baseline for Monitoring and Before starting a situation analysis, it is useful to define
Evaluation (M&E), it increases accountability and the information – quantitative and qualitative – that
it improves transparency. is needed, to identify why it is needed, and to weigh
• Pre-existing data are often scarce regarding the the costs and benefits of obtaining it. The situation
provision of quality, safe and affordable surgical analysis aims to assess the current provisions for
health services; a thorough situation analysis surgical healthcare, to quantify existing surgical
can address this data void. needs and demands within the population and to
assess how these are likely to change with time. The
The situational analysis provides a foundation for discussion framework described in Chapter 5 can
priority-setting because it facilitates an evidence- be a helpful resource for defining the information
informed response to the actual healthcare needs that is needed and setting priorities. A preliminary
of the health system and the population. It is list of data that may be useful to assemble ahead of
also an important platform for giving a voice to priority-setting is provided in Box 4.1.
stakeholders, for obtaining buy-in and for ensuring
mutual accountability. Furthermore, in the context
of sparse existing data and information, a situation
analysis can serve as a baseline against which future
data can be compared.

2020 EDITION 35
 BOX 4.1

PRELIMINARY LIST OF DATA FOR PRIORITY-SETTING

The following are lists of baseline data to assess, if already available within the country’s MoH or other
sources. It is useful to assemble the data as early as possible in the NSOAP process. Disparities within
regions must also be described and accounted for.

Health system data include:

• Information about all hospitals providing SOA healthcare, including type of hospital and location
coordinates;
• Information about referral pathways between different levels of the hospital system;
• Existing relevant policies and initiatives, including accompanying data;
• List of non-state actors involved in SOA care; and
• Any other relevant data or databases.

Infrastructure data include:

• Information about electricity, water, imaging equipment (X-ray, ultrasound, CT and MRI) and available
operating theatre equipment and supplies including anaesthesia machines, number of hospital beds
and beds for surgery
• Information about supplies, including intra-operative supplies such as sterile gloves and the availability
of oxygen and laboratory facilities;
• Information about the availability of blood products
• Information about the supply chain and list of essential medications; and
• Available information management strategies (medical records, billing systems, etc)

Workforce data include:

• Information about the skill-set and number of human resources, including surgical and hospital
personnel, general surgeons, orthopaedic surgeons, urologists, otolaryngologists (ear, nose and
throat surgeons), neurosurgeons, plastic surgeons, ophthalmologists, dental surgeons, obstetricians,
anaesthesiologists, nurse anaesthetists, anaesthetic officers, trained nurses, medical officers, assistant
medical officers and clinical officers;
• Doctors working in the public sector, private sector, civil society organizations or nongovernmental
organizations (NGOs);
• Staff at each health facility;
• Graduation rate, retirement rate, attrition and information on which specialists are leaving the country;
• List of training institutions for medical, nursing and allied health professionals (including class sizes and
expected numbers of graduates per year).

Service delivery and capacity data include:

• Availability of bellwether surgical procedures (emergency caesarean section, laparotomy and treatment
of open fractures);
• Number and type of other procedures provided by facilities (surgical volume); and
• Quality and safety of procedures, including postoperative in-hospital deaths and any checklists being
utilized (such as WHO checklist); and
• Peri-operative mortality rate (POMR)

Data on financing and costs include:

• Annual hospital budgets and budget allocation to surgery;
• Current procedures covered under national insurance schemes;
• Average cost for surgical procedures and supplies (caesarean section, laparotomy and fracture repair);
• Out-of-pocket costs, cost-sharing for surgery and supplies.

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4.3.2 Review existing information The SAT broadly assesses five of the six domains of
the surgical health system: infrastructure, service
A thorough review of existing available data can help delivery, workforce, information management,
to provide some of the data for priority-setting, and financing and governance. The qualitative portion
also avoids duplicating existing information. Rich of the assessment comprises of in-person semi-
data sources include, but are not limited to: structured interviews with key stakeholders – for
example, hospital directors and administrators,
• National population and housing censuses surgeons, obstetricians, anaesthesia providers and
• National and provincial health facility principal nursing officers. The overarching aim is to
assessments gain a better understanding of the entire surgical
• Nationwide sample surveys, such as: system in order to identify its strengths and shortfalls.
• Service Availability and Readiness Other tools, such as those piloted by the Global
Assessment (SARA) Initiative for Emergency and Essential Care, are
• Demographic and Health Survey (DHS) widely available. Existing tools can be adapted and
• Service Provision Assessment (SPA) expanded to reflect context-specific priority areas.
• Personnel, Infrastructure, Procedure, For example, additional questions can be added
Equipment, and Supplies to the SAT to capture information about children’s
• Living Standards Measurement Study surgery, neurosurgery, or congenital heart disease as
(LSMS) other priority areas.
• Performance reports (governmental and non
governmental) The SAT was used to build the surgery module of
• National health-sector strategic plans WHO’s Harmonized Health Facilities Assessment
• Health-sector management and information (HHFA), which is a soon-to-be-released digital
system (HMIS) and other administrative sources platform to streamline all existing facility assessment
• Published literature health data and is expected to reduce the need for
• Programmatic and policy reporting paper-based surveys. This module will have built-in
submodules for anaesthesia and paediatric surgery,
Actively engaging multiple stakeholders can help with submodules for other surgical subspecialties to
to capture and coordinate all relevant data points, be added over time. Each module and submodule
because many of those stakeholders may have will have appropriate links to other areas of the
useful perspectives and additional information to entire HHFA: for instance, anaesthesia will be linked
build the evidence base. to the essential medicines module and paediatric
surgery linked to the children’s health module. This
systematic approach aims to avoid redundancy in
4.3.3 Comprehensive situation data collection and allow for streamlined updates
assessment and additions. Anonymized data will be available on
WHO’s website.
In many settings, existing available information about
the surgical health sector remains insufficient. To aid DHS is the most comprehensive population
in data collection, the Program in Global Surgery and survey worldwide, administered to more than 320
Social Change at Harvard Medical School (Boston, households and facilities in 90 countries of Africa,
MA, USA) have developed a Surgical Assessment Tool Asia, Latin America/Caribbean and Eastern Europe.
(SAT) with qualitative and quantitative components The 2018 Zambia Demographic and Health Survey
(53). This mixed-methods tool is designed to collect (ZDHS) implemented by the Zambia Statistics
information through both facility and service- Agency (ZamStats) in collaboration with the Ministry
delivery assessments. It can be deployed on a of Health was the first national DHS to integrate five
regional or national scale and adapted to suit each surgical questions in their DHS (56). Zambia was the
context. The quantitative portion of the assessment first country to include questions on surgical need,
involves a combination of hospital walk-throughs, care and barriers to care. In its 2018 Demographic
retrospective reviews of operative logbooks and and Health Survey (Box 4.2).
interviews with hospital leaders and service providers.

2020 EDITION 37
 BOX 4.2
Partnerships are important in collecting data for the
situation analysis. Involving critical stakeholders can
help ensure a comprehensive evaluation, access to
facilities and applicability and accessibility of results CASE EXAMPLE: ZAMBIA DHS
at the country level. However, situation analysis is SURVEY SURGERY PILOT PROJECT
a resource- and time-intensive process. Directly QUESTIONS
measuring surgical metrics through hospital site
• Have you ever undergone a surgical
visits requires large amounts of planning and
operation in the past 5 years?
communication, adequate time to travel and
conduct the assessment, and the financial and • What type of operation(s) were they?
personnel resources necessary to support these (Name all that apply)
activities. In settings where on-the-ground facility
assessments are not feasible, situation analysis can • In the last 5 years has a doctor or another
be conducted through a remote survey of facility healthcare worker told you that you might
administrators and directors by email, phone or need (another) operation?
post. This strategy is less resource intensive, but it
• Were you able to access it?
may compromise data completeness and validity.
Table 4.1 provides an overview of the advantages and
• Why did you not access it?
disadvantages of different strategies for situation (Record all mentioned)
assessment. Tools and guides for performing and
analysing the results of these assessments are
available to guide the process (53).

Table 4.1 Situation assessment strategies

Strategy Advantages Disadvantages

• Strategy may have variable success based on

• Strategy is low cost amount of existing data which is often limited
Review of existing • Strategy can cover wide breadth of topics and/or not generalizable
literature and data • Strategy is likely to be comprehensive in setting of recent • Data points often are not validated
systematic facility assessment • Collating information from multiple sources
is challenging

• Data may be incomplete based on poor

Mail, phone or return rate
electronic survey • Strategy is rapid and low cost • Data points often are not validated
• There may be bias in returned data
• Data quality is potentially poor

• Strategy is efficient when paired with existing scheduled • Strategy is highly resource intensive
On-the-ground facility assessments • Capacity for quantitative and qualitative
assessment • Data are robust and validated analysis of results is required
• Quantitative and qualitative data can be collected • Qualitative analysis can be time consuming
• Sampling for efficiency is possible

• Strategy provides population-level data • Strategy is expensive and time consuming.

Household surveys • Data may be more representative of the entire country • Surveys may have limited number of surgery
• Surgery data collection can be added to large existing efforts, specific questions
such as Demographic and Health Surveys

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4.3.4 Conduct a SWOT analysis

As part of the situation analysis, a SWOT analysis stakeholders to meet and discuss these elements of
is a useful analytic method for exploring existing their health care system as it pertains to the delivery
internal capabilities (strengths and weakness) of SOA healthcare. Table 4.2 is an example of a SWOT
and potential extrinsic factors (opportunities and analysis for NSOAP service delivery in Zambia.
threats). Conducting such an analysis requires

Table 4.2 Example SWOT analysis of NSOAP service delivery in Zambia

Strengths Weaknesses Opportunities Threats

Level 1 hospitals are available in Not all level 1 hospitals are Resolution WHA68.15, Resolution may not be adapted
most districts with plans for full capable of providing essential sponsored by Zambia, on into domestic practice if
coverage and emergency surgical care emergency and essential awareness remains low
surgery supports its role in UHC

Most provinces have level Existing resources are not

2 facilities and plans are in Plans for service upgrades have sufficient to meet demands.
place to upgrade some level not translated to the ability to Increased demand among the There is also a need to change
2 hospitals to level 3 hospitals provide elective and referred population for SOA care the staffing establishment to
and level 3 hospitals to SOA services meet facility demands
teaching hospitals

Individual level 3 hospitals have Poor coordination among Potential cost-savings from Significant start-up costs
formulated plans to expand separate plans for expansion domestic treatment of patients are required to initiate and
services and introduce new have resulted in incomplete as opposed to international coordinate these services
aspects of SOA healthcare with translation to service delivery referrals domestically
support from the country’s MoH

MoH: Ministry of Health; SOA: surgical, obstetric and anaesthesia; UHC: universal health care

2020 EDITION 39
4.4 CORE SURGICAL INDICATORS
Establishing a baseline is essential for measuring and financial risk. WHO included all six indicators in
the future impact of policy and programmatic their 100 Core Health Indicators (2015 and 2018) and
interventions. In 2015, LCoGS convened to assemble the World Bank incorporated four of the indicators
evidence on the state of surgical care worldwide as part of the World Development Indicators (WDIs)
and to develop strategies for improving access and (2016) (see Box 4.3). Countries are urged to collect
quality (1). The Commission recommended that and analyse information on all six indicators to allow
all countries collect six core surgical indicators as assessment of the current state of surgical care and
measures of the strength of their surgical system to allow for comparison against international targets.
(see Table 4.3). These six indicators measure three Such metrics can be used as not only a component
domains of surgical care: preparedness for delivering of the baseline situation analysis, but also for ongoing
surgical services, volume and outcomes of service, monitoring and evaluation.

Table 4.3 LCoGS six core surgical indicators

Indicator (domain) Definition Target by 2030

Access to timely essential surgery Proportion of the population that can

(preparedness) access, within two hours, a facility that can 80% coverage of essential surgical and
perform caesarean delivery, laparotomy anaesthesia services per country
and treatment of open fracture (the
bellwether procedures)

Specialist surgical workforce density Number of specialist SOA physicians who 100% of countries with at least 20 SOA
(preparedness) are working per 100 000 population physicians per 100 000 population

Surgical volume Procedures done in an operating theatre 100% of countries tracking surgical volume;
(service delivery) per 100 000 population per year 5000 procedures per 100 000 population

All-cause death rate prior to discharge

Perioperative mortality rate among patients who have undergone 100% of countries tracking perioperative
(service delivery) a procedure in an operating theatre, mortality
divided by the total number of procedures,
presented as a percentage

Proportion of households protected

Protection against impoverishing against impoverishment (being pushed 100% protection against impoverishment
expenditure (financial risk) into poverty or being pushed further from out-of-pocket payments for surgical
into poverty) from direct out-of-pocket and anaesthesia care
payments for surgical and anaesthesia care

Proportion of households protected

against catastrophic expenditure from
Protection against catastrophic direct out-of-pocket payments for surgical 100% protection against catastrophic
expenditure (financial risk) and anaesthesia care (direct out-of- expenditure from out-of-pocket payments
pocket payments of greater than 40% for surgical and anaesthesia care
of household income net of subsistence
needs)

SOA: surgical, obstetric and anaesthesia.

Source: adapted from Meara et al. (1).

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BOX 4.3

WORLD BANK AND WORLD DEVELOPMENT INDICATORS (WDI) RELATING TO SURGERY

The World Bank plays a central role in country-level data management. Their influential annual WDI
publications are compiled from officially recognized international sources covering the most current
and accurate global development data available and provide national, regional and global estimates.
Data collection requires developing in-country contacts, developing an online systematic process for
data management, training teams of associates to manage relationships and data, and reporting clean
summary data to the World Bank. Data are evaluated for quality, sources and definitions used, and
are subject to critical appraisal over time. This requires developing mechanisms to review and improve
indicators alongside other global health indicators currently in use, such as the SDG indicators.

Four global surgery indicators are now included in the WDIs as the result of collaboration that began
in 2015 (57,58).

Number of surgical Specialist surgical Risk of catastrophic Risk of impoverrishing

procedurers (per workforce (per 100,000 expenditure for expenditure for
100,000 population) population) surgical care (% of surgical care (% of
people at risk) people at risk)

In addition to collecting data on national indicators, the NSOAP process includes the development of a
comprehensive M&E package (see Chapter 8). Data gathered during baselining can serve as advocacy
tools, metrics for M&E and benchmarks for comparing future data points. Box 4.3 provides an overview of
collaborative data collection on global surgery indicators, based on experience in the Asia-Pacific region.

2020 EDITION 41
 BOX 4.4

COLLABORATIVE DATA COLLECTION

ON GLOBAL SURGERY INDICATORS IN
THE ASIA-PACIFIC REGION

Through the Bangkok Declaration of 2015,

countries of the Asia-Pacific region made a
commitment to promote the key messages
and indicators of LCoGS (59). Later that year,
at the 4th Royal Australasian College of
Surgeons (RACS) Global Health Symposium,
14 countries resolved to come together
across the Asia-Pacific region to collect four
of the six global surgery indicators (60). To
collect the indicators, RACS established
a working group that developed a pre-
collection feasibility survey, created an online
chat group and held regular teleconferences
over a six-month period from October 2015
to April 2016. National representatives were
encouraged to work with their national
ministries of health; data were only included
once appropriate national permission was
obtained. Of the 14 countries, 13 obtained the
data on four indicators, each using a context-
appropriate methodology (60). The data are
being leveraged in three ways: to benchmark
surgical capacity across the region; to serve
as a baseline for measuring the success of
regional efforts to improve surgical capacity
and quality; and for advocacy to promote
surgery on national health agendas. However,
the collaborative effort of RACS reflects the
difficulty of obtaining even a relatively sparse
dataset, because of a lack of systematic
prospective data reporting and the absence
of a national mandate to collect the data. The
experience underscores the need to integrate
data collection mechanisms – individualized
and appropriate for each context – into
national systems to assist in national surgical
planning. Ultimately, these data highlight
the urgent need to improve the surgical
system, which remains invisible without data.
Recently, the Council of Health Ministers
of the Pacific have approved adoption and
reporting of the indicators and are working
towards developing a regional NSOAP.

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YOUR

Notes

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Notes

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CHAPTER 5

Stakeholder
engagement and
priority-setting

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T
he content and quality of an NSOAP is 5.1 WHY DO WE NEED A MULTI-
ultimately in the hands of the stakeholders STAKEHOLDER APPROACH?
involved in the process, so careful
identification and early involvement is crucial. To An NSOAP encompasses a broad array of objectives
ensure that the NSOAP’s content is comprehensive so adopting a multi-stakeholder approach is strongly
and reflects the values and experiences across advised. A diverse stakeholder group allows each
the breadth of the health sector, it is helpful to party to bring their unique lived experience of the
engage an inclusive cross-section of stakeholder system, area of specialization, geographical region,
groups: government, professional societies, local and level of engagement in the health care system
academic institutions, civil society organizations to the table. A multi-stakeholder approach allows for
including patient and community representatives, careful consideration of both top-down and bottom-
and industry and implementation partners. up priorities and concerns.
Furthermore, identifying the ambitions and
struggles of each stakeholder group, and listening Mobilizing multiple stakeholders can help to
closely to their personal experiences and expertise, garner support for the plan at multiple levels, and
will serve to inform and strengthen the NSOAP. to identify any opposition or obstacles early in
the process. Engagement provides a transparent
forum for stakeholders to address their reservations
The development of resilient openly and to come to joint solutions in the best
surgical systems will need interest of the overarching goals of the plan (61).
commitment and engagement Engaging stakeholders who ultimately will be the
from various stakeholders at implementation partners of the NSOAP can instill
the national and international ownership and a sense of duty to implement the plan
levels, and from public, private, that they have helped to shape.
and charitable sectors. A national
strategic plan that specifically
addresses surgery is essential for
the proper planning of care delivery, 5.2 STAKEHOLDER GROUPS
education, and research. This plan
should be country- and context- Table 5.1 highlights the major stakeholder groups that
specific, developed and owned by may contribute meaningfully to the NSOAP process.
all stakeholders, and rest within a The column labelled “Expertise/Contributions” offers
broader strategy of improvement of suggestions about which topics to engage each
national health systems (1). group on. The inclusion of these stakeholder groups
in the table is intended to serve as general guidance
for your consideration and may not be relevant in
every context.
A consideration before engaging stakeholders at all
levels, consider the local political priority for surgery,
and how this priority may be echoed and elevated
with the help of these groups. Multiple policy
analyses have concluded that prioritization of global
surgery in public policy will require the formation
of an organized and consolidated group that can
present shared interests and advocate at the highest
levels (50). It may be a helpful place to start to identify
broad strengths and obstacles within the context
that initiating an NSOAP, to create a strategy even
before involving other stakeholders.

