Funding flows to global surgery: an analysis of contributions from the USA.

BACKGROUND: In recent years, funds for global health have risen substantially, particularly for infectious diseases. Although conditions amenable to surgery account for 28% of the global burden of disease, the external funds directed towards global surgical delivery, capacity building, and research are currently unknown and presumed to be low. We aimed to describe external funds given to these efforts from the USA, the world's largest donor nation. METHODS: We searched the United States Agency for International Development (USAID), National Institute of Health (NIH), Foundation Center, and registered US charitable organisations databases for financial data on any giving exclusively to surgical care in low-income and middle-income countries (LMICs). All nominal dollars were adjusted for inflation by converting to 2014 US dollars. FINDINGS: After adjustment for inflation, 22 NIH funded projects (totalling US$31·3 million, 1991-2014) were identified; 78·9% for trauma and injury, 12·5% for general surgery, and 8·6% for ophthalmology. Six relevant USAID projects were identified; all related to obstetric fistula care totalling US$438 million (2006-13). US$105 million (2003-13) was given to universities and charitable organisations by US foundations for 14 different surgical specialties (ophthalmology, cleft lip/palate, multidisciplinary teams, orthopaedics, cardiac, paediatric, reconstructive, obstetric fistula, neurosurgery, burn, general surgery, obstetric emergency procedures, anaesthesia, and unspecified specialty). 95 US charitable organisations representing 14 specialties (ophthalmology, cleft lip/palate, multidisciplinary teams, orthopaedics, cardiac, paediatric, reconstructive, obstetric fistula, neurosurgery, urology, ENT, craniofacial, burn, and general surgery) totalled revenue of US$2·67 billion and expenditure of US$2·5 billion (2007-13). INTERPRETATION: A strong surgical system is an indispensable part of any health system and requires financial investment. Tracking funds targeting surgery helps not only to quantify and clarify this investment, but also to ultimately serve as a platform to integrate surgical spending within health system strengthening. Although USAID is a vital foreign aid service and the NIH is a leader in biomedical and health research, their surgical scopes are restricted both financially (less than 1% of respective total budgets over the study years) and in surgical specialty. By contrast, the private charitable sector has contributed more financially and to more specialties. Still, current financial global health databases do not have precise data for surgery. To improve population health in LMICs, more resources should be dedicated to surgical system strengthening. Furthermore, exact classification measures should be implemented to track these important resources. FUNDING: None.

Financial contribution to global surgery: an analysis of 160 international charitable organisations.

BACKGROUND: The non-profit and volunteer sector provides substantial contributions to global health. Within the field of surgery, this sector has made notable service contributions in low-income and middle-income countries (LMICs) where access to surgical care is poor. Little is known about financing and funding flows to surgical care in LMICs from both domestic and international sources. Because an estimated 55% of surgical care delivered in LMICs is via charitable organisations, understanding the financial contributions of this sector could provide valuable insight into estimating funding flows and understanding financing priorities in global surgery. METHODS: Between June, and September, 2014, we searched public online databases of registered charitable organisations in five high-income nations (the USA, the UK, Canada, Australia, and New Zealand) to identify organisations committed exclusively to surgical needs. Based on availability, the most current 5 years (2007-13) of financial data per organisation were collected. For each charitable organisation, we identified the type of surgical services provided. We examined revenues and expenditures for each organisation. FINDINGS: 160 organisations representing 15 different surgical specialties were included in the analysis. Total aggregated revenue over the years 2008-2013 was US$3·3 billion. Total aggregated expenses for all 160 organisations amounted to US$3·0 billion. 28 ophthalmology organisations accounted for 45% of revenue and 49% of expenses. 15 cleft lip and palate organisations totalled 26% of both revenue and expenses. 19 organisations providing a mix of diverse surgical specialty services amounted to 14% of revenue and 16% of expenses. The remaining 15% of funds represented 12 specialties and 98 organisations. The US accounted for 77·7% of revenue and 80·8% of expenses. The UK accounted for 11·0% of revenue and 11·91% of expenses. Canada accounted for 1·85% of revenue and 2·01% of expenses. Australia and New Zealand accounted for 4·94% of revenue and 5·29% of expenses. INTERPRETATION: Charitable organisations addressing surgical conditions primarily focus on elective surgical care and cover a broad range of subspecialties. The largest funding flows from charitable organisations are directed at ophthalmology, followed by cleft lip and palate surgery. However, there is a clear need for improved, transparent tracking of funds to global surgery via charitable organisations. FUNDING: None.

Mapping the playing field-a novel web-based strategy to identify non-governmental actors in global surgery.

BACKGROUND: In the face of staggering global unmet need for surgical care, non-governmental organisations (NGOs) play a substantial part in the surgical workforce, providing surgical care for those who are without it. The number of NGOs providing surgical care in low-income and middle-income countries (LMICs) is unknown. This information is needed to determine the scope of such care, its contributions to global surgical case volume, to improve collaboration in an effort to maximise efficiency, and to inform national surgical workforce planning. We aimed to create a comprehensive, publicly available catalogue of NGOs providing surgery in LMICs. METHODS: We used the United Nations Rule Of Law definition to define NGOs. We included low-income, lower-middle- income, and upper-middle-income countries as defined by World Bank lending groups. Delivery of surgical care by an NGO was defined as the therapeutic manipulation of tissues taking place within an operating room, and was distinguished from the financial or logistical support of such care. We screened an online humanitarian clearing house (ReliefWeb), a large public NGO database (Idealist.org), two surgical volunteerism databases (Operation Giving Back and the Society for Pediatric Anesthesia), and the US State Department Private Volunteer Organizations database, did a review of the literature, and used a social media outlet (Twitter) to identify organisations meeting criteria for inclusion. A complementary analysis additionally provided a list of organisations delivering exclusively surgical care from a search of the OmniMed database, the Foundation Center Online Directory, UK Charity Commission, Australia Charity Commission, New Zealand Charity Commission, and the Canada Revenue Agency Charity Search. FINDINGS: We identified 313 unique organisations, working in all 139 LMICs. Organisations often used more than one model of care and engaged in several surgical specialties. Both short-term surgical missions (206 organisations, 66%) and long-term partnerships (213, 68%) were common models, with 40 organisations (13%) engaging in humanitarian interventions in crisis settings. The most commonly represented specialty was general surgery (120, 38%), but subspecialty surgery such as ophthalmology (88, 28%) and cleft lip and palate surgery (70, 22%) were also frequently performed. INTERPRETATION: To our knowledge, this is the most complete directory of NGOs undertaking surgery in resource-limited settings in existence. However, it is difficult to determine whether this review is exhaustive. Further work is needed to determine the total and relative contributions of these organisations to global surgical volume. This database will be made available for public use and should be maintained and updated to further coordinate global efforts and maximise impact. FUNDING: None.