title: Global Surgical Ecosystems: A Need for Systems Strengthening.
abstract: As surgery is gaining recognition as a critical component of universal health care worldwide, surgical communities have come together with unprecedented unity to advocate for systems to support surgical care. This community has long believed that much care could be performed in a cost-effective manner even in low resource settings, despite skepticism voiced by many in public health. To do so will require the development of new systems and re-vamping of old systems that are not effective. In the last five years, coalitions, expert panels, commissions, consortia and alliances have emerged to address these issues and there has been landmark success in advocacy with a new resolution at the 2015 World Health Assembly to include surgical care as a component of universal health coverage. It is critical to understand the ecosystem that constitutes the surgical environment. A surgical ecosystem could be described as a network of people, processes, and materials necessary for surgical services in the context of the facilities and environment in which it functions.
  
  
  
  We describe components of a functioning surgical ecosystem in terms of administration, support staff and clinicians, and the necessary sub-systems for providing consumable materials such as anesthetic medication and suture and sterile instruments. Related systems that must be integrated are facilities and utilities such as electricity, lighting, plumbing and waste management and even laundry. But especially in low and middle income countries (LMICs) lack of any one of these may be rate-limiting. The World Health Organization (WHO) has developed situational analyses and checklists for first level district hospitals to identify missing elements.
  
  
  
  A siloed approach cannot solve a systems problem. However, to scale up rapidly and to develop and sustain quality standards, a holistic "ecosystem" approach, including local and global professional societies and advocacy organizations will need to become engaged.
authors.affiliation: Department of Surgery Center for Global Surgery, University of Utah, Salt Lake City, UT. Electronic address: Catherine.devries@hsc.utah.edu.
authors.forename: Catherine R
authors.initials: CR
authors.lastname: deVries
authors.affiliation: Department of Surgery Center for Global Surgery, University of Utah, Salt Lake City, UT.
authors.forename: Jenna S
authors.initials: JS
authors.lastname: Rosenberg
mesh_terms: D003695:Delivery of Health Care; D017753:Ecosystem; D014943:Global Health; D006801:Humans; D011634:Public Health; D013514:Surgical Procedures, Operative / Q000191:economics* / Q000379:methods / Q000592:standards; D019472:Universal Health Insurance
keywords: ecosystem; global surgery; health systems strengthening; surgical facilities standards; surgical quality