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 Table 5.1 Major stakeholder groups to consider involving in the planning process
Stakeholder Examples Expertise/Contributions

Local government, national • National MoH 1

• Bring political skill and political will to the process
government and interested • Finance, education and infrastructure • Drive the NSOAP process
elected leaders sectors • Ensure process is compliant and aligned with resources
• Policy officials • Coordinate existing efforts
• Other government representatives • Develop the governance structures to ensure plan is
implemented
• Ensure surgical care is integrated into national health plans

Academic and research • Academic deans • Conduct situational analysis of current training capacity
institutions • Teaching institution faculty • Set realistic goals for the growth of training programs
• Public health, health systems, and • Advocate for mentorship, research direction, and research
global surgery researchers opportunities
• Centres for global surgery/obstetrics
anaesthesia

Professional societies • Surgery society • Represent the collective interests of the SOA providers, their daily
• Anaesthesia society experiences and visions for the field of surgical delivery
• Obstetric society • Advise on licensing legalities
• Nursing association • Provide technical clinical expertise

Clinical providers • Representative sample of clinicians • Provide view from the front-line of care
from across subspecialties • Provide technical clinical expertise
• Non-physician SOA providers • Often provide lens of hospital CEO and administration
• Mixed urban and rural (district)
providers
• Regional representation

Ancillary surgical staff • Operating room nurses • Provide front-line view of multidisciplinary care
• Nurse anaesthetists • Ensure daily healthcare workflow and ecosystem are taken
• Lab technicians into account
• Physical therapists
• Occupational therapists
• Biomedical engineers

WHO • Emergency and Essential Surgical Care • Provide technical expertise in planning and costing
Programme • Serve as key partner with MoH
• WHO regional office • Potentially offer significant political influence for implementation
• WHO country office • Assist in identifying other stakeholders

NGOs, not-for-profit sector, • SOA implementers outside the public • Offer experience in care delivery
implementation partners sector • Develop innovative care models
• Public health initiatives • Provide knowledge of available funding mechanisms
• Implementers • Facilitate implementation

Patients, health service • Patients/users • Represent community interests and priorities

users and civil societies • Patient lobbyists • Advocate for quality-of-care priorities
• Parents • Participate in surveys about utilization and spending to inform
• Advocates planning
• Community groups

Trainees and organized • SOA Fellows and residents • Represent the future of the SOA fields, early engagement
trainee groups • Medical and nursing students • Provide knowledge of curriculum, training and opportunities for
• National and international organized improvement
student groups for surgery/OB • Assist in incentivization
anaesthesia advocacy

Private sector • Private health SOA providers • Coordinate with private system
• Private healthcare administrators • Inform/develop innovative care models
• Private healthcare patients/users

Funding bodies • Multilateral aid organizations • Identify realistic funding opportunities

• Foundations and private philanthropy • Align NSOAP with funding priorities
funding • Contribute employee expertise to budget consulting
• Aid agencies and donors
• National and provincial MoF

Industry representatives • Medical and surgical devices industry • Contribute their products and services
• Infrastructure industry • Develop context-appropriate products
• Provide clinical and leadership training
• Offer funding and sponsorship
• Provide leadership and supply chain expertise

UN Funds and Programs • UNDP • Advise about wider regulatory framework

• UNFPA • Endorse and progress international advocacy efforts
• UNICEF

MoH: ministry of health; MoF: ministry of finance; NGO: nongovernmental organization; NSOAP: National Surgical, Obstetric and Anaesthesia Plan; SOA: surgical,
obstetric and anaesthesia
1
MoH stakeholders may be drawn from the areas of NCD, maternal and child health, training, clinical care, quality, policy and planning, procurement and pharmacy.
5.3 STAKEHOLDER 5.4 INITIAL ENGAGEMENT AND
IDENTIFICATION PRIORITY-SETTING
The plan depends on the “political skill as well as Once the relevant stakeholders have been identified,
the political will” of the government to engage the next step is ensuring their engagement. The
in the NSOAP planning process (62). Ideally, the NSOAP lead team, ideally assembled earlier in the
government serves as the convener and coordinator NSOAP process, can play a pivotal role in driving and
of other stakeholder groups and makes the ultimate supporting stakeholder engagement (see Chapter 3
decisions regarding which stakeholder groups are for more information about the NSOAP lead team).
involved in the process. A stakeholder analysis can Before initial engagement with the broader group
be utilized to better understand the best approach of stakeholders, the NSOAP lead team can meet to
for engaging with each of the stakeholder groups agree upon the appropriate roles, responsibilities,
and addressing any potential opposition to the and expectations for each of its members.
plan. An additional resource is the detailed review
of stakeholder analysis methodologies performed
by Brugha and Varvasovszky (63). “The level of 5.4.1 Aims of engagement
stakeholder involvement points back to the steering
capacity of the MoH and the core team (i.e., not just Stakeholder engagement has multiple aims
ministry of health, but key planning stakeholders as throughout the dynamic NSOAP process:
well) to effectively lead, coordinate, and motivate the
right people to give their input on the one hand, and • To explain the NSOAP process, to discuss
assist implementation on the other” (61). the timelines that have been set and to clarify
stakeholders’ valued contributions
A range of methods can be used to facilitate the • To engage in a multilateral discussion of priorities
identification of stakeholders. For example, the and pain points for individuals and groups that
ministry directive approach and the snowball method inform each step in the NSOAP development
have both been used effectively in the NSOAP process. • To review the findings from the situational
In a ministry directive approach, the MoH selects and analysis and baseline assessments, eliciting
convenes a set of key individuals and groups with qualitative feedback from stakeholders that
whom the ministry is already familiar. Although this informs the quantitative results of the analysis
method is efficient, it may restrict engagement to • To identify strategic objectives and priorities for
those stakeholders who are already known to the the NSOAP (discussed further in Chapter 6)
ministry and already have existing influence. In the • To foster shared ownership of the plan by all
snowball method, initial contacts and representatives stakeholders
identify new stakeholders or contacts who they
feel would be relevant to the NSOAP. This process In practice, each stakeholder group will have
is highly participatory and can identify groups that different levels of involvement in the NSOAP
have been excluded previously; however, this method process. Therefore, different types of engagement
can be lengthy and time consuming. A combination approaches are appropriate for different groups.
of techniques for identifying stakeholders is often the For example, minimal engagement may be needed
most effective approach. for stakeholders whose expertise pertains only to
a specific domain of the plan. Other stakeholders
– such as clinicians and professional societies – are
integral to each of the domains of the NSOAP and
warrant a high level of engagement. See Box 5.1 for a
case study from the United Republic of Tanzania in
stakeholder engagement.

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UN Photo/JC McIlwaine

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 BOX 5.1

5.4.2 How to engage

STAKEHOLDER ENGAGEMENT: CASE
STUDY FROM THE UNITED REPUBLIC Stakeholder engagement may be carried out
OF TANZANIA through focus groups, semi-structured interviews,
workshops, and committees.
The United Republic of Tanzania’s NSOAP
process was initiated in November 2016 and
launched in March 2018. The process began 5.4.2.1 Focus groups
with a systematic review of existing data from
a wide range of sources: The United Republic
of Tanzania’s MoH; NGOs; grey literature; and Focus groups typically involve a planned discussion
academic literature. Upon completion of the with a group of stakeholders that is facilitated by a
review, a group of more than 200 diverse moderator, allowing for opinions to be expressed in a
stakeholders were identified using the relaxed and open setting. Examples of stakeholders
snowball approach. Stakeholders included: who could be engaged through focus groups include
patients, operating theatre nurses, anaesthesia
• Clinicians from each zone of the country, technicians, and student advocacy groups. Focus
including surgeons, anaesthesiologists, groups provide a good opportunity to identify
anaesthetists, obstetricians, radiologists,
individuals who may wish to be more involved in
nurses, laboratory technicians,
biomedical engineers and midwives; the NSOAP process. A potential pitfall is that focus
• Representatives from civil societies, groups can be dominated by more outspoken
NGOs and patient groups; and individuals, which may lead to a skewed perception
• Government representatives from the of the views of the group.
areas of curative and preventive services,
policy and planning, human resources,
training and procurement. 5.4.2.2 Semi-structured interviews

Stakeholders were consulted using semi-

Semi-structured interviews are best suited to get
structured interviews and focus groups.
Following the initial broad engagement, 80 of direct perspectives of individuals or small groups
the most engaged participants were selected of two or three people. Ideally, the interviews would
from across the stakeholder groups to take be carried out by unbiased data collectors and then
part in a two-day technical workshop. The could be collated centrally and organized for review
initial workshop used discussion frameworks by the NSOAP lead team. The online supplemental
for priority-setting that were synthesized material provided at the end of this chapter includes
into a draft. The initial draft was iterated guidance for semi-structured qualitative interviews,
and validated by these stakeholder groups. which can be tailored to each stakeholder group.
The next step was to cost the plan and pass
These interviews can be useful for getting advice on
the final draft. The final NSOAP has been
integrated into the health sector’s strategic certain elements of the plan from stakeholders who
plan. It is both ambitious in scope – including may not need to be engaged for the entire process.
more 150 individual activities – and feasible Individual interviews are also a good method for
to implement, costing less than US$ 1.70 per identifying people who may want to play a key role
capita per year and 3.28% of the country’s in driving the NSOAP process and implementing
current health expenditure. The plan is the plan.
also inclusive, in that it directly reflects the
stakeholders’ priorities and is supported
by strong partnerships with professional
organizations.

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5.4.2.3 Workshops and committees

Once appropriate stakeholders have been identified example in Infrastructure domain, see Fig. 5.1). For
and initial engagements established, workshops each topic, the framework proceeds through the
or committees can provide a platform for more baseline for that subcategory, as well as challenges
in-depth, systematic priority-setting. For practical and proposed solutions relevant to the topic. The
purposes, it may help to divide the stakeholders committee can also set targets and then decide
into committees, each assigned to one of the upon an M&E plan for that subcategory. The number
NSOAP’s domains (infrastructure, service delivery, of committee meetings required is dependent on
workforce, information management, financing and the degree of its stakeholders’ involvement and the
governance) to address each systematically. When depth of detail that the committee deems necessary.
possible, each committee’s membership should Setting and maintaining a timeline is crucial for
represent a cross-section of stakeholders. keeping committees on task and moving the NSOAP
process along. After each committee has completed
The supplementary material for this chapter includes their discussion framework, a compilation of the
discussion frameworks for conducting committee proceedings from each committee meeting should
meetings that have been created for each of the be reviewed by the NSOAP lead team. Further
domains. The discussion frameworks are divided prioritization will likely be needed, which is discussed
into subcategories that detail suggested systematic in the next section.
discussion topics pertinent to that domain (for an

Fig. 5.1 Example of discussion framework for the infrastructure domain

INFRASTRUCTURE

Number and Distribution of Surgical Facilities

I. Background
1. What are the different levels of health facilities that exist in the country?
a. How many facilities are there of each level in the country?
2. Which of the facilities should be capable of providing the Bellwether procedures (C-section, laparotomy,
and treatment of open fracture)?
a. What is the geographic distribution of Bellwether-capable facilities?
i. Is this distribution deliberate, and if so how?
b. What percent of population do you estimate can reach a Bellwether-capable facility within 2 hours?
3. Is the current number and distribution of facilities adequate?

II. Challenges & Proposed Solutions

4. What are the major barriers to developing new facilities?
5. What are previous and current initiatives to improve distribution and number of facilities?

III. Targets
6. In 5 years, what changes need to be made in regards to the number and distribution of surgical
facilities?

IV. Monitoring and Evaluation

7. Key Metrics
a. How can 2-hour access to Bellwether procedures be measured accurately?
b. What is the frequency that access to Bellwether procedures should be measured?
8. Which body of government or organization will lead this initiative and monitor progress?

Source: NSOAP Discussion Framework created by Yihan Lin, Isabelle Citron, Kristin Sonderman and Swagoto Mukhopadhyay, Program in Global
Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA (64).

2020 EDITION 51
5.4.3 Setting priorities

It is unlikely that all of the funds needed to implement and disability averted, but they are less cost-effective
an NSOAP will be available upon completion of the than the first set of activities. As even more money
plan. At this point, the key question is: “Given current is mobilized, it may be possible to fund activities to
budget constraints, what should be emphasized improve access to services that are relatively costly
first and what activities can be postponed?” This and may be life-enhancing rather than life-saving;
is another way of asking, “How should the plan’s such activities may also focus on prolonging the
various goals be prioritized?” Discussions of priority- lives of older populations rather than saving lives
setting in global health tend to focus on three criteria: and averting major disability among relatively young
health impact, equity, and cost-effectiveness. Each of populations.
these criteria are explored in this section to illustrate
how they can converge in health planning – rather Although there are scenarios in which these three
than conflicting with each other – which holds true criteria may diverge with respect to priority-setting,
in plans to expand access to SOA care. The section on a practical basis, they almost always converge
concludes with a set of suggested activities that are in the context of expanding surgical services. For
likely to be high priority according to all three criteria. example, expanding access to services for the
Health impact criteria can be used to prioritize poor and other underserved populations who
funding for activities that have the greatest impact currently have little or no access to care is likely
on the public’s health by reaching a large number of to be equitable, high-impact and cost-effective.
people with services that significantly improve their Per the general principle of decreasing marginal
health status. Consequently, specialized services returns on investment, expanding access is likely
needed only by a small portion of the population to make a greater difference for those who have
may be postponed. the least access than for those who can already
obtain decent care. Generally, health impact and
Equity criteria can be used to prioritize services for cost–effectiveness criteria are unlikely to conflict
people who currently have the least access, such because emphasizing high cost–effectiveness is
as low-income, uninsured, and rural populations. tantamount to maximizing health impact (subject
The idea of prioritizing these populations is rooted to budget constraints). Therefore, all three criteria
in the principles of social justice, or the equitable justify assigning high priority to expanding access to
distribution of resources in society, and of the essential surgery among underserved populations.
preferential option for the poor in healthcare, which In most countries, these will be rural, uninsured,
hold that people who have historically been and impoverished populations; these groups often
deprived of services should now have a high-priority overlap significantly, further amplifying this point.
claim on new resources being made available.
Both of these principles apply to the allocation of Producing a rigorous set of cost–effectiveness
resources for surgery, which has historically not analyses (CEAs) to fully inform NSOAP priority-
been made available to vulnerable populations, setting is desirable but doing so is costly and
and which addresses a disease burden that afflicts time consuming. Although CEAs can help to
people without access to safeguards, screening, and rationalize the allocation of surgical resources, the
preventive medicine at higher rates. development and implementation of NSOAPs
should not be delayed by awaiting completion of
Cost–effectiveness criteria are used to prioritize a large set of country-specific CEAs. Much of this
activities that have the greatest health benefit for work has been explored in broad strokes which can
a given investment. Activities aimed at expanding serve as guideposts, including the DCP3 and the
access to essential surgical activities, as described by WHO Emergency and Essential Surgical Procedures.
the DCP-3 and others (see Table 5.2), are likely to be in Over time, CEAs can help to refine the set of surgical
the first tier, or highly cost–effective. As more funds services that should be considered essential and
become available, a second tier of activities can be to select the optimal technology and workforce for
undertaken. These are activities that provide a good delivering those services. This is an important area
return on investment as measured in lives saved for future research.

