E EDITORIAL
Safe Surgery Globally by 2030: The View From Surgery
Thomas G. Weiser, MD, MPH, FACS,* Abebe Bekele, MD, FCS (ECSA),† and Nobhojit Roy, MD, PhD‡§
S
afety in medicine has meant different things to dif-
ferent people; for surgeons, it typically invoked the
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skills a surgeon brings to bear in caring for patients
on the table. However, our anesthetic colleagues are
decades ahead of us when it comes to engineering safety
into practice. From the early work of pioneers in Boston to
the organizational structures put into place by professional
societies, anesthesiologists have led the field.1,2 And yet, as
we reflected on the task of providing a surgical perspective
to the themes of safety in surgical care (for an anesthesiol-
ogy audience, no less), we recognize that our role is in many
ways unique. Our task as surgeons is to provide a voice to
all disciplines that have a stake in surgical safety. We must
promote the work the anesthesia community has engaged
in, but we must also reach out to our obstetric and gyneco-
logical colleagues, our theater nurses, and the ancillary staff
and other health professionals who labor behind the scenes
to ensure that the tools, materials, and processes we rely on
to deliver care are well resourced, organized, and supported
by our hospital administration, our professional societies,
our health ministries, and the people we stand ready to
serve. Below, we have provided 3 personal perspectives of
the directions that we see making a difference in the next
decade.
FROM CHECKLIST TO REALITY AND BACK
In 2006, as I was finishing a Masters of Public Health
(MPH) degree, Atul Gawande, a surgeon at Brigham and
Women’s Hospital, agreed to lead the WHO (World Health
Organization) Safe Surgery Saves Lives program. He hired
me as a research fellow. I was taking time from my surgical
training to pursue my MPH, something that was not par-
ticularly common for surgeons at the time, and I extended
my research time to work on this project. Our first meeting
occurred in his office, where we sat down and he announced
From the *University of Edinburgh, The Royal Infirmary of Edinburgh,
Clinical Surgery, Edinburgh, United Kingdom; †Addis Ababa University,
School of Medicine, Addis Ababa, Ethiopia; ‡Surgical Unit, BARC Hospital
(Government of India), World Health Organization Collaborating Centre for
Research on Surgical Care Delivery in LMICs, Mumbai, India.
Accepted for publication October 16, 2017.
Funding: T. G. Weiser was funded in part by a grant from the GE Foundation
for the Clean Cut program in Ethiopia.
Conflicts of Interest: See Disclosures at the end of the article.
Reprints will not be available from the authors.
Address correspondence to Thomas G. Weiser, MD, MPH, FACS, University
of Edinburgh, The Royal Infirmary of Edinburgh, Clinical Surgery, Room
F3307, Ward 106, 51 Little France Crescent, Edinburgh EH16 4SA, United
Kingdom. Address e-mail to thomas.weiser@ed.ac.uk.
Copyright © 2018 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000002673
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Copyright © 2018 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
to me and Bill Berry, a retired cardiac surgeon who was
helping him with some of his other research work, that our
goal was to improve the safety of surgery everywhere—in
rich and poor countries, in all settings, anywhere and every-
where surgery might happen. Oh, and we had 2 years and a
tiny budget. “So, what are we going to do?” he asked.
My first weeks were spent brainstorming and writing
down every possible way I could think of to improve sur-
gical outcomes: appropriate antibiotic use, postoperative
walking, venous thromboembolism prophylaxis, improved
equipment, advanced training, common standards for
resources and infrastructure, anesthetic monitoring and rou-
tine use of pulse oximetry, sterile practices, improved surgi-
cal instruments and equipment, assurance of sterile glove
availability, insurance schemes, and pay for performance;
the list was extensive and diverse. Over the course of the
first few months, some themes emerged, which clustered
into 5 main categories: surgical infrastructure, infection
control, anesthetic safety, surgical teamwork, and ongoing
monitoring and evaluation. Because of our time limitations,
we dismissed the idea of tackling surgical infrastructure.
Besides, we knew that surgery was happening around the
world, and that health facilities and systems were “making
do” with the resources they had. Our goal became to ensure
that the resources being consumed to provide surgical care
were efficiently and appropriately used. In addition, our
initial perception that we would be able to find 1 or 2 spe-
cific interventions was quickly dispelled; no one thing was
going to address the major burden of unsafe surgery.
