Beyond Resolutions: How Local Activism Can Reshape Global Surgery Policy
I failed to secure a Swiss Schengen visa to attend 2024’s 77th World Health Assembly (WHA) global surgery side events. This sparked my reflection on the impact of global health institutionalism on global surgery and why global surgery advocacy must radically change to effectively influence global health policy.
A team of surgeons, anesthetists and nurses perform cleft lip and palate surgery on a patient. AMISOM Photo.
Institutionalism refers to the rules of the game. The current setup of global health institutionalism requires being present at major global health events to access funding and influence policy change. While this isn't necessarily negative, the challenge lies in the fact that many actions are carried out just for the sake of it. Side events are organized or attended without clear impactful outcomes. It's important to reflect on how these institutional norms affect the advocacy for access to surgical and anesthesia care at a national and local level, and whether they lead to significant changes in global health.
Global Surgery and Global Health Institutionalism
In 2015, at the 68th WHA, global surgery gained attention with the passing of WHA Resolution 68.15 on access to essential and emergency surgical and anesthesia care as part of Universal Health Coverage (UHC). Until 2023, this resolution was the focus of global surgery advocacy. Member states agreed to develop and implement surgical healthcare plans to strengthen surgical care delivery, as outlined in the resolution. Most countries have yet to develop their own plans. In 2017, the World Health Organization (WHO) Director-General reported challenges related to resource mobilization, inadequate health workforce, and essential medicines while discussing the progress of the 68.15 resolution. In 2023, surgery was again prominent on the global agenda at the 76th WHA with the introduction of a new WHA resolution, the emergency, critical, and operative (ECO) care resolution (also known as WHA 76.2). At the 77th WHA, the WHO Director-General was asked to develop a global strategy to operationalize the ECO resolution. Based on the pattern from Resolution 68.15, it is anticipated that there may be another resolution on surgical care in 2030.
The Pitfall of Institutionalism For Global Surgery
Global surgery advocates engage in global health institutionalism to promote surgical and anesthesia healthcare for all. They use international policy to influence national policy, quoting WHA resolutions and attending WHA side events. They also remind donors and global North governments of the moral imperative to address inequitable access to safe surgery and anesthesia while having conversations with like-minded individuals who agree that action is necessary.
Historically, significant changes in health equity have rarely occurred solely through adherence to global rules. Instead, advocates for change have often taken a more radical approach, from bottom to top, seeking to overturn the status quo. For example, the Treatment Action Campaign (TAC), a South African HIV/AIDS activism organization, used litigation, lobbying, and social mobilization, including civil disobedience, to ensure access to lifesaving antiretroviral (ARV) medications for all in South Africa. TAC's efforts supported global HIV/AIDS advocacy, which eventually led to financial resources being provided to ensure access to ARVs for all people living with HIV/AIDS. The maternal, newborn, and child health (MNCH) movement has employed a similar model to call for accountability from governments and healthcare providers for the deaths of pregnant mothers and newborns.
Global Surgery Advocacy Must Be More Radical
Like the HIV/AIDS and MNCH movements in their nascent stages, Global South surgery and anesthesia advocates mustn’t quickly acquiesce to the modus operandi of present-day global health actors. At present, those advocating for global surgery lack the influence needed to instigate and uphold substantial policy changes, unlike their dominant counterparts in other fields of global health. The dominant global health advocates have gained their influence by using local and radical advocacy, effectively shaping global health policy and institutionalism.
It is imperative that the advocacy and activism capacity of global south surgery and anesthesia advocates is strengthened. This will allow them to influence their governments to set the stage for global surgery at WHA and associated side events or effectively demand the inclusion of surgical care in the country's Universal Health Coverage (UHC) packages. "Effective global surgery advocacy requires strong local support to hold accountable those responsible for helping children who are unable to attend school due to lack of cleft or fracture care, have poor nutrition as a result, or die prematurely due to unequal access to safe surgery and anesthesia care
Advocates for global surgery must learn from history, which has shown that global initiatives often stem from local actions.