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Table 5.2 Essential surgical procedures recommended for each setting

HEALTHCARE DELIVERY SETTING

Priority Type of Community facility and First-level hospital4 Second- or third-
procedure2 primary health centre3 level hospitals5

• Repair of perforations (such as peptic

ulcer)
• Appendectomy
• Bowel obstruction
• Drainage of superficial • Colostomy
Must General surgical abscess • Gallbladder disease including emergency –
• Male circumcision surgery
• Hernia, including incarceration
• Hydrocelectomy
• Relief of urinary obstruction:
catheterization or suprapubic cystostomy

• Caesarean birth
• Vacuum or forceps delivery
• Ectopic pregnancy
Obstetric, • Manual vacuum aspiration and dilatation
gynaecologic and curettage
Must and family Normal delivery • Tubal ligation Repair obstetric fistula
planning • Vasectomy
• Hysterectomy for uterine rupture or
intractable postpartum haemorrhage
• Visual inspection with acetic acid and
cryotherapy for precarious cervical lesions

• Resuscitation with advanced life-support

measures, including surgical airway
• Tube thoracostomy (chest tube)
• Resuscitation with basic life- • Trauma laparotomy
support measures • Fracture reduction
Must Injury • Suturing laceration • Irrigation and debridement of open –
• Management of non- fractures
displaced fractures • Placement of external fixation or traction
• Escharotomy or fasciotomy
• Trauma-related amputations
• Skin grafting
• Burr hole

• Cataract extraction and

insertion of intraocular
Should Visual – – lens
impairment • Eyelid surgery for
trachoma

• Repair of cleft lip and/or

palate
• Repair of club foot
Should Congenital – – • Shunt for hydrocephalus
• Repair of anorectal
malformation and
Hirschsprung’s disease

Should Non-trauma – • Drainage of septic arthritis –

orthopaedic • Debridement of osteomyelitis

• Extraction
Can Dental • Drainage of dental abscess – –
• Treatment of caries

2
The column in which a procedure is listed is the lowest level of the health system in which it would usually be provided. Not included in the table are prehospital
interventions, such as first aid, basic life-support procedures or advanced life-support procedures done in the prehospital setting. Health systems in different countries
are structured differently, and what might be suitable at the various levels of facilities will differ. Not included in the list of essential procedures would be procedures that
are more applicable at higher-level facilities: repair of vascular injury, open reduction and internal fixation, drainage of intracranial hematoma other than through burr
hole or exploration of neck or chest.
3
In this table, community facility implies primarily outpatient capabilities (as would be used to provide the elective procedures such as dental care), whereas primary
health centre implies a facility with overnight beds and 24-hour staff (as would be needed for procedures such as normal delivery).
4
First-level hospitals imply fairly well-developed surgical capabilities with doctors with surgical expertise; otherwise, many of the procedures would need to be carried
out at higher-level facilities. Trauma laparotomy applicable at first-level hospitals: exploratory laparotomy for hemoperitoneum, pneumoperitoneum or bowel injury;
specific procedures include splenectomy, splenic repair, packing of hepatic injury and repair of bowel perforation.
5
Referral and specialized hospitals (which could also be considered second- and third-level hospitals) imply facilities that have advanced or subspecialized expertise for
treatment of one or more surgical conditions, not usually found at lower-level facilities.
Source: Adapted from DCP-3 Volume 1 (3).

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In defining a set of high-priority activities, planners 5.5 SUPPLEMENTAL RESOURCES

and other stakeholders should seek to identify
specific expenditures that are both low cost and Full discussion framework is available from:
high impact. One method is to identify locations https://tinyurl.com/ybsk5eqo (64).
in the system where critical inputs are lacking. For
example, well-equipped facilities staffed by trained Qualitative interview tools for specific
surgeons can make little impact if the staff does stakeholders (Hospital director, physicians,
not include enough anaesthesiologists or nurse nurses) are available from:
anaesthetists. In this case, training and deploying https://tinyurl.com/yb2m9lr4 (65).
anaesthesia staff may be near the top of the
implementation priority list. Similarly, the range,
quantity and quality of surgery provided at a facility
can be severely compromised if the facility lacks
essential equipment such as continuous oxygen
supply, functioning suction or basic capacities such
as reliable electricity. In those surgical facilities,
ensuring the availability of critical inputs should be
a high priority. This can catalyse more efficient use
of existing resources, especially in facilities accessed
by underserved populations. In such contexts, it can
be helpful to focus on upgrading multi-capacity
platforms – such as the surgical facilities in clinics or
health centres – that share resources across surgical
procedure types, rather than a narrower focus on
specific surgical procedures with unique resources
that are not shared.

The specific opportunities for high-impact new

investments will vary between and within countries.
Other potentially promising high-priority strategies
include, but are not limited to:

• Paediatric surgical capacity, which is often

neglected yet can have a high return in lives
saved and years of disability averted;
• Training and deployment of additional operating
theatre and ward nurses (cadres that are often in
insufficient supply); and
• Incentive schemes that ensure that the surgical
workforce is available in underserved areas.

Once priorities have been identified, the next step

is drafting the plan. Chapter 6 provides guidance on
drafting and validating an NSOAP.

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Notes

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CHAPTER 6

Drafting and
validating
the plan

2020 EDITION 57
 D
rafting of the NSOAP is the culmination of it is critical that the priorities of the plan be evidence-
the steps described in previous chapters. The informed. To the extent possible, priorities in the
NSOAP drafting process aims to produce a plan should be based on reliable and recent data
document that details: and on programmes that have been tested and
proven in similar contexts. It is the responsibility of
the NSOAP drafting committee to ensure that all
• Gaps and challenges identified from baseline proposed priority interventions are evidence-based.
situation analysis and stakeholder engagement One way to ensure evidence-based decisions are
• Goals to be achieved during the span of taken by stakeholders is by sharing findings of the
the NSOAP completed situation analysis with the stakeholders
• Solutions and activities to reach those goals prior to bringing them together for priority setting.
• An evaluation framework to assess whether If the stakeholders involved in priority setting are
goals have been achieved aware of the most up to-the-date data, this may
help ensure that their decisions are data-driven and
This chapter highlights key considerations and complemented by their on-the-ground perspectives.
provides guidance and tools to support the process A skilled NSOAP committee will be needed to be able
of drafting the NSOAP and generating consensus to broker decisions between potentially divergent
on the final plan among stakeholders. views among stakeholders.

6.1.3 Align with priorities of the

6.1 KEY CONSIDERATIONS government and ministry

There are several key considerations during the Given the cross-cutting nature of surgical systems,
drafting process. The plan should reflect the views of addressing systemic challenges requires a horizontal
the stakeholders, provide balanced perspectives and approach. Ideally, priorities set forth in the NSOAP
evidence and align with priorities of the government will align closely with the current policies and
and ministry. plans of the country’s government and its MoH –
particularly the national health policy, strategy or
plan – and be congruent with cross-sectoral priorities
6.1.1 Reflect views of stakeholders of other ministries, such as finance, education and
energy. This helps to avoid duplication of efforts and
Guidance on NSOAP development emphasizes the to prevent contradictory policies. NSOAP writing
need for plans to be developed and owned by local committees are advised to conduct a thorough
stakeholders, which is particularly relevant to the review of current national and regional policies to
drafting process (1). To gain sufficient buy-in, a broad identify key priorities across sectors, to find areas of
and diverse group of in-country stakeholders should policy overlap and to plan complementary policies.
be engaged throughout the drafting process.
Circulating drafts of the plans to key stakeholders for For the final NSOAP to be achievable and affordable
feedback at various stages of the drafting process within the specified time frame, it is important for the
– for example, through workshops and individual NSOAP writing committees and other stakeholders
discussions – can help to ensure that the contents to delineate the scope of the plan from the outset of
are a consensus of the views of all relevant parties. the process. For example, electricity and water supply
are crucial for safe surgery. However, connecting
all health facilities to the national electricity grid
6.1.2 Ensure priorities are evidence- and piped water supply may be more appropriate
informed objectives for a national health strategy than for
an NSOAP, because those capacities are crucial
While it is important that the NSOAP reflects the for many other areas of the health system. Their
views of stakeholders, especially frontline providers inclusion in an NSOAP may be too overwhelming
who understand first-hand the daily challenges of and expensive for a new and relatively modest SOA
providing surgical care in resource-limited facilities, department in the MoH; further, the activities are

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likely to be tackled in the plans of other sectors, such 6.2.1 Integrating themes and
as infrastructure and energy. A more feasible activity establishing consensus on priorities
for the NSOAP could be to advocate to appropriate
departments within the MoH and other government The initial steps in drafting an NSOAP are to
sector for the prioritization of those capacities in integrate themes that emerged during stakeholder
the national health plan, for example, by working consultation interviews, focus groups and workshops,
with the ministry of energy and ministry of water. as well as establish a consensus on priorities. It may
This adds weight and urgency to the issue without be helpful to organize diverse stakeholder priorities
pledging to resolve it within the NSOAP. into coherent strategic objectives, goals, outputs and
activities. This ensures that priorities are referenced
from stakeholder discussions and key areas are not
omitted. One strategy commonly used for organizing
6.2 DRAFTING THE NSOAP ideas is mind-mapping, using a central theme from
which subthemes originate. Fig. 6.1 is an example
This section provides guidance for the process of of a mind map of multiple stakeholder priorities
drafting an NSOAP, including: and themes around information management.
Originating from this central theme are subthemes
• Integrating themes and establishing consensus which are the various strategic objectives of the
about priorities information management domain. Each strategic
• Assembling a writing team objective is linked to the specific outputs to achieve
• Drafting the plan: outlining, goal setting, that objective. Many free mind-mapping software
identifying strategic objectives, defining programs are available to assist with this (66).
expected outputs, determining activities and
defining indicators
• Recommendations for writing the plan

Fig. 6.1 Mind map of stakeholder priorities and themes around information management

Increase incentives for providers to

collect and report quality data

Ensure that data and reports are SO 1. Develop and

used by health facilities to improve implement data use and Ensure the tracking of surgical
and strengthen the system dissemination strategy providers including specialist
surgeons, anesthesiologists,
obstetricians and related task-sharers
Ensure health facilities are equipped SO 2. Implement
with hardware, software, electricity electronic medical records
and internet connection to collect at all zonal and national Ensure the tracking of surgical
data using EMR hospitals volume by type of procedure
performed and outcomes
SO 5. Integrate surgical
INFORMATION indicators into HMIS data
Increase the number of hospital- MANAGEMENT collection platform for
based research projects designed AND RESEARCH frequent assessments
and implemented by residents and
surgeons Ensure the tracking of peri-operative
SO 3. Build research mortality rates
capacity around surgical
Increase the number of community- systems
based research projects designed
and implemented by residents
and surgeons Catastrophic expenditure?
Impoverishing expenditure?

SO 4. Enhance
telemedicine services at
health facilities Revise all surgical data collected at
health facilities

HMIS: health management information system

2020 EDITION 59
6.2.2 Assembling a writing team

To organize stakeholders’ priorities into a cohesive an external consultant. The draft is then rigorously
plan, assembling an NSOAP writing team is a useful reviewed by a broader group of stakeholders who
strategy. Although the plan should reflect the views provide in-depth feedback. Involving policy writers
of the stakeholders, it may not be practical to have who are fluent in the language of MoH documents
all of them at the table for the writing process. can help to facilitate the incorporation of the NSOAP
During the drafting process, it is important to remain into the national health plan.
committed to the priorities set by the stakeholders
rather than generating new priorities. In an ideal
scenario, the members of the writing team represent 6.2.3 Drafting recommendations
a cross-section of stakeholders including front-
line clinicians (for example, specialists and nurses), This section provides recommendations for the
patient organizations, government representatives, drafting process related to outlining the draft,
professional associations, private providers, faith- setting the goals, identifying the strategic objectives,
based providers and civil society organizations. More defining expected outputs, determining activities
commonly, the first draft of the NSOAP is created by and defining indicators.
a smaller writing team, an individual stakeholder or

BOX 6.1

SAMPLE OUTLINE FOR NSOAP

I. Introduction
a. Rationale for the plan
b. Development process

II. Guiding principles, vision and mission

a. Guiding principles
b. Vision
c. Mission

III. Background
a. Health and development progress
b. National policies and priorities

IV. Situation analysis

a. Service delivery
b. Infrastructure, products and technologies
c. Health workforce
d. Health care financing
e. Information and research
f. Leadership and governance

V. Detailed goals, strategic objectives, outcomes and activities

a. Presented in a table format with indicators, baseline and targets

VI. Monitoring and Evaluation Framework

VII. Governance framework

VIII. Cost of implementation

IX. Appendix
a. Supporting documents, such as costing details

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6.2.3.1 Outlining the draft

Although there is no universal template for country’s health and development progress and its
developing NSOAPs, any template used should national policies and priorities. The situation analysis
align (to the extent possible) with templates used for might be described in the next section, along with
existing policies of the MoH. A sample outline for an the results of any baseline assessments that were
NSOAP draft is provided in Box 6.1. conducted. One way of presenting a situation
analysis is to structure it around WHO’s building
Key components of an NSOAP outline may include: blocks of health systems (67), which underpin the
structure of the NSOAP (see Fig. 6.2). These domains
• Introduction include service delivery, health workforce, medical
• Guiding principles, vision and mission products and technologies, health care financing,
• Background information and research, and leadership and
• Situation analysis governance. See Chapter 4 of this manual for more
• Goals, strategic objectives, outputs and activities information on situation analysis and baselining.
• Governance framework
• Monitoring and evaluation framework The section detailing goals, strategic objectives,
• Cost of implementation. outputs and activities is the most important part of
the NSOAP. For each domain of the health system, it
The introduction section typically includes the describes which priority aims will be achieved (goals
rationale for developing an NSOAP in the specific and strategic objectives), how they will be achieved
country and a discussion of the overall NSOAP (outputs and activities) and when they will be
development process. achieved. It is crucial that a thorough monitoring and
evaluation plan be developed as part of the NSOAP to
The section on guiding principles, vision and mission monitor implementation progress towards achieving
should seek to highlight the overall purpose of the the goals of the NSOAP and its impact. Advice about
plan. The mission is usually a succinct sentence which establishing targets and measuring each strategic
summarizes what the plan aims to achieve, with the objective is provided in Chapter 7 of this manual.
vision framed more broadly in terms of the potential Costing an NSOAP and establishing organizational
impact of achieving the mission. The background structures and governance frameworks are covered
section may include an overview of country-specific in Chapters 8 and 9, respectively.
health and development indicators, as well as the

Fig. 6.2 Organizing an NSOAP situation analysis around building blocks of health systems

Service Infrastructure,
Delivery Products and Workforce
Technology

Governance
Information
and Finance
Management
Leadership

2020 EDITION 61
6.2.3.2 Setting goals

In the context of health systems, a goal is a broad can be presented in an operational plan. Activities are
statement about what the overall system aims to commonly written using action verbs in the present
accomplish (61). For example, an NSOAP goal could tense. The following are important considerations for
be to increase surgical volume nationally. A single determining the activities to include (61).
goal often has one or more strategic objectives
needed to accomplish it. • Which levels, organizations and groups
are targeted?
• What resources may be available?
6.2.3.3 Identifying strategic objectives • Which populations, geographical areas and facility
levels are targeted?
An objective, as defined by WHO’s Health Systems • Will the activity achieve the desired output?
Strengthening Glossary (68), is “a statement of a • Who can most benefit and contribute?
desired future state, condition, or purpose, which an
institution, a project, a service, or a program seeks
to achieve”. The essence of a strategic objective is 6.2.3.6 Defining indicators
to clearly define what the NSOAP aims to achieve.
Strategic objectives are identified based on priorities To measure progress towards achieving the goals set
determined by stakeholders and policymakers. A forth in the NSOAP, it is crucial to define indicators. If
common approach to developing useful strategic possible, all indicators should have a baseline value
objectives is to use the criteria defined below. and an end-line target to attain during the timeline
of the NSOAP. Common criteria used for defining
• Specific: what exactly will be done for whom useful indicators are provided below (59).
and by whom?
• Measurable: is it quantifiable and how can we • Relevance: clear relationship between the
measure it? output and the indicator;
• Achievable: can it be done in the proposed time • Accuracy: measures what it purports
frame with the resources and support available? to measure;
• Relevant: will the objective have the desired • Importance: captures something that makes
effect on the desired goal or mission of the a difference;
strategic plan? • Usefulness: the results point to areas which can
• Time-bound: by when will the strategic be changed;
objective be attained? • Feasibility: can be obtained with reasonable
and affordable effort;
• Credibility: recommended and is being used by
6.2.3.4 Defining expected outputs leading experts and organizations such as WHO
and World Bank (for example, LCoGS indicators
The next step is to define the outputs required or WDIs);
to attain the strategic objectives. These are the • Validity: to the extent possible has been field
products or services required to achieve a strategic tested and used in practice; and
objective, which result from a series of activities. The • Distinctiveness: lacks redundancy and does
distinction between strategic objectives and outputs not measure something already captured under
is that strategic objectives are broader and may have another indicator.
several constituent outputs that are more specific.
A more in-depth discussion of indicators is provided
in Chapter 7 of this manual.
6.2.3.5 Determining activities

Activities or strategies are specific, actionable items

to be implemented in order to achieve a particular
output. Details of activities related to implementation

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6.2.4 Writing recommendations

This section describes a set of guiding principles that The third is to be objective. The NSOAP writing
can assist in writing the NSOAP recommendations. committee should be well-informed, objective and
The first is to write simply. To ensure that the responsible for translating stakeholder priorities
NSOAP can be read and understood by a variety into the final document by devising objectives and
of stakeholders, especially implementers and end- strategies that are based on facts and evidence. The
users, the NSOAP should be written in plain language fourth is to present information in the most suitable
that avoids the use of jargon that is difficult for non- way. For example, NSOAP goals, strategic objectives,
experts to understand. All stakeholders should be outputs, activities, indicators, baselines and targets
able to read and understand the contents of the could be presented in one table, because they are all
plan without needing to consult experts. The second related to each other (see Table 6.1).
principle is to be clear and concise in writing the
NSOAP, avoiding long and drawn-out discussions.