After discussing ideas with experts and talking with
perioperative team members from surgery, nursing, anes-
thesia, sterile processing, and infection control, and con-
versing with patient advocates and safety experts from
around the world, it became clear that no one thing would
make a profound difference in surgical safety; surgical ser-
vices were just too complicated. It was also clear that the
most important element would always be the knowledge
held by each person gathered around a patient at the time
of surgery. We felt that if we could leverage this knowledge
through some prompt that codified expectations and helped
improve communication around the critical aspects of peri-
operative care, we would be able to avoid much surgical
harm. And thus the checklist was born.
With the release of our pilot study on the effect of the
checklist on surgical outcomes, we realized we had a pow-
erful tool for improving surgical care.3 But we also recog-
nized that the tool would be hard to implement and difficult
to deploy. There would be resistance, and spreading the
message would be an uphill battle. We wanted to avoid the
lag time experienced by many “best practices,” in which
 EE Editorial
behavior was glacially slow to follow evidence.4 Would it
take a generation? Would I be a gray-haired surgeon whom
residents would point out and say, “He used to operate
without a checklist”? Would I even be so lucky as to have
been a part of a radical cultural change in surgery? Do we
really need to wait until 2030 and beyond to make this a
reality?
In many ways, the question is being answered as this
issue of Anesthesia & Analgesia is released. National surgi-
cal plans are focusing on both surgical capacity and safety,
and they include safety tools such as the checklist as core
components of their platforms. Countries from around the
world have committed to using the checklist.5 And nongov-
ernmental organizations involved in the delivery of surgi-
cal care have incorporated the checklist into their standard
processes. It is encouraging to see such progress, and we
have learned much about how to implement the checklist
in rich and poor settings. I have seen the checklist flat-
ten hierarchies, improve communication, and strengthen
quality improvement programs. I have also seen it used
to lobby for increased resources and materials, introduce
improved perioperative protocols, and initiate new surgi-
cal outcomes surveillance programs. With each new expe-
rience, we improve our perioperative teams, develop our
ability to communicate with each other and our colleagues
from other disciplines, and bring knowledge and inclusiv-
ity that are so vital for surgical safety to the bedside. While
we do this in the name of increased safety for our patients,
it will endure because, frankly, it makes our own difficult
and stressful lives just a little bit easier.
SaLTS: THE ETHIOPIAN NATIONAL SURGICAL
PLAN
Over the past 2 decades, the Ethiopian Federal Ministry
of Health (FMOH) has sought to improve its public health
system by implementing 4 strategic health sector devel-
opment plans for its population of more than 90 million
people. Before 2014, maternal, newborn and child health,
nutrition, and infectious disease were often the focus of its
health policy. However, the current strategic plan, called the
Health Sector Transformation Plan, emphasizes an agenda
for change specific to essential and emergency surgical and
anesthesia care, and embeds it within its quality initiative.
Ethiopia is one of the first low-income countries to prioritize
surgical system reform within its national health agenda.
Before the World Health Assembly (WHA) resolution
68.15 on emergency and essential surgical and anesthesia
care, FMOH had identified the lack of adequate and equi-
table surgical services, the scarce surgical workforce, and
insufficient infrastructure as issues of major importance.6
Although it is estimated that more than 5 million surgical
interventions are needed in Ethiopia each year to adequately
serve the needs of the population, estimates show that no
more than 300,000–400,000 operations are actually per-
formed annually.7 Patients seeking surgical care may experi-
ence waiting times as long as 1 or 2 years in some instances,
and the lack of access to quality care is further exacerbated
by a shortage of qualified surgical and anesthesia providers.
Since the adoption of the WHA resolution in 2015,
Ethiopia has emerged as a pioneer among low-income
countries with respect to a national surgical plan.
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Cognizant of the fact that fulfilling the aims of the Lancet
Commission on Global Surgery and the WHA resolution
requires strong political and government led commit-
ment, FMOH launched the Saving Lives Through Safe
Surgery (SaLTS) initiative, a 5-year (2015–2020) strategy
designed to be implemented across all levels of the health
care system, from first-level to tertiary hospitals.8 SaLTS
is designed to address quality and equitable health sys-
tem reform, 1 of 4 transformation agendas of the FMOH
National Health Sector Transformation Plan. It is built
on the already existing Ethiopian Hospitals Alliance for
Quality platform created by FMOH to foster collaboration
and self-reliance among clusters of hospitals in a specific
region.
