Improving global surgical outcomes through collaborative research

More than 4 million people die within 30 days of surgery each year, which is more than from all causes related to HIV, malaria, and tuberculosis combined, and around 8% of all deaths globally. The Lancet Commission and World Health Organization (WHO) estimate that 5 billion of the world’s 8 billion people lack access to safe, affordable surgery and that patients are three times more likely to die in low and middle income countries (LMICs) after an operation than in high-income countries. There is a critical need to both improve quality and reduce inequalities in surgical care globally. 

In 2017 the NIHR established the NIHR Global Health Research Unit on Global Surgery (GSU) to address these challenges around the world. Based at the University of Birmingham and jointly run with the Universities of Edinburgh and Warwick, the NIHR’s £7 million award for the GSU funded the organisation of international research centres across Africa, central and south America, and south Asia.

Delivering safe and effective surgical care across the world is one of the greatest challenges facing global health today. Our work impacts the most disadvantaged and vulnerable populations of the world - we are training surgeons in these countries to continue the research drive that is helping to save lives.
- Professor Dion Morton OBE, Co-Director of the GSU and Barling Professor of Surgery at the University of Birmingham

The GSU enables surgeons and researchers in LMICs to identify priority areas for research, carry out studies and bring these solutions to their patients. To achieve this, the Unit developed the GlobalSurg Collaborative as a platform and network of surgeons from more than 100 countries worldwide to build relationships between local hospital networks, government health bodies and related organisations, paving the way for research findings to be efficiently incorporated into evidence-based patient care. 

The Unit originally prioritised five areas of surgical research to improve patients’ health outcomes: 

• reduce surgical site infection after surgery
• reduce morbidity and mortality after high-risk surgery
• increase capacity for routine surgery
• improve access to surgery
• develop research across rural surgery networks. 

A sixth priority area of providing data to support recovery of surgical services affected by the COVID-19 pandemic was added later. The GSU launched the CovidSurg platform to collect prospective patient data to support surgeons globally to perform surgery safely and protect patients from Covid-19 infection. The WHO has since adopted evidence from this data in their guidance and it is now influencing surgical practice worldwide.

The GSU is unique in bringing together surgeons, researchers and policy makers to set the local research agenda according to patient need. 

To achieve this, the research teams need to reach the most disadvantaged and vulnerable people, who often live in very remote areas of the world. Research hubs established in larger, urban hospitals support the delivery of local training and research at smaller, often rural, hospitals. This model has been used to co-ordinate surgical research in India, South Africa, Rwanda, Nigeria, Benin, Ghana and Mexico.

The GSU is training the next generation of research surgeons and future global health leaders from its partner LMICs to lead ongoing improvements in surgical care. Thousands of surgeons, nurses, data managers and other healthcare professionals have already received training. The Unit has also launched two data centres in India and Ghana to give researchers better access to data collected during international studies, as well as a new surgical statistics centre in South Africa. 

The impact of GSU’s research collaborations is already evident from the results of its first randomised controlled trial into surgical site infection (SSI), which is the most common healthcare-associated infection in LMICs. The Unit’s FALCON trial showed that the relatively expensive methods of skin preparation and sutures recommended by WHO guidelines were no more effective in preventing SSIs than cheaper alternatives. 

In the world’s largest wound infection study to be carried out exclusively in LMICs, FALCON’s research spanned seven countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa) to recruit 5788 patients from 54 hospitals to test the recommended and lower-cost methods. Its results were published in The Lancet. 

While the longer-term impact of FALCON is still being realised, it shows that LMIC surgeons are keen to contribute to further surgical research, that more surgical teams are using the WHO surgical checklist to plan surgery, and that patients are interested in taking part in surgical trials. 

Another GSU-funded study is CHEETAH, which is investigating whether changing sterile gloves and instruments before repairing a wound after surgery can reduce SSIs. Although still underway, many participating surgeons have changed their practice to routinely change gloves in these instances. 

Telephone and video follow-up of surgical patients in LMICs has been tested and found effective for post-surgery check-ups to avoid the time and cost of travelling, especially during the Covid-19 pandemic. These findings will have a significant long-term impact in changing routine practice follow-up.

The GSU is making surgery safer and improving outcomes for patients by improving research infrastructure across the world.

Rwanda is a small country in East Africa where access to surgery is still challenging. The NIHR Global Surgery Unit has helped me to interact with other surgeons from around the world. Now, all my patients are benefiting from the same standard of care they would receive elsewhere.
- Dr JC Allen Ingabire, Kigali Teaching Hospital, Rwanda Hub

The Unit also ensures that more patients can take part in locally beneficial research. Before the launch of the GSU, community engagement for surgical research in LMICs was relatively unheard of. Researchers take account of which interventions local communities value participating in and co-ordinate them through the network of hubs and more remote local hospitals.  The GSU continues to work closely with the World Health Organization to influence international policy with its research outcomes and is working with health policy makers in the governments of Ghana, Benin and India to deliver research in line with national priorities.  The development of the Global Surgery Policy Consortium has improved guidance and policy, and this, alongside its links with the Royal College of Surgeons, national surgical societies and approximately 20,000 surgeons worldwide, means the Unit is well placed to share knowledge and change practice in surgery worldwide.  The GSU widely disseminates its research, with over 35 articles published in high impact journals. Their work has featured in the general media, including The Economist and other major news outlets across more than 100 countries. 

In 2021, the Unit was awarded a further NIHR Global Health Research Unit award of £7 million to build on this work over the next 5 years. The Unit has outlined a programme of studies that will develop the tools and infrastructure to improve surgery in LMICs. The new research will include:

• training non-surgeons to perform essential hernia operations to treat the 5 million patients awaiting surgery in sub-Saharan Africa
• testing simple innovations such as the use of high-dose oxygen, mouthwashes and inhalers to improve post-operative recovery
• testing innovative practices in LMICs and incorporating them into high-income countries’ health systems.

Professor Stephen Tabiri, Dean of the Medical School at University for Development Studies in Tamale, Ghana, and Co-Director of the new Unit and Network, said: “With the new funding our global network of surgeons will continue to co-ordinate surgical research across the GSU’s network of more than 100 urban and rural hospitals, and support local and international research training and education. 

“Working with our colleagues across the GSU we will develop the surgeon leaders, skills and infrastructure needed to improve surgical outcomes for our patients. We are also looking to improve access to safe emergency surgery, as most people in LMICs requiring urgent surgical care experience considerable delay in accessing health services.”

• For more information, visit the NIHR Global Health Research Unit on Global Surgery website.