Table 6.1 Example of an NSOAP goal to increase surgical volume nationally

GOAL 1: INCREASE SURGICAL VOLUME NATIONALLY

Strategic objective Output Activities Indicators

SO1. Increase the O1. Train specialist SOA • A1. Train 500 specialist general surgeons by 2025 Number of specialist SOA
number of SOA providers • A2. Train 500 specialist anaesthesiologists by 2025 providers per 100 000 population
providers from 0.02 • A3. Train 500 specialist obstetricians by 2025
to 2.0 per 100 000
population by 2025. O2. Train non-physician A1. Train 1000 non-physician anaesthesia providers Number of anaesthesia providers
anaesthesia providers by 2025 per 100 000 population

SOA: surgical, obstetric and anaesthesia

6.3 ARRIVING AT BROAD

CONSENSUS ON THE FINAL NSOAP
When the first draft of the NSOAP has been person. Alternatively, the draft can be circulated to
written, it can be shared with the wider stakeholder participants for feedback electronically or by post.
community to generate consensus on the final These methods have the advantage of being quick,
plan. Generating consensus ensures that the plan’s cheap and useful for reaching a greater number of
strategic objectives, goals, outputs, activities and stakeholders. However, the disadvantage is that the
targets are all aligned with stakeholders’ views and depth of discussions and feedback may be limited.
available evidence. The consensus process can be A combination of these methods may be ideal;
carried out in various ways including through an in- for example, an initial smaller workshop could be
person workshop, by email or by post. followed by wider consultation conducted remotely.
Once consensus is reached and the final NSOAP
Using a workshop allows for the assembling of a draft is complete, the next steps are creating a
comprehensive group of stakeholders to comment framework for M&E (see Chapter 7) and costing and
on each section of the plan in turn, with the aim budgeting the plan (see Chapter 8) before the plan is
of eliciting feedback and attaining consensus sent to Ministerial leadership for approval.
on all components of the draft. The in-person
approach can facilitate a deeper engagement
from the stakeholders, but it can be costly and
time consuming to convene the participants in

2020 EDITION 63
6.4 SUPPLEMENTAL RESOURCES
Strategic Planning: Transforming priorities into
plans is available from:
https://tinyurl.com/y76vtg9u (61).

National Surgical, Obstetric and Anaesthesia

Strategic Plan Year 2017-2021 is available from:
https://tinyurl.com/ybeb7yqq (Zambia) (69).

Saving Lives Through Safe Surgery (SaLTS) 2016-

2020 is available from:
https://tinyurl.com/y9jafp99 (Ethiopia) (70).

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YOUR

Notes

2020 EDITION 65
YOUR

Notes

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CHAPTER 7

Monitoring
and
evaluation

2020 EDITION 67
A
n essential part of any NSOAP is a well- towards implementing the NSOAP. The goals of M&E
defined monitoring and evaluation (M&E) for NSOAPs are similar to those for M&E of national
strategy to assess the results of the plan health plans (71):
and track the progress towards achieving its goals.
The Surgical Assessment Tool (SAT), the Anaesthesia • Tracking progress through the NSOAP process.
Facility Assessment Tool and other snapshot facility • Prioritizing SOA in the health system and
assessments are often used to assess, a surgical increasing awareness of the importance
system at baseline and to track long-term changes of surgery.
over time. In contrast, an M&E strategy can be used • Aligning with regional and global SOA priorities
to set specific indicators for ongoing prospective (for example, by collecting and reporting
monitoring of each health facility’s surgical capacity common international surgical indicators).
and quality. Such indicators are collected by health • Identifying and addressing inequities in SOA
facility staff and then integrated into the overall health care delivery.
national Health Information System (HIS) or Health • Creating a surveillance mechanism.
Management Information System (HMIS). This • Instilling accountability for the policy and
chapter explores the importance of M&E of NSOAPs, implementation.
offers examples of proposed indicators, describes • Using data to drive evidence-based health
mechanisms for collecting and reporting data and policy decisions.
explains how the information.

7.1 GOALS OF MONITORING AND 7.2 FRAMEWORKS FOR SURGICAL

EVALUATION (M&E) INDICATORS
M&E provides the framework for change in the Several different frameworks have been proposed for
health system. A clear picture of a health program, surgical indicators. In 2015, LCoGS proposed six major
in this case the surgical care system, can be captured indicators spanning three groups: preparedness for
through data collection and analysis. The picture surgery and anaesthesia care (see Table 7.1), delivery
illustrates the needs or current deficits in order to of surgical and anaesthesia care (see Table 7.2),
drive change. By collecting, compiling, and analysing and the effect of surgery and anaesthesia care (see
relevant data or indicators, the current state of the Table 7.3) (1). These six indicators provide the most
health system is revealed, and areas in need of information when used and interpreted together; no
improvement can be acted upon. Indicators, or the single indicator provides an adequate representation
data points chosen for measurement, should be of surgical and anaesthesia care when analysed
directly tied to the goals of the health care program independently.
in order to facilitate improvements. With a clear
M&E framework and mechanisms for information In 2016, four of these six indicators were incorporated
feedback, changes can be made in a timely manner. into the WDIs from the World Bank (72). WHO
The proper collection, aggregation, and reporting of includes the six surgical indicators in the Global
these indicators are essential for this process. Reference List of 100 Core Health Indicators, which
The data collected and reported through an M&E also contains perioperative mortality rate and
strategy can be used to directly measure progress service-specific availability and readiness both for
basic and comprehensive surgical services (73).
Additional WHO surgical indicators, beyond the 100
core indicators, include postoperative sepsis and wait
time for elective surgery (73). These indicators can
serve as examples for countries seeking to integrate
surgical data into their national HIS.

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Table 7.1 LCoGS indicator group 1: preparedness for surgery and anaesthesia care
HEALTHCARE DELIVERY SETTING
INDICATOR GROUP 1: PREPAREDNESS FOR SURGERY AND ANAESTHESIA CARE1

Access to timely essential surgery Specialist surgical workforce density

Proportion of the population that can access, within

Definition two hours, a facility that can perform caesarean delivery, Number of specialist SOA physicians who are working
laparotomy, and treatment of open fracture (the per 100 000 population
Bellwether procedures)

All people should have timely access to emergency

surgical services; Bellwether procedure performance The availability and accessibility of human resources
Rationale predicts accomplishment of many other essential surgical for health is a crucial component of surgical and
procedures; two hours is a threshold of death from anaesthesia care delivery
complications of childbirth

Data sources Facility records and population demographics Facility records, data from training, and licensing bodies

Responsible entity MoH MoH

Informs policy and planning about location of services in

Comments relation to population density, transportation systems, Informs workforce, training, and retention strategies
and facility service delivery

Target A minimum of 80% coverage of essential surgical and 100% of countries with at least 20 surgical, obstetric,
anaesthesia services per country by 2030 anaesthesia providers per 100 000 population by 2030

LCoGS: Lancet Commission on Global Surgery; MoH: Ministry of Health; SOA: surgical, obstetric and anaesthesia.
1
Access and workforce density indicators would be reported annually.
Source: adapted from Meara et al. (1).

Table 7.2 LCoGS indicator group 2: delivery of surgical and anaesthesia care
HEALTHCARE DELIVERY SETTING
INDICATOR GROUP 2: DELIVERY OF SURGICAL AND ANAESTHESIA CARE2

Surgical volume Perioperative mortality

All-cause death rate before discharge in patients who

Definition Procedures done in an operating theatre per 100 000 have had a procedure in an operating theatre,
population per year divided by the total number of procedures, presented
as a percentage

Surgical and anaesthesia safety is an integral

The number of surgical procedures performed per year is component of care delivery; perioperative mortality
Rationale an indicator of met need encompasses death in the operating theatre and in the
hospital after the procedure

Data sources Facility records Facility records and death registries

Responsible entity Facility and MoH Facility and MoH

Informs policy and planning about met and unmet needs Informs policy and planning about surgical and
Comments for surgical care anaesthesia safety and surgical volume when number
of procedures is the denominator

80% of countries by 2020 and 100% of countries by 2030 80% of countries by 2020 and 100% of countries by 2030
Target tracking surgical volume; 5000 procedures per 100 000 tracking perioperative mortality; in 2020, assess global
population by 2030 data and set national targets for 2030

LCoGS: Lancet Commission on Global Surgery; MoH: Ministry of Health.

2
Surgical volume and perioperative mortality indicators would be reported annually.
Source: adapted from Meara et al. (1).

2020 EDITION 69
 Table 7.3 LCoGS indicator group 3: financial effect of surgical and anaesthesia care
HEALTHCARE DELIVERY SETTING
INDICATOR GROUP 3: FINANCIAL EFFECT OF SURGICAL AND ANAESTHESIA CARE3

Protection against impoverishing expenditure4 Protection against catastrophic expenditure5

Proportion of households protected against Fraction of households protected against catastrophic

Definition impoverishment from direct out-of-pocket payments for expenditure from direct out-of-pocket payments for
surgical and anaesthesia care surgical and anaesthesia care

Billions of people each year are at risk of financial ruin Billions of people each year are at risk of financial ruin,
Rationale because they have accessed surgical services; this is a because they have accessed surgical services; this is a
surgery-specific version of a World Bank UHC target surgery-specific version of a World Bank UHC target

Data sources Patient surveys, facility records, Patient surveys, facility records,
and population demographics and population demographics

Patient surveys may be completed by the facility or Patient surveys may be completed by the facility or
Responsible entity externally by independent agencies, MoH responsible for externally by independent agencies, MoH responsible
final indicator for final indicator

Comments Informs policy about payment systems, insurance coverage Informs policy about payment systems, insurance
and balance of public and private services coverage and balance of public and private services

Target 100% protection against impoverishment from out-of- 100% protection against catastrophic from out-of-pocket
pocket payments for surgical and anaesthesia care by 2030 payments for surgical and anaesthesia care by 2030

LCoGS: Lancet Commission on Global Surgery; MoH: ministry of health; UHC: universal health coverage.
3
Financial protection indicators should be reported alongside the World Bank and WHO measures of financial protection for UHC.
4
Impoverishing expenditure is defined as being pushed into poverty or further into poverty by direct out-of-pocket payments, defined by national or international
poverty lines.
5
Catastrophic expenditure is defined as direct out-of-pocket payments of greater than 10% of total household expenditure.
Source: adapted from Meara et al. (1).

7.3 SELECTION OF ADDITIONAL

INDICATORS
It is advisable for each country to consider additional It is preferable and efficient to integrate any new
indicators for their NSOAP in order to more directly indicators which can be easily measured within
target country-specific goals or better address currently available mechanisms of data collection,
previously identified deficits in surgical care delivery. although it may require updating current hospital
Selecting additional indicators for M&E of NSOAPs registries or data reporting forms. Choosing
involves developing specific definitions, collection additional indicators that can be successfully
tools, analysis plans and targets. The following integrated is best accomplished through an
principles can serve as a guide for the selection of inclusive consultation process with national HIS
additional indicators: teams. In some cases, new tools will be required to
accurately measure an indicator in conjunction with
• Indicators with relevance at the facility level as a relevant population-sampling methodology. Prior
well as the regional, national and global levels. to roll out, adequate testing, iteration and training on
• Indicators that are feasible to collect within the how to complete the tool can help to avoid mistakes
currently available data collection system. that are costly or compromise data quality. This is
• Indicators that are amenable to adaptation at especially relevant for indicators requiring patients’
the facility, regional and national levels. perspectives, such as emergency surgical access and
• Indicators with clear targets that can be set financial risk protection. It is important to carefully
and measured. consider the resources needed to collect potential
• Indicators with effective reporting mechanisms indicators that are outside of the standard health
in place. facility data system.
• Indicators that are inclusive of a broad range of
metrics (inputs, outputs, outcomes and impact).
• Indicators that span several specialties, such as
SOA and trauma.

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7.5 SETTING MEASURABLE

TARGETS FOR INDICATORS
Staff in settings without an existing culture of data Specific, measurable targets should be set for each
collection may need education on the importance of indicator. When developing targets, there are three
data collection, coupled with hard-skills training on general approaches (71):
how to collect data accurately. A culture of collecting,
reporting, ad efficiently using data can be fostered by • Absolute targets are numbers or values (for
demonstrating the potential power of data to drive example, surgical volume).
change and monitor improvement. It is important to • Relative targets describe a relative change when
communicate and adhere to the principle that data the baseline is unclear (for example, decreasing
reporting is never used to blame, only for objective perioperative mortality rate by 50%).
reflection and quality improvement. • Annual rate of change describes an annual change
when the baseline is known (for example,
increasing emergency surgical access by
5% per year).
7.4 DATA FLOW PLAN FOR
INDICATORS Creating measurable goals for each indicator can
motivate progress at both the facility and the
Creating a specific data flow plan for each indicator national levels towards the objectives set out in the
improves accountability and consistency. It is NSOAP. Definitions, collection tools and operational
recommended to assign a specific staff member plans for all six Lancet indicators, as well as additional
of the health facility to accurately collect data, with SOA indicators that are commonly used, are available
clear direction on where to record each element. As online (74).
an example, the responsibility of collecting data on
surgical volume may be assigned as follows:

• The surgeon or workforce equivalent leading 7.6 USING THE DATA

the surgical case will be responsible for
recording each case in the operating room Finally, the foundational purpose of the M&E process is
logbook. how the data are used. Reporting the data effectively
• The operating room head nurse will count the at the national level to assess progress of NSOAP
number of cases in the logbook at the end interventions is a key factor in improving surgical
of each month and record this on the data capacity at all levels. It is equally important that
reporting form. facilities are empowered to use the data for their own
• The data quality focal person will aggregate quality improvement. To that end, it is useful to create a
all data reporting forms for an overall hospital process for regular review, problem solving and action
report. around indicator collection. At the facility level, the
• The report is then escalated through district, monthly surgical team meeting (described in Chapter
regional and then national designees. 9) is ideal for this purpose. These M&E metrics provide
• The data are then aggregated nationally and opportunities for local surgical teams to evaluate
reported back in a usable way back through their performance, to design more efficient hospital
the regional, district and facility levels to be systems, and to focus on the quality of their work.
effectively used to facilitate positive change. At the national level, key data provided to NSOAP
governance committees can guide decision-making,
promote accountability and help create environments
where facilities can thrive. Indicators and their targets
can provide valuable insight about gaps in the current
surgical system and about opportunities for policy
and interventions. Regular evaluation of these metrics
can determine how successful interventions are at
reaching these national aims. A case study of NSOAP
M&E in Ethiopia is provided in Box 7.1.

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 B OX 7.1

M&E: CASE STUDY FROM ETHIOPIA

M&E is one of the eight major pillars of excellence in the foundation of Ethiopia’s national surgical
plan: Saving Lives Through Safe Surgery (SaLTS). SaLTS, a national five-year flagship program, is part of
the broader Health Sector Transformation Plan. Accordingly, the M&E strategy associated with SaLTS
has been integrated into the national Hospital Performance Monitoring and Improvement (HPMI)
framework. The SaLTS project team, in conjunction with Harvard Medical School’s Program in Global
Surgery and Social Change, met regularly over six months to develop a strategy to (a) evaluate Ethiopia’s
national surgical system every 1–2 years with a cross-sectional tool and to (b) monitor ongoing surgical
services at the facility level for continuous performance feedback on a quick loop. The products of these
collaborative sessions include a Hospital Assessment Tool (HAT), adapted for the Ethiopian context from
the WHO-Harvard survey tool, and the establishment of 15 key performance indicators (KPIs) for regular
monitoring of surgical services (see Annex 1). The HAT has been administered at 29 facilities spanning
three regions in Ethiopia and is set to be expanded nationally and repeated on a cycle of 2 to 5 years.
The KPIs encompass measures of surgical capacity, safety, and quality (see Annex 1). To capture data
elements for each indicator, patient survey tools were created and perioperative, anaesthetic, and
hospital admission and discharge registries were updated. Of the 15 surgical KPIs, nine will be rolled out
nationwide in the newly revised HPMI strategy and available open access on Ethiopia’s District Health
Information System dashboard (see Fig. 7.1). Indicators were chosen based on their relevance and ability
to affect change at the facility level. An example of the flow of data from the facility through to the federal
MoH is shown in Fig. 7.2. National training on both the HAT and the new KPIs has now been completed.
Through the support of General Electric Foundation’s Safe Surgery 2020 initiative, the next step for the
KPIs is to promote local capacity-building on indicator collection at the facility level, through provision
of and training on the revised registries and data collection tools. In conjunction with the federal MoH
and the regional health bureaus (RHB), Harvard’s Program in Global Surgery and Social Change will start
facility-based training around the SaLTS KPIs to assess the best practices for quality data collection and
provide a road map on next steps for scale up.

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Fig. 7.1 Surgical key performance indicators (KPIs) in Ethiopia

1 Surgical volume

2 Peri-operative mortality rate

3 Rate of safe surgery checklist utilization

4 Surgical site infection (SSI) rate

5 Anaesthetic adverse outcome

6 Delay for elective surgical admission

7 Mean duration of in-hospital pre-elective operative stay

8 Blood unavailability ratio

9 Patient satisfaction

10 Surgical bed occupancy rate

11 Surgical, obstetric, and anaesthesia provider density

12 Rate of first elective case on-time theatre performance

13 Rate of cancellation of elective surgery

14 Emergency (2h) surgical access

15 Protection against catastrophic expenditure

16 Births by surgical, instrumental or assisted vaginal delivery

17 Major surgeries per surgeon

Indicators 1–9 (bolded) have been incorporated into the national HIS. Indicators 10–15 are included in the SaLTS monitoring and evaluation strategy but have not been
integrated at the national level. For full indicator definitions and collection tools, see Annex 1.
Source: Ethiopia’s Federal Ministry of Health.