Despite recommendation of the Lancet Commission for
countries to develop a national surgical plan, global expe-
rience demonstrates that the articulation of a “plan” is
not enough to improve access to safe, affordable, surgery,
and anesthesia care. The Ethiopian initiative is exemplary
because the plans were translated into actions within a few
months of its approval by the government.
The targets of the initiative are founded on 8 major pil-
lars of excellence, and since inauguration of the program
in 2016, a number of major accomplishments have been
achieved:
1. Excellence in Leadership, Management, and
Governance: A national SaLTS Project team along
with regional SaLTS leadership structures have been
formed, along with a comprehensive 5-year plan that
includes training on SaLTS provided to regions and
hospital in the country through a cluster hub-and-
spoke model. Furthermore, Jhpiego, an international
nonprofit health organization affiliated with the
Johns Hopkins University, has, through its Ethiopia
team, provided leadership training and mentoring in
the Amhara and Tigrai regions in partnership with
the GE Foundation. It has plans to bring this next to
the Oromia and Southern Nations, Nationalities, and
Peoples Region.
2. Excellence in Infrastructure Development: FMOH
allocated monies for the construction of 370 additional
theater blocks in 2 phases; 80 new theater blocks have
been completed, and 290 more are underway.
3. Excellence in Supplies and Logistics Management:
Theater equipment worth $25 million has already
been procured and is being distributed to hospitals
throughout the country. This included the develop-
ment of a more detailed plan for essential anesthesia
equipment and supplies, although the final plan is
still pending approval.
4. Excellence in Human Resource for Surgery
Development: A general surgery human resources
National Roadmap has been developed and
approved. This was based on an assessment of
the regional availability and need for a special-
ized surgical workforce. Regions and hospitals are
being supported to commence training of the sur-
gical workforce at the regional level. An anesthesia
human resources National Roadmap has also been
developed, but is still pending approval.
ANESTHESIA & ANALGESIA
 Surgical Perspective of Safe Surgery
5. Excellence in Partnership and Advocacy: In February
2017, Addis Ababa hosted an International Safe Surgery
Conference in partnership with the African Union, the
College of Surgeons of Eastern, Central, and Southern
Africa, and the Pan African Academy of Christian
Surgeons. There has been ongoing collaboration to
improve surgical and anesthetic safety and capacity
with international partnership including the College of
Surgeons of Eastern, Central, and Southern Africa, the
American College of Surgeons, Lifebox, and the Lancet
Commission. Within the country, the program is pro-
moted through periodic newspaper articles, radio, and
television programs to inform the public.
6. Excellence in Quality and Safety: FMOH, in con-
junction with the Society of Surgeons of Ethiopia,
have approved a list of National Essential Surgical
Procedures along with national perioperative guide-
lines. These guidelines are now being supported by
country-specific projects such as the Lifebox Clean
Cut program, a surgical safety checklist–based
intervention to reduce surgical site infections, wide-
spread implementation of the WHO Surgical Safety
Checklist, and improved safety and quality training
for hospital managers and leadership.9
7. Excellence in Innovation: An innovative oxygen
delivery system is being implemented at selected
hospitals in the Amhara region. Approval for con-
struction of an oxygen plant has also been completed.
8. Excellence in Monitoring and Evaluation: Monitoring
and evaluation tools and indicators have already been
developed. Full implementation of a monitoring and
evaluation surveillance system is underway.
With these pillars, an action plan, government com-
mitment, and leadership from the professional societies in
Ethiopia, we hope to make the ideals of the resolution on
Safe Surgery and Anesthesia For All a reality.
THE REALIST IN MUMBAI SPEAKS TRUTH TO
POWER
The concept of high-, middle-, and low-income countries is
being replaced by an understanding of the wider disparities
within countries. In fact, these disparities are perhaps greater
determinants of surgical outcomes than national-level met-
rics of surgical safety would suggest. Although a national
perioperative mortality rate is a recommended metric artic-
ulated by the World Health Organization and the Lancet
Commission on Global Surgery, its capture, when such a
thing actually occurs, reflects only a part of the picture. In
low- and middle-income countries, mortality frequently
occurs outside the hospital during transfer or at home.