Fig. 7.2 Data flow for KPIs in Ethiopia

FMOH

Clinical Data KPI Focal

HPMI RHB
Providers Owners person

FMOH: Federal Ministry of Health; HPMI: Hospital Performance Monitoring and Improvement; KPI: Key Performance Indicators; RHB: Regional Health Bureau.
Source: adapted from Ethiopia’s SaLTS Monitoring and Evaluation Plan (70)

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7.7 SUPPLEMENTAL RESOURCES

KPIs FROM ETHIOPIA’S NSOAP

Reporting
frequency
Indicator (category) Definition Data source (type or unit)

Total number of major surgical procedures performed in an

operating theatre per 100 000 population per year.
Note: a major surgical procedure is defined as any procedure
Surgical volume conducted in an OR under general, spinal or major regional
(access) anaesthesia. OR registry; regional Monthly
health bureau (proportion)
Formula: records
[(total number of major surgical procedures performed in OR
per reporting period) ÷ (total regional catchment population)]
* 100 000

All-cause death rate prior to discharge among patients who

underwent a major surgical procedure in an operating theatre
during the reporting period. OR registry; inpatient
Perioperative mortality Note: Stratified by emergent and elective major procedures. admission and Monthly
rate (quality) discharge registers (percentage)
Formula:
[(total number of deaths prior to discharge among major
surgical cases) ÷ (total number of major surgical cases)] * 100

Proportion of surgical procedures where the safe surgery Patient charts

checklist was fully implemented. (random review of
Rate of safe surgery at least 25 surgical Monthly
checklist utilization Formula: patient charts (percentage)
(safety) [(number of surgical patient charts in which the safe surgery for completed
checklist was completed entirely) ÷ (total number of patient checklists)
charts reviewed)] * 100

Proportion of all major surgeries with an infection occurring at

the site of the surgical wound prior to discharge.

One or more of the following criteria should be met:

• purulent drainage from the incision wound;
• positive culture from a wound swab or aseptically aspirated
fluid or tissue; or
• spontaneous wound dehiscence or deliberate wound
revision or opening by the surgeon in the presence of pyrexia
>38 ºC or localized pain or tenderness.

Any two of the following:

• wound pain, tenderness, localized swelling, redness or heat; or
• an abscess or other evidence of infection involving the
deep incision that is found by direct examination during re-
operation, or by histopathological or radiological examination.

Surgical site infection Note: A major surgical procedure is defined as any procedure Surgical site infection Monthly
rate (safety) conducted in an OR under general, spinal or major regional surveillance logbook; (percentage)
anaesthesia. OR registry

Suggested operational definition:

To diagnose an incisional surgical site infection (superficial or
deep) a patient must have at least one of the following:
• purulent drainage from the incision
• abscess within the wound (detected clinically or
radiologically).

Or one of the following combinations:

• pain or tenderness or localized swelling or redness or heat or
fever and
• the incision is opened or deliberately or spontaneously opens
(dehisces).

Formula:
[(total number of inpatients with new surgical site infection
arising during the reporting period) ÷ (total number of major
surgical procedures performed in OR in reporting period)] * 100

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Percentage of surgical patients who developed any one of

the following:
• cardiorespiratory arrest
• inability to secure airway
• high spinal anaesthesia.

Cardiorespiratory arrest is defined as cessation of cardiac

activity evidenced by:
• chest compressions being performed
• loss of femoral, carotid and apical pulse with ECG changes.

High spinal is defined as within 15 minutes of

administration of spinal anaesthesia:
Anaesthetic adverse • patient experiences loss of sensation in the shoulder and Anaesthesia Monthly
outcome (safety) • need for positive pressure ventilation after administration of registry (percentage)
spinal anaesthesia
• Includes any administration of spinal anaesthesia extending
above T4 level.

Inability to secure airway defined as:

• having to awaken patient due to inability to intubate
• cardiac-respiratory arrest due to failure to intubate.

Formula:
[(number of surgical cases with an anaesthetic adverse
outcome in the reporting period) ÷ (number of major surgical
procedures performed in OR in reporting period)] * 100

The average number of days that patients who underwent

major elective surgery during the reporting period waited for
admission (that is the average number of days between the
Delay for elective date each patient was added to the waiting list until date of Liaison registration
surgical admission admission for surgery) book; inpatient Monthly
(quality) admission and (days)
Formula: discharge registers
[total sum of (date patient was admitted - date patient was
added to surgical waiting list)] ÷ total number of patients
admitted for elective surgery during the reporting period

The average number of days patients waited in-hospital (after

admission) to receive elective surgery during the reporting
Mean duration of in- period. Inpatient admission
hospital pre-elective and discharge Monthly
operative stay (quality) Formula: registers (number)
[total sum of (date patient received elective surgery - date of
admission)] ÷ (total number of elective surgical procedures
during the reporting period)

The percentage of major surgical and obstetric cases which

are referred or cancelled because of unavailability of blood.
Blood availability ratio OR registry;
for surgical patients Formula: OR scheduling Monthly
(quality) [(total number of major surgical procedures cancelled due to register; referral (percentage)
lack of blood) + (total number of patients referred because of registry
lack of blood for transfusion)] / (total number of major surgical
procedures performed in the reporting period) * 100

Average rating of a hospital on a score of 0–10 from surgical

I-PAHC surveys.
Surgical patient I-PAHC Patient Quarterly
satisfaction (quality) Formula: Satisfaction Surveys (number)
(sum total of I-PAHC rating scores) ÷ (number of I-PAHC
surveys completed)

The average percentage of occupied surgical beds during the

reporting period.
Surgical bed Inpatient admission
occupancy rate Formula: and discharge Monthly
(access) [(sum total surgical patient length of stay days during the registers; ward nurse (percentage)
reporting period) ÷ (average number of surgical beds *
number of days in reporting period)] * 100

2020 EDITION 75
 Number of surgical, anaesthetic and obstetric physicians,
integrated emergency surgical officers and anaesthetic
providers, including BSc. anaesthetists, nurse anaesthetists
and ‘others’ (nurses, MS anaesthetists and health officers),
who are working per 100 000 population.

SOA provider density Formula: Hospital human Annually

(quality) [(number of surgical, anaesthetic or obstetric physicians, resources records (proportion)
integrated emergency surgical officers or anaesthetic
providers including BSc anaesthetists, MS anaesthetists, nurse
anaesthetists, other nurses and health officers working) ÷
(total population of catchment
area)] * 100 000

The percentage of first elective cases that began on or prior to

the scheduled time (per agreed hospital protocol) during the
Rate of first elective reporting period.
case on-time theatre OR scheduling Monthly
performance (quality) Formula: register (percentage)
[(total number of first elective cases commenced on time) ÷
(total number of first elective cases performed in reporting
period)] * 100

Percentage of elective surgeries that were cancelled on the

planned day of surgery.
Rate of cancellation OR scheduling Monthly
of elective surgery Formula: register (percentage)
(access) [(number of elective surgeries cancelled) ÷ (total number of
elective surgeries scheduled)] * 100

The proportion of patients requiring emergency surgical care

whose travel time from when they first seek care to their
arrival at a facility providing any of the selected Bellwether
procedures (caesarean sections, laparotomies or open fracture
Emergency two-hour stabilization) is less than or equal to two hours.
surgical access Patient survey; OR Every six months
(access) Formula: registry (proportion)
(number of emergency surgical patients whose travel time
from when they first seek care to their arrival at a facility
providing caesarean sections, laparotomies or open fracture
stabilization is less than or equal to two hours) ÷ (total number
of emergency surgical patients surveyed)

Proportion of households protected against catastrophic

expenditure from direct out-of-pocket payments for surgical
Protection against and anaesthesia care. Protection Against
catastrophic Catastrophic Every six months
expenditure (finance) Formula: Expenditure Survey; (proportion)
(number of patients whose aggregate cost for accessing and OR registry
receiving care is less than 40% of reported household income)
÷ (total number of surgical patients surveyed)

OR: operating room; SOA: surgical, obstetric and anaesthesia.

Source: Ethiopia’s Federal Ministry of Health.

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CHAPTER 8

Costing and
budgeting

2020 EDITION 79
A
ssigning costs to implementation items in 8.1 STEPS INVOLVED IN COSTING
an NSOAP is a pivotal stage in the planning THE PLAN
process. It is the inflection point at which
the plan may either be transformed into a feasible, The procedure for costing an NSOAP can be flexible,
fundable policy document or shelved due to overly but it is usually defined by representatives of the
optimistic or unrealistic targets. Costing is a multistep departments of policy, planning and budgeting
process that requires input from a broad range within the country’s MoH and MoF to ensure that
of government and health-sector stakeholders. the product is aligned with official costing and
It is typically performed after the creation of an budgeting procedures. If there is no designated
implementation framework. Careful consideration costing protocol, there are resources available that
of the costing methodologies of programmes and the costing committee can use as a guide (75).
services – from conception to completion of the Most of the following steps can be performed in
NSOAP cycle – can help to ensure that the finalized a workshop setting by a small group of experts
plan is realistic within the budgetary constraints of (or taskforce) in each of the national surgical
the government and funding partners. As one of planning domains: infrastructure, workforce, service
the final steps in the creation of the NSOAP, costing delivery, financing, information management and
ultimately allows a plan to be co-developed and information technology. Prior to building consensus
submitted to the government’s MoF as an advocacy on a unified costing document, the experts can
tool for resource mobilisation. At this stage, the collaborate to define cost objects for each activity
costed plan can be considered for funding, and and then determine the cost base for the relevant
options can be explored for allocating domestic domain’s implementation. Cost objects include
funds and for leveraging external funding platforms activities, programmes, services and any other items
such as bilateral and multilateral organizations, that have an associated cost; the cost base is the
NGOs and civil society organizations. Moreover, the associated local unit cost for each cost object.
costing and budgeting process creates an avenue for
further prioritizing activities based on the availability
of resources. The process also allows the NSOAP 8.1.1 Assemble available costing
committee to coalesce around the activities that information
are immediately achievable and cost-effective, while
deferring activities that are less so. See Chapter 5 for Before embarking upon costing an NSOAP, it is
more specific guidance on priority-setting. efficient to gather as much of the relevant data as
possible ahead of time from multiple stakeholders
This chapter provides an instructive overview of the and select a costing methodology to be deployed in
steps involved in costing an NSOAP: the costing exercise. A summary of items that may
need to be costed is included in Table 8.1, but the table
• Selection of the costing methodology is not exhaustive. Representatives from the MoH and
• Assembling available costing information MoF can assist in developing a comprehensive list by
• Defining the cost objects and the ensuring that the list of cost bases and objects is as
quantities required complete as possible before costing commences
• Determining the cost base and by assigning individuals to gather specific cost
• Attributing costs to the cost objects base data for the costing exercise. As described in
• Validating and confirming the results of the the next section, the quantity of each cost object
costing exercise required is usually determined during the costing
• Creating a summary and sharing the results exercise through discourse and debate.

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 Table 8.1 Sample Cost Items

Category Sample of items to be costed

• Number of health facilities at each level

• Per diem scale of all government employees
Basic demographic information • Transport reimbursement
• Telecoms reimbursement
• Standard cost per person for catering and facilities
• Printing cost per page for a standard 20-page booklet

• General and specialist surgeons

• Obstetricians
• Anaesthesiologists
• Intensivists
• Radiologists
• Pathologists
Workforce (training costs and wage costs • Physiotherapists
per year) • Nurse anaesthetists
• Critical care and theatre nurses
• Midwives
• Biomedical equipment technicians
• Laboratory technologists
• Surgical administrators or data clerks
• Prehospital personnel
• Emergency physicians

• Facility building costs for each hospital level

• Overhead costs for new facilities
• Surgical equipment
• Sterilization system purchasing and upgrades
• Medical imaging and diagnostic equipment
Infrastructure • Operating theatre equipment
• Ambulance costs
• Pathology and laboratory equipment
• Physiotherapy equipment
• Emergency departments

• Essential surgical and anaesthetic medications

• Delivery ward equipment and supplies
• Surgical ward equipment and supplies
Recurring consumable costs • Ambulance maintenance and fuel costs
(equipment and medicines) • Recurrent equipment maintenance costs
• Laboratory supplies
• Medical implants and devices

• Continuing medical education and professional development

Service delivery and implementation costs, if applicable
• Quality improvement initiatives and training workshops

Financing • Indirect costs including accounting and administration

• Government-sponsored workshops

• Internet and information technology costs

• Costs of training new data clerks and technologists
Information technology • Electronic medical records
• Hospital connectivity implementation costs, if applicable
• Electronic medical records and Internet training for clinicians
• Costs of creating and improving surgical research programmes

Source: Zambia MoH NSOAP (2017–2021) (69).

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8.1.2 Define the cost objects and the

quantities required

The next step is to define the cost objects and more workshop time for consolidation and building
quantities required. Each of the activities in the consensus. For example, the government official
implementation framework should be broken overseeing biomedical equipment technicians may
down into its constituent cost objects. These should bring documentation on the cost of their training as
include: well as the capital, operating and maintenance costs
of anaesthesia machines. A sample list of information
• Capital expenses items to prepare ahead of workshops can be found
• Maintenance in Table 8.1.
• Installation costs for large equipment
• Shipping If the cost bases for some cost objects remain
• Operating costs for the duration of the plan (for undefined by the end of a costing workshop, it is
example, fuel and reagents) helpful to specifically assign people to research
• Wages additional historical, neighbouring country or expert-
• Training costs derived cost bases. A list of sources for each cost
• Indirect costs such as planning workshops, base should be documented as clearly as possible,
administrative support, and programme M&E so they can be referenced for accountability and
validation. For some items, it may not be possible
A useful rule of thumb can be to include a scaling to assign an exact cost due to significant national
percentage of the capital cost of large equipment variation between facilities – for example, the cost to
for maintenance, training repairs, installation and upgrade all facilities to minimum national standards.
shipping. Such items may require assumptions, such as the
proportion of functional equipment by which the
The quantity of each implementation item required total cost of equipment for an operating theatre
should then be defined in this step – for example, can be scaled. These assumptions can be further
the number of anaesthesiologists to be trained, the informed by the findings of the baseline assessment.
number of facilities to which Internet access should
be provided or the number of new district hospitals
to be built. This is often determined by group 8.1.4 Attribute costs to the cost objects
consensus.
The quantified cost objects can be multiplied by
their cost base using a prepared costing tool or
8.1.3 Determine the cost base spreadsheet. The costs within each implementation
activity can then be summed to create a final cost.
Determining the cost base is the next step. Each This cost aims to reflect a best estimate of the true
of the cost objects has a per-unit cost which is total cost of a full implementation of the desired
multiplied to determine the final cost of the line activity within the duration of the NSOAP. Many
item. Ideally, the cost base for each cost object would activities have similar cost objects and by attributing
be determined from historical costing data from the the cost bases to those activities first, quick early
country itself. Depending upon how recently costs progress can be made that leaves more time for
have been updated, they may need to be adjusted for discussion about more complex items. At this point it
inflation. If historical data are not available, cost bases may be useful to list a potential source of funds, such
may be gathered from similar programmes or from as central MoH, devolved district funds, facility funds,
acquiring data from local or neighbouring countries nongovernmental sources, bilateral and multilateral
or from regional or international sources. If a cost organisations.
base cannot be found for a cost object, experts may
be called upon to make estimations as a last resort.
Much of the information gathering for this step
is best done in advance for efficiency and to allow

2020 EDITION 83
8.1.5 Validate and confirm the results of
the costing exercise

Once a consensus is reached across all the The first group of important stakeholders are
stakeholders, the costing draft can be submitted government officials, healthcare practitioners,
to the relevant government party (for example, including NSOAP sponsors, policymakers, budget
the MoF) for official validation and approval before experts, technicians and costing experts. To ensure
final dissemination as an advocacy tool for resource that the costing exercise is valid and appropriate,
mobilisation. Throughout the planning process, costing is usually led by a government official or
the NSOAP should be situated within the broader consultant who is intimately familiar with the MoH’s
context of existing government policies and plans. customary costing process. Representatives from
the MoF or budgetary division of the MoH typically
This can serve as a final checkpoint to ensure that open the costing exercise by encouraging group
NSOAP activities do not overlap with existing members to aim for targets that are feasible within
activities. At this stage, costs may need to be current funding limitations of government and
adjusted for projected annual inflation and projected nongovernmental sources.
exchange rate fluctuations and also discounted in
line with ministry and government protocols. Finally, Depending on local circumstances, the costing
it is important to distinguish between the existing exercise may also involve clinicians, health-
funding commitments for the current state of system administrators, professional organization
surgical services and the incremental costs needed representatives, actors from NGOs and civil society
to implement the expanded and upgraded services organizations, private-sector representatives and
outlined in the NSOAP. outside consultants. These groups can often provide
additional costing information based on their
programming experience that is not otherwise
8.1.6 Create a summary and share the available within the MoH. It is also important to
results ensure that purchasers open a call for tender to
ensure a competitive spirit between the product/
Both a summarized, palatable version and the full- service providers and institutions.
detail costing document can be shared with the
appropriate government parties and all government-
approved potential funding partners. At this stage,
it may be useful to divide costs into recurrent and 8.3 TOOLS AVAILABLE TO GUIDE
capital expenditures. To build a strong case for THE COSTING PROCESS
funding, it can be useful to include references to
previous cost–effectiveness studies relevant to the Available costing tools range from spreadsheet
plan’s line items. templates to in-depth modelling and simulation
tools such as WHO’s One Health Tool software (76).
A guide and review of 13 WHO costing tools (77) is
available through the Partnership for Maternal,
8.2 PARTICIPANTS IN THE COSTING Neonatal and Child Health. A simple free template
PROCESS (53) is also available online from Harvard Medical
School’s Program in Global Surgery and Social
To develop a comprehensive and accurate costing Change. However, NSOAP costing committees
document, it is important to involve representatives should use costing tools available through their
from each discipline and stakeholder group that will governments’ budgeting and costing departments
be affected by the NSOAP. This section describes a wherever possible.
partial list of important stakeholders, but the invited
participants will vary in different countries.

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CHAPTER 9

Organizational
structures and
governance

2020 EDITION 87
T
he concept of governance broadly relates the facility level to the national level. Sections of
to the rules, laws, organizational structures, the chapter focus on NSOAP governance at the
and mechanisms that help an organization national, regional, district, and facility levels, as well
achieve the objectives set out in its strategic plans as suggestions for training around leadership and
(78). Health governance involves mechanisms governance.
to promote health on the national agenda and
balance policy priorities within the health agenda.
It also includes the terms of engagement and
legal regulation of health stakeholders as well as 9.1 NATIONAL-LEVEL
the establishment of transparent accountability ORGANIZATION AND
mechanisms. GOVERNANCE
The majority of this complex legal framework Although it is intuitively understood that the NSOAP
is defined at the national or sectoral level (79). process should be part of a country’s MoH priorities, it
Therefore, the key to the successful governance of an is worth emphasizing the importance of a country’s
NSOAP is to understand this framework and align MoH in being identified as the primary “owner” and
NSOAP governance mechanisms to the existing leader of the NSOAP governance structure.
strategies. Focusing on additional responsibilities
created by the NSOAP, rather than redefining An early step that can help to define roles is to
the entire national framework, allows for more determine which department within the country’s
efficient drafting and implementation of NSOAP MoH will be responsible for the NSOAP. Given the
governance. In addition to a governance strategy cross-cutting nature of the NSOAP, some countries
that encompasses the entire NSOAP more broadly, may opt to include the plan under the RMNCH
each of the domains typically requires governance department, due to the close alignment with the
specific to its implementation and evaluation. CEmONC agenda. Others may see the plan as
fitting better within the NCD department, due to
One of the most important functions of the NSOAP its inclusion of cancer and trauma. Still others may
is to strengthen the visibility and accountability consider health services or quality departments
around access to and quality of SOA service delivery. most appropriate. Any of these options are viable,
Setting up a strong governance system for the but the NSOAP agenda may be broad enough to
NSOAP process facilitates the following advantages: merit the creation of a new department dedicated
to promoting SOA care.
• Improved visibility for SOA care for promotion
on national health agendas Given the breadth of activities required for an NSOAP
• Better coordination of the SOA care agenda to be successful at the national level, it is important
with complementary programmes within the to have enough dedicated staff to advance the
health sector and across other sectors, mission. In many cases, full-time, dedicated staff
including health financing members may be needed to successfully implement
• Setting up cyclical communication and the NSOAP, which requires managing and liaising
accountability mechanisms from the national with the implementing ministry and external
level to facility levels and back to the national personnel. Adding these broad responsibilities to
level, to ensure widespread implementation of the workload of existing staff, who may already be
the plan working at capacity, is likely to impede the plan’s
implementation. If circumstances permit, creating
The organizational structure, implementation, mana- the position of a dedicated NSOAP coordinator or
gement, and accountability mechanisms will vary director to serve as the central focal point for the
from country to country, depending on existing NSOAP is highly recommended. This individual can
structures and policies. However, this chapter aims be responsible for devising strategies, developing
to provide broad suggestions about the roles and guidelines, convening stakeholders, coordinating
responsibilities of NSOAP actors in order to establish and leading efforts, representing the SOA agenda at
a clear chain of accountability and escalation from higher levels, and mobilizing resources.

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It can also be advantageous to create a working facilities. This creates the capacity to disseminate,
group to assist and advise in prioritizing NSOAP interpret, and operationalize the NSOAP at the
implementation and monitoring its progress. This appropriate levels. It also facilitates the feedback
technical working group (TWG) could include of information from regional levels as to what
representatives from each of the major stakeholder their actual needs are. The actual structure of this
groups to ensure coordination of programming, level of governance varies based on the degree of
such as: centralization or decentralization adopted by the
government. Additional responsibilities for this level
• Professional associations (obstetrics and of governance are suggested in Table 9.1.
gynaecology, surgery, anaesthesia and nursing)
to contribute technical expertise
• Licensing and credentialing bodies
• Development partners
• Nongovernmental organizations
• Patient advocacy groups and lay-person
representatives
• Representatives from the other
complementary MoH departments
• Representatives from other working groups,
such as, RMNCH and/or NCDs
• Human resources and training
• Biomedical and pharmaceutical directorates

The potential roles of the working group are

outlined in Table 9.1, which also describes the wider
role of civil society organizations and industry in
the implementation of NSOAP. For each of the
stakeholder groups to be effective, they require access
to accurate data from the M&E plan (see Chapter
7) to inform decision-making and review progress.
Accountability mechanisms should be put in place
to evaluate the plan’s progress against set targets;
ideally, these mechanisms would align with existing
mechanisms already in place for other national-level
plans, which are often under the purview of quality
assurance departments. Structures should strive to
achieve gender parity.

9.2 REGIONAL- AND DISTRICT-

LEVEL ORGANIZATION AND
GOVERNANCE
To advance the NSOAP portfolio of activities, it can
be helpful to appoint a named regional or district
NSOAP coordinator, representative, working group
or focal unit at each level of regional and district
health management. The designated entity can
act as a bridge between national-level NSOAP
governance and the regional- or district-level

2020 EDITION 89
9.3 FACILITY-LEVEL
ORGANIZATION AND
GOVERNANCE
Improved leadership and coordination at the facility
level is a cornerstone to improving quality of SOA
care and implementing the NSOAP. A key strategy
for improvement is to ask each facility that provides
SOA care to form a multidisciplinary surgical team
(MST), including SOA providers, nurses, midwives,
pharmacists and non-clinical staff (those responsible
for sterilization and cleaning, for example). The team,
led by the NSOAP champion, would report to the
facility in-charge, director or CEO. NSOAP planners
should consider stipulating that all facilities should
appoint a named operating theatre manager,
whose responsibilities would include managerial
support and monitoring of the MST. More detailed
responsibilities for each group are suggested in Table
9.1. It may benefit each facility to devise a facility-
specific compliance strategy, devised by the surgical
team and the hospital management, to ascertain
how best to implement the recommendations of
the NSOAP and how to mobilize resources to achieve
their goals. In many cases, facilities will already have
an identified SOA leader that has already been
working hard to improve surgical care.

At the facility level, establishing formal mechanisms

for discussing SOA issues at regular meetings is
strongly advised. Such meetings provide opportuni-
ties to review facility NSOAP M&E data collected at
the facility (such as morbidity and mortality rates),
to raise any other challenges and opportunities
(such as equipment or human resources issues),
and to form actionable plans for quality improve-
ment around SOA. In smaller facilities, the SOA re-
view meetings can be included as a part of wider
management meetings in the interest of efficien-
cy. As detailed in Chapter 7, these review meetings
can also be used to discuss formal progress reports
sent to the regional and district levels for further re-
view. In setting up these processes, it is important
to maintain accountability and responsibility, while
simultaneously promoting systems improvement
and offering a safe environment to voice concerns.

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 Table 9.1 NSOAP governance at multiple levels

Level of governance and actor Responsibilities may include

National-level governance and MoH

• Drivers, instigators and owners of the NSOAP

Reporting directorate1 • Assume responsibility for the overall NSOAP plan
• Conveners of outside stakeholders

• Develop strategy, guidelines and manuals

• Coordinate and lead all NSOAP activities
National SOA coordinator or director • Escalate NSOAP priorities to higher levels of government
• Represent SOA on interdepartmental and intersectoral committees
• Mobilize resources for the service

• Participate in strategy, guidelines and manual development

SOA technical working group • Supervise, monitor and evaluate NSOAP activities
• Prioritize NSOAP activities within allocated budget
• Represent the view of multiple stakeholders, including front-line clinicians and patients

• Integrate NSOAP targets and reporting into national quality assurance mechanisms
Quality directorate • Supervise and evaluate NSOAP implementation
• Report results of NSOAP supervision to TWG and others

Regional and district-level governance

• Coordinate and lead all NSOAP activities at regional level

• Coordinate and lead the regional TWGs
• Collate data from facilities through district then regional levels
• Liaise between the facilities and the MoH
Regional and district health bureau SOA • Visit facilities to supervise NSOAP implementation
representatives • Coordinate capacity-building activities
• Collate and disseminate best practice information
• Sensitize front-line staff around the NSOAP content and implications for each facility
• Arrange training around SOA for facility staff
• Arrange community sensitization around SOA

Facility-level governance

• Oversee NSOAP activities

• Set up ongoing data collection activities at the facility
Facility CEO or medical director • Identify NSOAP champion
• Assign operating room manager
• Allocate and mobilize resources for NSOAP agenda
• Ensure inclusion of NSOAP in facility health plan

• Lead, mobilize and motivate the facility SOA team (clinical and non-clinical)
• Ensure that the surgical team works together and feels valued
• Lead development an NSOAP specific action plan for the facility for review by the
NSOAP champion hospital leadership
• Coordinate collection of surgical monitoring data
• Arrange internal surgical team conferences to discuss mortality and morbidity, review
surgical data monthly and discuss opportunities for quality improvement

• Contribute towards facility specific NSOAP plan

NSOAP surgical team • Participate during the monthly feedback meeting
• Collect relevant data for monitoring and evaluation

• Act as secretary for the NSOAP surgical team

Operating room manager • Oversee day-to-day activity of operating rooms
• Identify any issues to escalate to the NSOAP facility team
• Represent surgery to hospital senior management of the hospital (with NSOAP champion)

Civil society organizations

• Provide evidence-based guidelines for surgical and anaesthesia services

• Advocate around the NSOAP to their members
Professional societies • Provide quality assurance around education and continuing professional education
• Develop curricula for training programmes
• Participate in supportive supervision programme development and support

• Ensure that projects are aligned with priorities of NSOAP

Development partners and NGOs • Coordinate and communicate plans with the NSOAP coordinator, director and regional or
district teams to ensure coordination between programmes and avoid duplication
• Ensure practices comply with effective development cooperation practices2

Industry • Create shared value in SOA care through sustainable, responsible and affordable products
and product systems

NCD: noncommunicable disease; NSOAP: National Surgical, Obstetric and Anaesthesia Planning manual; RMNCH:
reproductive, maternal, newborn and child health; SOA: surgical, obstetric and anaesthesia; TWG: technical working group.
1
Appropriate directorate may include (depending on the context for each individual country): specific SOA directorate,
NCDs, RMNCH or quality, curative or preventive services.
2
Concept defined by UHC2030 (80).
Source: Burssa et al. (81).
9.4 TRAINING AROUND
LEADERSHIP AND GOVERNANCE
Given the additional responsibilities generated by and safety (82). Formal training for operating room
NSOAP governance structures, formal leadership managers, such as a diploma or degree, is already
and management training can be very valuable. widespread in high-income countries and the
On the global level, substantial efforts are moving development of such courses, adapted to specific
towards formalizing health care management low-resource settings, have proven beneficial (83,84).
training through qualifications such as diplomas and Expansion of formal leadership and management for
master’s degrees and these activities are presently SOA staff should be considered as one of the NSOAP
featured in many NHSPs. In the context of NSOAPs, activities. See Box 9.1 for an overview of Ethiopia’s
training around operating room leadership and commitment to strong governance of its NSOAP.
teamwork has shown promise in improving quality

BOX 9.1

ETHIOPIA'S COMMITMENT TO STRONG GOVERNANCE

Ethiopia, one of the first countries to develop an NSOAP (the SaLTS initiative), has committed to a strong
governance framework by making excellence in leadership, management, and governance the first of the
eight pillars of their plan. The other seven pillars of the plan are: infrastructure; supplies and logistics; human
resources; advocacy and partnership; innovation; quality of SOA care and service delivery; and M&E.

The NSOAP framework establishes clear accountability, with named personnel at each level of the hierarchy
assigned responsibility for SaLTS implementation (see Fig. 9.2). The NSOAP is part of the medical service’s
general directorate and quality directorate. An executive committee supervises the SaLTS TWG, a diverse
group of more than 19 stakeholders that includes representatives from the Surgical Society of Ethiopia,
the Ethiopian Society of Gynaecologists and Obstetricians, the Ethiopian Society of Anaesthesiologists,
the Ethiopian Association of Anaesthetists, African Medical and Research Foundation, Safe Surgery 2020,
WHO and the Clinton Health Access Initiative.1 The diversity of stakeholder representation aims to ensure
that SaLTS strategies reflect the needs at front-line facilities; it also cements close partnerships to ensure
increased support for implementation outside of Ethiopia’s MoH. The project management team within
the TWG acts as the engine for SaLTS implementation. At the regional level, each RHB should have regional
surgical advisory councils and each facility should have a multidisciplinary SaLTS programme coordinating
team, which is championed by a SaLTS focal person and reports to a facility director committed to the
advancement of the SaLTS agenda. M&E of the SaLTS programme has been integrated into the national
quality framework, with systematic reporting due to begin in 2018.

Recognizing the need for formal capacity-building to maintain the governance around SaLTS, Ethiopia’s
MoH has developed training materials and implemented a nationwide leadership training for the facility-
based SaLTS program’s coordinating teams. The training, initially piloted in two regions by Jhpiego, begins
with one-week intensive training, followed by nine months of supportive supervision and mentorship
aimed at improving teamwork and problem-solving skills among the surgical team.2 The training has been
scaled to 700 surgical team members and has deployed clinical mentors to 38 hospital sites to date. In
addition to short course trainings in leadership, Ethiopia’s MoH has recognized the need for more formal
training and has proposed developing a master’s level operating theatre manager degree, which aims to
graduate 150 theatre managers by the end of the plan in 2020. This is currently under discussion with the
relevant stakeholders. This new degree will complement the more general master’s degree in hospital and
health care administration that was pioneered in Ethiopia, in collaboration with the Yale School of Public
Health (83).

1
Additional SaLTS stakeholders include: Safe Surgery 2020 (including GE Foundation, Dalberg, Assist International, Jhpiego, G4 Alliance, and the Harvard University
Program in Global Surgery and Social Change); academic institutions (including Stanford University, Addis Ababa University, Addis Ababa Tegbare-ID Polytechnic
College, Bahir Dar University, and Mekelle University); partners (Sterile Processing Education Charitable Trust, Amref Health Africa, Engineering World Health, and
ALERT); and professional and governmental organizations (including the College of Surgeons of East, Central, and Southern Africa, the Pan African Association of
Surgeons, the United States President’s Emergency Plan for AIDS Relief, and the World Federation of Anaesthesiologists).
2
More information about the Safe Surgery 2020 initiative is available from http://www.safesurgery2020.org/how/ (accessed 19 April 2019).

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Fig. 9.2 Ethiopia’s SaLTS initiative leadership structure

FMOH Executive
Committee

Health Services Quality

Directorate

Federal Ministry of Health

SaLTS National Technical

Working Group

SaLTS Project
Team

Regional Health
Bureau

Regional Surgical Advisory

Council

Facility Director (Hospital

Medical Director)

SaLTS Focal
Person Facility level teams
Surgical team leadership
training participants
SaLTS Program
Coordinating Team
(Multidiscipliary Surgical
Team)

FMOH: federal ministry of health; SaLTS: Saving Lives Through Safe Surgery.
Source: adapted from Burssa et al. (81).

9.5 CONCLUSION
Building a strong governance structure for the
NSOAP process will provide strong leadership,
adequate oversight and program credibility. The
MoH, as the leaders of the NSOAP governance
structure will ensure engagement of stakeholders
at each level and increase likelihood of
implementation success. Broad inclusion of SOA
experts, champions and stakeholders in the NSOAP
governance structure, each with clearly defined
roles, responsibilities, targets, and reporting
structures helps ensure that at the end the NSOAP
planning process there are clear next steps for
implementation to ensure all stakeholders are
coordinated in achieving a common goal.

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CHAPTER 10

Financing

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10.1 INTRODUCTION

H
ow to finance an NSOAP is the central essential to be aware of these specificities, together
focus of this chapter. A country can with the internal political factors that influence the
have both strong political support and budgeting process. In general, the process is led by
institutional capability to implement an NSOAP, but the Office of the President, Ministry of Finance (MoF),
if lacking in resources to finance the NSOAP policy, and relevant planning ministries.
surgical care will not be prioritized. A systematic
and coherent NSOAP financing strategy is required After consultation with sector ministries, for
at the beginning of the NSOAP process to avoid example, the Ministry of Health (MoH), the budget is
funding challenges during policy implementation. approved by a political body, usually the parliament,
after closer examination through more specialized
We will draw on both empirical experiences parliamentary committees. Key functions central to
of countries that have formulated and begun the PFM and the budgeting process are to ensure
implementing NSOAPs and on key concepts and fiscal health, promote efficient spending, and
knowledge in health systems financing to provide manage national debt. Understanding the principles
a general, though practical strategy to NSOAP and cycles of the central budgeting system, along
financing. Part one situates NSOAP financing within with the political dynamics affecting budgeting
the broader political process of national health decisions, is needed to influence the final budget
system budgeting. Part two introduces the concept allocation at critical points in the budget process.
of fiscal space to provide a systematic approach to The budget process and its overall direction is
mobilizing health system resources for NSOAPs. influenced by the broader developmental vision and
Finally, part three discusses the stakeholders “national interests” of the state, which is ideologically
relevant to NSOAP financing and a stakeholder constituted. National strategic plans on economic
engagement plan. development, social redress, or poverty reduction,
for example, are often articulated fiscally within
medium-term expenditure frameworks (MTEF)
(85). In this way, the MTEF sets a limit on the space
10.2 INCORPORATING THE for negotiation for new policies such as the NSOAP.
NSOAP WITHIN HEALTH SYSTEM Early and close collaboration between the MoH and
FINANCING MoF is therefore, critical to enable both institutions
to understand differing perspectives and to reach
The key challenge that confronts all governments consensus around the need to finance an NSOAP.
when considering a new health care policy is the The NSOAP funding plan should be aligned within
question of whether the investment can be justified, this overall process of government budgeting.
given other competing health care and national
development priorities of the state. In order to get an
NSOAP funded and implemented, an understanding 10.2.2 Making a strong investment
of the following is required: 1) the national budgeting case to inform budget allocation and
process; 2) constructing a persuasive investment decisions
case and; 3) mobilizing political support.
To justify first, the inclusion of an NSOAP into the
national health strategic plan (NHSP) and, second,
10.2.1 Aligning the NSOAP with the to expand spending on the surgical components in
national budgeting process the NHSP, there must be sufficient evidence to both
1) mobilize political support for the NSOAP within
National budgeting is a political and deliberative the MoH and; 2) persuade the MoF that an NSOAP
process that determines government expenditure is a cost-effective (with GDP growth potential)
for the next financial year. Each country has a unique inclusion within the national budget during budget
Public Financial Management (PFM) system, and it is consultation.