Furthermore, participation in surgical safety audits propa-
gates a selection bias of better-performing hospitals. These
are usually the university public hospitals, which can afford
to undertake such surveillance, and also have incentives to
report their outcomes as they treat complex patients and are
under tighter regulatory control. However, the majority of
the health care in India occurs in unregulated private facili-
ties and through private fee-for-service providers.
Thus, one surgical safety standard cannot do justice within
a single country such as India because the intracountry
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context may be both resource-rich and resource-poor. In this
situation, patient safety is often confused with resources,
and resources are more often than not blamed for failure
of surgical safety. Blaming poor resources rather than poor
behaviors runs the risk of increasing costs of surgical care
by making mandatory the use of expensive medical devices
(like end-tidal CO2) that are contextually inappropriate and
currently unaffordable.10 It will be a disservice to the patient
safety agenda if such purchases, disguised as patient safety
measures, contribute to the catastrophic expenditure faced
by an already vulnerable population.
The Indian Society of Anaesthesiologists has failed to
rise to the challenge of providing anesthesia services in
the rural areas of India. Yet it has also prevented medi-
cal officers trained in providing “Life-saving Anaesthesia
Services” from functioning as task-shifted anesthetists in
physician-shortage areas by using patient safety as a justifi-
cation. Anesthesia, in these circumstances, regresses into the
hands of untrained providers who use open-ether and ket-
amine with no monitoring devices to fill the unmet need for
anesthesia for the critical bellwether procedures. Numerous
examples of task sharing, as recommended by the Lancet
Commission, exist that help extend the reach of anesthesia
and surgery in areas where such providers either cannot or
will not serve.11 Canada and Australia address this issue by
providing certified extra training for general practitioners
going to work in rural areas.12 Tanzania and other coun-
tries have long histories of task sharing cesarean delivery
and hernia repair, and their results have been demonstra-
bly comparable to physician providers when they are well
trained and supervised, and their roles and responsibilities
are clear.13,14 Many European and North American facili-
ties hire nurse anesthetists who work under the supervi-
sion of anesthesiologists. It is vital that the Indian Society
of Anaesthesiologists involve itself and become a leader in
helping the government address this issue.
Solutions include using low-cost interventions for
patient safety. The WHO trauma care checklist and the
childbirth checklist are classic examples for promoting safe
behaviors and improving compliance with best practices.
The provision of anesthesia in many of the poorest settings
is best done in a task-shared model, in which medical offi-
cers trained in anesthesia are provided oversight by a fully
trained anesthesiologist. Task-shifting has been only par-
tially successful in low- and middle-income countries, and
although proven to be safe in routine surgical cases in terms
of competency, the legal responsibility, when faced with
complications after care, remains unresolved. For the global
surgery agenda for 2030, the task of providing safe anes-
thesia is more difficult than providing safe surgery because
the unmet need of anesthesia manpower, equipment, blood,
and critical care is far greater. E
DISCLOSURES
Name: Thomas G. Weiser, MD, MPH, FACS.
Contribution: This author helped organize the study and write the
introduction and the section, “From Checklist to Reality and Back,”
review the study, and edit the content.
Conflicts of Interest: T. G. Weiser is currently working with Lifebox
to improve surgical safety. T. G. Weiser is a trustee of Lifebox.
Name: Abebe Bekele, MD, FCS (ECSA).
 EE Editorial
Contribution: This author helped write the section, “SaLTS: The
Ethiopian National Surgical Plan,” review the study, and edit the
content.
Conflicts of Interest: A. Bekele is currently working with Lifebox to
improve surgical safety.
Name: Nobhojit Roy, MD, PhD.
Contribution: This author helped write the section, “The Realist
in Mumbai Speaks Truth to Power,” review the study, and edit the
content.
Conflicts of Interest: N. Roy is currently working with Lifebox to
improve surgical safety.
This manuscript was handled by: Angela Enright, MB, FRCPC.
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ANESTHESIA & ANALGESIA