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Making this argument should be carefully analyzed Mobilizing and sustaining political support also
and articulated. Though this is the focus of chapter means understanding the interests of the citizenry
two in this manual, the investment case should and attitudes of civil society to galvanize popular
broadly reflect the health system context, health support. The question of how best to frame the
needs, and overall developmental agenda of the NSOAP, given key political actors in the system, and
state, within the global political commitments to identify “windows of opportunity” to influence
already made. Typical arguments for surgical care political behaviour in support for the NSOAP is a
have included those that increase health system critical element of a political strategy. According to
performance, improve welfare, and promote macro- Kingdon’s policy stream model, governments take
economic development (1,3,42). Given the current policies seriously during “windows of opportunity”
emphasis on primary health care (86), universal when three “streams” come together: the problem
health coverage, and maternal and child health stream (objective situation), policy stream (availability
(87,88), it may be prudent to examine how quality of a policy solution) and political stream (political
surgical care can improve each of these as means to will and popular support) (89). Highly dependent
strengthen health systems and be more responsive on country context, these opportunities often
to the health care needs of the citizenry as well as emerge during times of change (new government,
towards achieving the targets of the SDGs. economic crisis, sustained economic growth) or
when there is a local or global “champion” that
drives a groundswell of political support. A coherent
10.2.3 Mobilizing and sustaining political political strategy is needed to assess these factors
support for NSOAP financing in relation to political, economic, and sociocultural
specificities in order to make the NSOAP (and the
Getting an NSOAP onto the political agenda involves financial plan) politically feasible.
multiple actors in the political system but ultimately
depends on both the effective persuasion of senior
members within the Ministry of Health and later,
the Ministry of Finance. Resource mobilization, thus, 10.3 RESOURCE MOBILIZATION
cannot be isolated from the political factors necessary FOR NSOAP POLICY FINANCING
to secure proper financial support. A thorough
analysis of the political terrain is required in order to 10.3.1 The concept of fiscal space
build political support. This includes understanding
health policy and planning decisions in the context Fiscal space has been formally defined as: “the
of the fundamental values that underpin political capacity to increase public spending but doing so in
decisions happening at the central level and which a fiscally sustainable manner that does not threaten
are likely to influence political support for the government solvency” (90). By increasing the fiscal
NSOAP. One strategy to mobilize political support space for health care spending, the government can
is the inclusion of an NSOAP in the health sector provide a way to finance an NSOAP. In the 2000s,
strategic plan, and MTEF, to emphasize it as a priority the approach was adapted to the health care sector
among other health sector plans. The integration to guide government health care spending (91). Five
allows the government to align the NSOAP policy components or pillars are commonly used to assess
across all other strategic health priorities, which sources of fiscal space (table 1). In this manual, a sixth
can help to minimize inefficient spending. This step pillar is included in the framework to incorporate
secures both political and economic support for innovative financing sources, which are increasingly
the plan and promotes sustainable public funding gaining traction (92). A fiscal space analysis for
by ensuring that NSOAPs are considered in yearly health can be conducted to evaluate the likelihood
government budgets. of generating funding for the NSOAP based on this
framework.

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 Table 10.1: Fiscal space approach to health system financing: “pillars” to consider when evaluating
NSOAP resource mobilization, indicators examples, and actions for each pillar

Fiscal space pillar Sample Indicators Action taken to assess fiscal space

• Projected GDP growth rates • Evaluate how macroeconomic and political

1 Macroeconomic conditions • Tax reforms conditions are likely to influence fiscal space
• Elasticity of health expenditure to GDP for health

• Assess discrepancies in political commitments

to health and current budgetary allocations
2 Reprioritization of • Health budget as % of government budget • Assess budgetary allocation to health in
government budget • Health budget per capita proportion to health needs
• Compare budgetary allocation to health in
relation to countries with similar economic levels

• Current tax rates on alcohol, tobacco and other • Evaluate additional political context around
3 Increase health sector- “sin taxes” “sin taxes”
specific resources • Mandatory health insurance coverage • Evaluate potential for introduction of mandatory
health insurance

• Effective coverage of key interventions • Assess sources of both technical and allocative
4 Efficiency of existing • Degree of corruption inefficiency as a means to improve service
resources • Rate of health workers absenteeism delivery
• Variation in per capita funding across • Evaluate financial and non-financial incentives
geographic areas of providers to improve performance

• Development Assistance for Health (DAH)

as % of Total Health Expenditure (THE) and
Government Health Expenditure (GHE) • Assess compatibility of aid flow with country
5 External sources • Trends in aid flow and future commitments needs/priorities
• % of external funding earmarked for disease
specific programs
• % of health aid as direct budget support

• % Innovative financing of THE and GHE • Which innovative financing sources exist or
• Number of innovative financing mechanisms could be adapted to create fiscal space given
6 Innovative Financing for surgery developed at global, national and the political conditions in the country
sources sub-national levels • What factors could positively or negatively affect
• Amount of funding. mobilized through the adoption of these funding mechanisms
innovative financing for surgery at global and
national levels

Adapted from Tandon A., and Cashin C., Assessing public expenditure on health from a fiscal space perspective (93).

10.3.1.1 Macroeconomic conditions 10.3.1.2 Aligning priorities of government budget

It is important to consider how macro-fiscal An increase in the proportion of the national budget
conditions, such as economic growth, revenue allocated for health care spending can unlock
generation, and government debt, will affect the funding for the NSOAP. One major factor indicative
fiscal space for NSOAPs. Macroeconomic plans of the prioritization level of health is the share of
that promote and sustain economic growth and public resources allocated to health. The 2001 Abuja
that improve tax administration will likely lead to declaration by the African Union countries set a
an increase in total fiscal space amendable for target of at least 15% of the national budget to be
healthcare expenditure. The sustained economic used towards health (97), yet few countries have
growth in many countries has allowed them to invest maintained this commitment. Several countries are
in new health care programs, while economies that steadily increasing government health expenditure.
have contracted are often forced to decrease health Uganda, for example, increased its health budget as a
care spending (94–96). share of government budget from 7% 1997-98 to 10%
in 2002-03, following through on its commitment to
increase health shares in the government budget

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(93). A persuasive case can be made for increasing among primary health care facility workers to be
the total health budget to accommodate NSOAP as high as 40% (102). Addressing both healthcare
financing if: 1) the proportion of government worker and facility manager absenteeism within this
spending on surgical services is lower than context could improve healthcare service delivery
comparable countries and; 2) the ministry of health and free up fiscal space for other competing health
can demonstrate the cost-effective investment priorities. Considering the examples set within the
nature of surgical spending over the long-term. global sexual and reproductive health community,
for instance, a review of reproductive health policies
in eight countries across five continents and
10.3.1.3 Increase health sector-specific resources sub-continents illustrates ways in which efficient
integrated reallocation of existing health funding
Tax reforms to both direct and indirect taxes and may be carried out to strengthen service delivery
introducing new health sector-specific resources (103). During the Millennium Development Goal
such as earmarked taxation or mandatory health (MDG) era, Namibia undertook a critical analysis
insurance can serve as another source of fiscal of existing health funding to address climbing
space for NSOAPs. Earmarked taxes, for example, maternal mortality (104).
can be used to direct tax revenue towards specific
and related health programs. Zimbabwe’s AIDS
Trust Fund received funds from a 3% tax levied on 10.3.1.5 External sources: the global level
formal sector employers and employees (98). Taxing
tobacco and sugar have also been introduced to LMICs must often look beyond the domestic
generate revenue for the health sector (99,100). In resources to finance health care programs. However,
South Africa, for example, a health promotion levy since the 2008 economic recession, growth in
mobilizes funds from a sugar tax to expand fiscal international aid has gradually decreased (105)(106).
space for health care services that target non- Countries looking to increase fiscal space using
communicable diseases (101). A fiscal space analysis international sources may need to adapt the NSOAP
should consider how health sector-specific resources to the requirements of these funding agencies to
may be introduced to fund NSOAP implementation make a stronger case for support. For example, since
while taking into account the political conditions a significant area of international funding is targeted
of introducing such measures. Taxing petrol, for towards maternal and child health (MCH) and sexual
example, could contribute towards a road accident and reproductive health and rights (SRHR), countries
fund that helps to finance emergency surgical care can emphasize those specific aspects of the NSOAP
at the district level of the health system. that improve MCH and SRHR surgical service
outcomes. If global sources are determined to be a
major source of funding for the NSOAP, it is critical
10.3.1.4 Efficiency of existing resources that these funders are engaged early in the process
and that the funding stakeholder management
“Efficiency of government health expenditures” strategy (Chapter 5) incorporates these actors.
can be defined as the degree of maximum levels Rwanda’s Human Resources for Health program is
of health systems outputs to (financial) resource an example of a program that used external funding
inputs (93). Assessing technical and allocative effectively to achieve national strategic health goals.
inefficiencies of available resources can be used Over seven years, $150 million were deployed to
to determine fiscal space for NSOAPs within the Rwandan Government in a system-wide, skills-
health budgets. Common ways in which efficiency transfer program that was responsible for training
could be improved include improved geographic physicians, nurses, and other health care workers
spending across regions, changing the allocation of (107).
resources across clinical service delivery categories
within the health sector, targeting cost-effective
programs, and aligning health expenditure with
identified needs and strategic plans. In Indonesia
and India, for example, a study found absentee rates

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10.3.1.6 Innovative financing

Innovative financing can help to increase fiscal framework (108). Though not yet harnessed for
space and to reduce the need to borrow capital from surgical care, innovative financing mechanisms are
external sources. Innovative financing is a general an untapped resource for financing NSOAPs that
term used to describe several “non-traditional” forms have been successfully scaled in global health to help
of financing for the health system. When discussing bridge funding gaps (109). There is an opportunity
innovative financing, we distinguish between for countries and inter-governmental regional
innovative financing instruments used to mobilise blocs to think creatively and develop innovative
funds and innovative financing mechanisms that are financial mechanisms to expand fiscal space.
used to pool and channel funds for health programs. These mechanisms can also be aligned with other
Examples of innovative financing mechanisms underfunded health system priorities. Countries
that have reached a global scale include the Global can base their approaches on those innovative
Fund, GAVI, and UNITAID to finance HIV, TB and mechanisms that have been scaled successfully.
malaria, vaccinations and expanded access to new The Global Financing Facility (Box 10.1) is an example
diagnostics and treatments by influencing market of an innovative financing mechanism that can be
dynamics respectively (92). The defining feature of leveraged for NSOAP financing.
innovative financing mechanisms is that innovation
occurs at each stage of the health care value chain

BOX 10.1

INNOVATIVE FINANCING – GLOBAL FINANCING FACILITY

The Global Financing Facility (GFF) was established in 2015 to “accelerate efforts to end preventable maternal,
new born, child and adolescent deaths and improve their health and quality of life.” The Secretariat is
housed within the World Bank, and along with the GFF Trust Fund, it aims to catalyse the financing for
country-driven investment cases that address maternal and child health. The GFF mechanism employs the
following innovations:

• Resource mobilization from multiple sources: GFF trust fund, domestic IBRD (International Bank for
Reconstruction and Development)/IDA (International Development Association) financing, aligned
external financing, and private sector resources.

• GFF trust fund finance is used primarily to provide initial seed funding, provide technical assistance and
preparatory work, and importantly, to help coordinate a multisectoral partner approach.

• Each dollar from the trust fund is multiplied many times over through: 1) attracting additional funding
and; 2) identifying and allocating funds to high-impact solutions via the GFF channelling mechanism.

• Finally, a broad range of stakeholders preside over both the GFF trust fund and the country GFF-funded
projects, helping to promote performance-based funding approach.

Although surgery, obstetrics, and anaesthesia (SOA) are not explicitly included in the GFF programmatic
objectives, SOA have a crucial role in preventing deaths and improving quality of life within the RMNCH
(reproductive, maternal, neonatal and child health) spectrum. NSOAP teams can liaise with the GFF team
in-country to create a country-driven investment case for SOA care. The NSOAP process and final plan
provides all the elements needed to make a country-driven investment case to GFF: baseline assessment,
interventions required, cost and a strategy to increase fiscal space for the NSOAP through domestic sources
and improved spending efficiency.

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10.4 FUNDER STAKEHOLDER
ANALYSIS AND ENGAGEMENT
STRATEGY
Two key outcomes of the funding stakeholder committee within the MoH should work closely with
analysis are both to identify all the stakeholders the MoF during budget negotiations to ensure the
involved in funding decision-making and to develop a NSOAP is incorporated in final budget proposals to
stakeholder engagement strategy. While the former be submitted to and approved by parliament.
is merely a descriptive activity, the latter is inherently
a political process. Continuous engagement with Finally, the public and Civil Society Organizations
key stakeholders throughout the NSOAP process (CSOs) often play a vital role in the budgetary
is needed to ensure that resources are allocated for process as they influence budget priorities from
NSOAP implementation during budgetary decisions the grassroots level, advocate for transparency
and disbursements. The key stakeholders to consider in budgetary processes and sometimes even
when developing a resource mobilization plan are participate in budget-setting processes when such
presented in Table 10.2. Further information on decisions are decentralized to the local level. In
conducting a stakeholder analysis and engagement countries where the decision space for financing is
plan are detailed in Chapter 5 of this manual. decentralized, local actors (CSO’s citizens and local
health boards/offices) have expanded choice and
The MoF is the major actor when it comes to influence over local resource mobilization and health
domestic resources and is also usually the primary expenditure. Engaging with these local actors,
state institution that engages with external funders. including the media, could be used to both support
It is thus the principal actor with respect to NSOAP NSOAP financing at the local level and shape the
financing. The importance of engaging with the MoF political agenda for improved surgical care at the
early in the NSOAP development process cannot be central level. While this inevitably translates into
overemphasized. Although the MoH is responsible engagement with a larger number of stakeholders,
for developing health policies like the NSOAP, the this approach inherently promotes ownership at the
MoH is dependent on the MoF to secure funding grassroots level, with enhanced potential for long-
for the implementation of these policies. Ministry term sustainability.
of Health policies that are developed in isolation
without MoF input may not be prioritized in budget
allocations and risk being underfunded. The NSOAP

Table 10.1: Fiscal space approach to health system financing: “pillars” to consider when evaluating
NSOAP resource mobilization, indicators examples, and actions for each pillar

Key Stakeholder Role in Funding

1 Ministry of Health, Department of Policy and Planning Authority to develop MoH policies and formulate yearly MoH budgets

2 Ministry of Finance Authority to approve and disburse public funding

3 Politicians/ Policymakers Influence the political agenda and priority of health needs that are
ultimately funded

4 Public, civil society organizations and media Influence politicians to allocate funding to health priorities

5 Bilateral and multilateral funders, e.g. USAID, World Bank, Provide additional funding to meet public funding gaps through
Bill & Melinda Gates Foundation loans and grants

6 Private Sector Provide funding through public-private partnerships, reduce public

funding needs through private health service provision

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10.5 CONCLUSION
The main challenge to improving surgical care is
arguably financing. This chapter highlights three
critical steps in developing a strategy to mobilize
resources for NSOAPs. Firstly, situating NSOAPs
within broader processes of health systems financing,
including the national budgeting process through
the articulation of a coherent NSOAP investment
case. The chapter stressed the importance of
mobilizing political support for the NSOAP within
these budgeting processes. Secondly, the chapter
provided an approach to resource mobilization for
NSOAPs through fiscal space analysis. Finally, we
focused on identifying and mobilizing the support
of the main funding stakeholders involved in the
NSOAP process.

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CHAPTER 11

Implementation

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11.1 INTRODUCTION

P
olicy implementation is the act of using In this chapter, we highlight a few considerations
available resources, mechanisms and ensuring the successful implementation of an
partnerships to translate policy into NSOAP along with empirical lessons from countries
practice to achieve policy goals (110). As policies, that have begun NSOAP implementation.
National Surgical, Obstetric and Anaesthesia Given that NSOAPs are so nascent, many of the
Plans (NSOAP) have the potential to reduce lessons highlighted below are drawn from early
health inequalities associated with surgical experiences of implementation from countries
disease, improve health outcomes, enhance with NSOAPs as well as policy implementation
surgical service delivery efficiency across special- lessons from other sectors that could be applied
ties, improve overall health of the population, to NSOAPs. While this chapter aims to provide
and promote economic growth. Countries recommendations for NSOAP implementation,
with NSOAPs have begun implementing their readers should note that policy implementation
NSOAPs (69,70,111–113). The success of any public is context-specific and highly influenced by
policy or strategic plan such as an NSOAP complex social, political, economic, and external
depends on the degree to which the policy is factors that must be taken into account during the
effectively implemented. implementation of NSOAPs. For example, political
context such as the type of political system (highly

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centralized vs decentralized states with popular holder, especially frontline healthcare workers,
political participation) and degree of political in the policy development process. After the
stability have varying effects on how policies are plan is fully developed, stakeholder engagement
developed and implemented (114,115). Hence this transitions from representative to comprehensive
chapter should be read in a broad, general sense engagement.
rather than in a prescriptive manner and should
be adapted to each country’s socio-political and The NSOAP may be disseminated through different
economic context. Most of all it is intended to methods including the traditional and social media,
serve as a pragmatic guide to tangible problems national and regional workshops, and conferences
that may be reasonably expected in the process of depending on target audience. Dissemination of
implementing an NSOAP. the plan to the general public can occur through
print and social media or community gatherings.
In the following sections, we discuss disseminating If there is an official launch of the NSOAP, different
and operationalizing the NSOAP resources needed types of traditional and social media could be used
for implementation, establishing leadership for to inform the general public of the new strategy,
implementation, and conclude with considerations using locally available methods that assure reaching
for creating feedback mechanisms for monitoring the largest, and remote, segments of the population.
progress on implementation. Dissemination to the general population helps
ensure increased awareness on how the new policy
could affect their access to surgical care and their
role as patients in implementation. An informed
11.2 DISSEMINATING THE NSOAP public can hold their leaders accountable, further
assuring successful policy implementation.
One of the first steps of NSOAP implementation
is the dissemination of the plan to relevant
stakeholders and wider audience, particularly those BOX 11.1
who will be financing and implementing the plan. In
addition, patients, family, and the community could
benefit from a fully and efficiently implemented
NSOAP DISSEMINATION IN ZAMBIA
plan since they are voters and could also hold the
government/leadership accountable during and
Dissemination of the Zambian NSOAP (2017-
after implementation. The level of dissemination of 2021) occurred at the global, regional and
a policy will influence its degree of implementation national levels. It was disseminated at the
(115). Dissemination serves to inform stakeholders on global level through an official launch at the
the new priority framework of the Ministry of Health 2017 World Health Assembly, at the regional
and can be used to engage them on their new roles level in Africa through the East Central and
and responsibilities in NSOAP implementation. Southern Africa Health Community (ECSA-
Without dissemination, frontline providers who are HC) and the Southern African Development
Community (SADC) and at national level
the ultimate implementers will not be aware of the
through a national surgical forum and
NSOAP and will therefore be less likely to support
at professional association meetings.
and contribute to its implementation, resulting in The integration of the NSOAP strategy of
policy resistance. Frontline clinician support for the implementation into the Zambian National
NSOAP is better when the policy is disseminated Health Strategic Plan 2017-2021 (ZNHSP) also
to stakeholders right after its completion. Ideally, serves as a means of disseminating the new
many of these stakeholders would have already health policy to strategic partners and other
been aware of the NSOAP through their inclusion stakeholders in health and non-health sectors.
in the stakeholder policy team during the NSOAP However, work remains to be done to ensure
more awareness among stakeholders at sub-
formulation process as discussed in chapter five of
national level, especially the patients and the
this manual. While stakeholder engagement in the
general population who are better placed to
NSOAP development process is aimed at ensuring hold policy makers accountable.
representation from all relevant stakeholder groups,
it is not possible to involve every individual stake-

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 BOX 11.2

For implementers of the plan, targeted dissemina-

tions may be conducted through national and SUMMARY: NSOAP OPERATIONAL
regional workshops and conferences. For example, PLANNING
the NSOAP could be presented and discussed
in countries where regular health managers What is it? The process by which the goals of
planning meetings are institutionalized. Annual the NSOAP are transformed into short-term
conferences by professional societies are also actionable activities
dynamic venues through which cross-cadre health
Why do one? Operationalizing is needed to
professionals, the frontline NSOAP implementers, concretize NSOAPs to be implementable
may be engaged. No matter the dissemination
strategy, it is crucial that all stakeholders be When should it be done? On a yearly basis,
included in a productive way that will allow ideally once the budget ceiling for the sector
them to better understand the goals and innate is known
advantages of the NSOAP in order to determine
how they can operationalize and execute the plan. Who should be involved? Every stakeholder
group that will be involved in implementing
components of the NSOAP.

11.3 OPERATIONALIZING
THE NSOAP
According to the World Health Organization Who is involved in developing an
(WHO), operational planning is the process by operational plan?
which strategic objectives and goals of a national
health policy, strategy, or plan are transformed into As operational planning is intensely activity-focused
actionable activities (116). Operational planning and reliant on available resources for implementation,
is distinguished from strategic planning in that operational plans are often undertaken by budget
strategic planning focuses on long-term goals and centers in the MoH and other implementing
visions with long-term spans of five to ten years, institutions. Within the MoH, this could be done by
while operational planning deals with the concrete the department of policy and planning that oversees
day-to-day activities that are needed to achieve the the MoH’s annual budget. In decentralized systems,
long-term goals of the strategic plan. Operational each province, state or region may need to develop
plans are typically developed on a yearly basis, ideally their own operational plans and set their NSOAP-
once the overall health budget is known. aligned goals depending on resources available to
the local government. Outside the MoH, budgeting
Developing a short-term operational plan for the and planning departments within universities
NSOAP helps determine what needs to be done in and hospitals may develop NSOAP operational
the near term, within available resource constraints, plans at the facility level within resources available.
to achieve the goals and strategic objectives of Ideally all individuals and institutions, including
the NSOAP. Without operationalizing the NSOAP, all departments within and outside the MoH with
implementing stakeholders will not be aware of their NSOAP-related responsibilities will develop an
roles and responsibilities in implementation nor of NSOAP operational plan. The operational plan
the resources available or the anticipated timelines. should align with the budget cycles of the financing
Thus, one of the first tasks of NSOAP implementation institution. For example, MoH operational planning
is the creation of a yearly operational plan that may be aligned with the budget cycles of the MoF.
illustrates how the objectives of the first year of the
NSOAP will be achieved. Stakeholder participation in the operational
planning process is vital. While stakeholder
engagement in the priority setting phase
of the NSOAP process aims to set high-level
objectives, operational planning solicits input

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from stakeholders on concrete activities with NSOAP implementation, many MoHs will need to
immediate and direct impact on day-to- dedicate significant time to advocacy in order to
day activities. Without the buy-in of frontline increase available financial resources available for
clinicians, the operational plan risks being poorly the NSOAP.
implemented. Operationalizing the NSOAP may
also ensure transparency and accountability Apart from financial resources, human resources
among implementing stakeholders. Consequen- will be needed. An assessment of available and
tly, it’s crucial to engage frontline healthcare dedicated human resources within the MoH who are
workers (surgical clinicians and nurses, hospital skilled in policy implementation is recommended.
managers, ancillary staff, non-clinical support Existing MoH personnel may need to allocate time
staff, educators, etc.) in the yearly process of to the implementation of the new NSOAP. However,
NSOAP operationalization. Resistance to the this may become a challenge as MoH personnel are
NSOAP from frontline clinicians can undermine often juggling multiple responsibilities and priorities
implementation and prevent the achievement of that may result in the NSOAP being neglected. To
NSOAP goals. overcome this challenge, the Ministry of Health of
Tanzania opted to hire dedicated full-time NSOAP
Additional detailed information on operational coordinators to oversee the implementation.
planning is available in the WHO manual: Dedicated NSOAP coordinators will ensure that
Strategizing national health in the 21st century: a NSOAP implementation is not overshadowed by
handbook (61). competing priorities of MoH personnel. Similarly,
in the Zambian scenario the responsibility of
implementation was placed under the oversight
of a senior MoH officer, the director of clinical care,
11.4 RESOURCES NEEDED FOR who is supported by several national coordinators
NSOAP IMPLEMENTATION in surgery, obstetrics and gynaecology, anaesthesia
and nursing.
Exploring the availability of the different types of
resources necessary for NSOAP implementation is Sometimes those developing the policy will not be
done during the early stages of NSOAP develop- leading the implementation. Staff turnover within
ment. Without financial, human, governance, and the implementation and leadership team risk
infrastructure resources, NSOAP implementation stalling implementation. Innovative and region-
will not be realized. It is therefore essential to identify specific strategies for retaining staff as well as
available resources and define any additional resour- training new oncoming personnel may help to
ces needed to implement the NSOAP. prevent this. Financial and non-financial incentives
may be required to reduce staff turnover rates. New
The availability of financial resources is critical staff will need to be trained, and their roles in NSOAP
for the successful implementation of any policy. implementation clearly defined. A training manual
Sustainable, sufficient and earmarked funding is and course could be useful for bringing all new
needed for most activities within NSOAPs. Without members of the NSOAP implementation team up
funding, an NSOAP will remain aspirational and to speed on implementation.
without a way forward for implementation. In
many low-income and middle-income countries
(LMICs), NSOAP financing will likely be the main
initial barrier (see Chapter 9). The inherent cross-
cutting nature of NSOAPs as a comprehensive and
complex health system intervention, makes analysis
of surgical care funding within other, pre-existing
non-NSOAP policies a challenge. A targeted review
of previous annual budgetary allocations could help
determine financial resources available for NSOAP
implementation. In addition, in the early stages of

2020 EDITION 109

Partnerships can also be viewed as essential determining which individuals, organizations or
resources for NSOAP implementation. For example, partnerships are responsible for different aspects
a significant proportion of healthcare in developing of the NSOAP and who should be accountable for
countries is provided by faith-based institutions various outcomes. This governance structure will
and private facilities. Establishing partnerships with vary from country to country and should be clearly
these institutions with clear roles and responsibilities defined in the formulated NSOAP. Chapter 9 detail
could help accelerate NSOAP implementation. both organizational and governance structures
Equipment, supplies and infrastructure resources that should be considered during NSOAP
needed should also be considered in the planning development and implemented thereafter. Box
phase. Strategies for mobilizing these resources will 11.3 outlines an example of a strategy undertaken
depend on the context in each country. For example, in Tanzania to establish a governance structure at
in some countries partnerships with the biomedical the national level.
industry could help secure needed equipment
for the provision of safe surgery through public- Leadership at all levels is crucial for effective NSOAP
private partnerships. Partnership with academic implementation. At the national level, high level
institutions could also be established to support the MoH officials and influential actors can champion
data collection and implementation research. the implementation, advocate for resources, and
communicate clear rationale and mechanisms
NSOAPs are a relatively new policy approach to for implementation. Continued ownership and
strengthening the health system’s capacity to deliver guidance is needed from leaders at the national,
multidisciplinary surgical care. It is likely that most regional and local levels of government throughout
countries, particularly LMICs, will need continued the implementation process. Effective leadership is
advocacy even after the NSOAP is developed and needed at the MoH level to guide implementation
launched to mobilize the specific financial, human, and ensure that all implementing stakeholders are
leadership, equipment, and infrastructure resources appropriately engaged throughout the span of the
needed for its implementation and to document plan. MoH leadership is also needed for mobilizing
the benefits resulting from implementation. Thus, additional resources. Leaders at the regional and
advocacy will need to be one of the first and most local levels should also have sustained commitment
important components of implementation. Chapter during the implementation of the NSOAP. Leaders
10 provides some strategies for financing an NSOAP. within professional societies, medical colleges and
academic organizations, equally have a significant
role to play in advocating for implementation,
advising on implementation and implementing
11.5 ESTABLISHING LEADERSHIP relevant sections of the plan. At the community
AND GOVERNANCE level, religious and other civil society leaders may be
STRUCTURE FOR THE NSOAP included as NSOAP champions, as well as playing a
IMPLEMENTATION role in holding other leadership cadres accountable
for equitable NSOAP implementation.
It will be beneficial to consider aspects of
governance, levels of commitment and ideologies
that could positively or negatively impact NSOAP
implementation. Accountability and transparency
is important for effective NSOAP implementation. A
poor understanding of the roles and responsibilities
of policy implementers can lead to inadequate
implementation. Therefore, one of the first
activities of NSOAP implementation should be the
establishment of organizational and governance
structures with clear roles and responsibilities from
the national to the community level. Establishing
a clear governance structure can be useful for

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BOX 11.3

ESTABLISHING AN NSOAP GOVERNANCE UNIT: THE TANZANIA CASE

In recognition of the need for a governance unit to lead and guide the implementation of the Tanzanian
NSOAP, the Ministry of Health of Tanzania took deliberate steps to establish such a unit within the MoH. The
NSOAP governance unit at the MoH consists of NSOAP coordinators, a ministerial NSOAP coordinating unit,
and an external technical working group.

NSOAP coordinators
The NSOAP is a comprehensive and complex policy that requires dedicated staff to coordinate activities
and numerous actors that are responsible for implementing different portions of the plan. With this in
mind, one of the first steps in the implementation of the Tanzanian NSOAP was the establishment of a
full-time NSOAP coordinator position within the MoH to lead the implementation. An additional advantage
to establishing such a position early on in the NSOAP implementation process is that they were able to
advocate for additional resources for the NSOAP implementation. In Tanzania, policy implementation at the
primary and secondary health levels is coordinated by the President’s Office, Regional Administration, and
Local Government (PORALG) which works closely with the MoH. An additional NSOAP coordinator position
will be established in PORALG to coordinate the NSOAP implementation at the primary and secondary
health levels with the MoH NSOAP coordinator.

Ministerial NSOAP Coordinating Unit

The NSOAP reaches accross multiple pillars of the health system and implementation requires
coordination among multiple departments of the MoH. The Tanzania NSOAP is primarily housed
under the directorate of curate services within the MoH. To ensure that NSOAP implementation is
coordinated by all relevant departments of the MoH and activities are not operationalized in isolation
of one another, an NSOAP coordinating unit comprising of various departments within the MoH will
be set up. The coordinating unit will consist of at least one representative from each department of
the MoH.

NSOAP Technical Working Group

In addition to the Ministerial NSOAP coordinating unit, a separate NSOAP technical working group
containing representatives from stakeholder groups from outside the MoH was created. The objective
of the technical working group is to advise the MoH on the implementation of the NSOAP. It consists of
representatives from professional societies, nongovernmental organizations, researchers, and universities.

DIRECTORATE OF
CURATIVE SERVICES

NON COMMUNICABLE
DISEASES UNIT

NSOAP COORDINATION UNIT

NSOAP
TECHNICAL MOH NSOAP PORALG NSOAP
WORKING COORDINATOR COORDINATOR
GROUP
Emergency
Preventive Nursing and Human resource
preparedness and
Services Midwifery development
response

Information
Health Quality Policy and Procurement
communication
Assurance Planning management
and technology

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11.6 INITIATION OF NSOAP 11.7 FEEDBACK ON
IMPLEMENTATION – PILOT IMPLEMENTATION PROGRESS
AND RESULTS
Initiating the implementation of an NSOAP from
scratch in LMICs is unwise and unrealistic given Throughout the implementation of the NSOAP,
limited resources. The NSOAP implementation progress in achieving the NSOAP goals should
should be supportive and complementary to be tracked through monitoring and evaluation,
other pre-existing health programs as it is to pre- as detailed in Chapter 7. Frequent and routine
existing health policies. Thus, there is need to feedback from frontline implementers is needed
identify entry points for the initiation of the NSOAP to adjust goals, amend strategies, and identify
implementation within the health system’s existing additional necessary resources. Establishing
health programs. In the case of Zambia, the entry the proper mechanisms to monitor progress
point for initiating the NSOAP implementation is a top priority of any policy implementation.
was through addressing hemorrhage as a cause of For example, the Federal Ministry of Health of
maternal mortality via improved obstetric surgical Ethiopia developed a comprehensive monitoring
healthcare. Hemorrhage is the leading cause of and evaluation tool using 15 Key Performance
Maternal Mortality in Zambia and many other LMICs Indicators (KPI) and a comprehensive surgical
and can be adequately managed with surgical capacity assessment tool to monitor facility-level
healthcare. Maternal Mortality has been declared a implementation of their country's NSOAP. They
public health emergency by the Zambian Head of developed long-term KPIs to inform decision
State (2019). Thus, provision of improved and safe making at the national level and short-term KPIs
obstetric surgery for safe motherhood was used as to inform facility-level decision making, along with
the first entry point, then the call to all stakeholders clear reporting mechanisms.
to respond to the declared maternal mortality
health emergency with innovative and unorthodox Research is needed to better understand
measures (in this case, implementation of the contributing factors that affect the NSOAP
NSOAP) was the second entry point for initiating implementation process and impact of the
NSOAP implementation in Zambia. implementation. Such research on the NSOAP
development and implementation process will
Once the entry point(s) have been identified, there shed light on facilitators and barriers to achieving
is then need to initiate NSOAP implementation the goals of the NSOAP and determine factors
with a pilot program of the innovative policy in that contribute to successful implementation.
one district or province/state. This is to generate
evidence, demonstrate of impact (on health
systems strengthening and improvement of health
outcomes), and to gain knowledge that will be 11.8 CONCLUSION
critical for nation-wide scaling of the said NSOAP
implementation and to share best practices The NSOAP implementation process must be
between countries. adaptable. Policy implementation is not often a
linear process. Long-Term objectives may change
over time, often for reasons beyond the control of
policy implementers. While this chapter provides
some general considerations for NSOAP imple-
mentation, careful consideration of local contextual
factors that could positively or adversely affect
the effective implementation of this NSOAP is
necessary from the beginning of and throughout
the implementation process.

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YOUR

Notes

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YOUR

Notes

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CHAPTER 12

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