National Surgical, Obstetric, and Anaesthesia Plan (NSOAP)

The National Surgical, Obstetric, and Anaesthesia Plan (NSOAP) is a strategic framework adopted by many countries to strengthen surgical, obstetric, and anaesthesia (SOA) care as an integral part of national health systems. It is designed to ensure safe, affordable, and timely access to essential surgical and anaesthesia services, particularly in low- and middle-income countries (LMICs), where gaps in surgical care contribute significantly to preventable deaths and disabilities. NSOAPs form part of a broader global health agenda to integrate surgery and anaesthesia into universal health coverage.

Background and Context

Surgical care has long been overlooked in public health policies, with greater emphasis placed on infectious diseases and primary care. However, the Lancet Commission on Global Surgery (2015) revealed that approximately 5 billion people worldwide lack access to safe, timely, and affordable surgical and anaesthesia care. In LMICs, nine out of ten individuals cannot access even basic surgical services within two hours of travel.
The Commission identified six core indicators to measure surgical system performance:

• Access to timely essential surgery
• Specialist surgical workforce density
• Surgical volume
• Perioperative mortality rate
• Protection against impoverishing expenditure
• Protection against catastrophic expenditure

In response, the development of NSOAPs was recommended as a structured way for countries to align surgical and anaesthesia care with national health priorities and the Sustainable Development Goals (SDGs).

Objectives of NSOAP

The NSOAP aims to strengthen health systems by improving surgical, obstetric, and anaesthesia services through structured planning and implementation. Its major objectives include:

• Enhancing access: Expanding geographical and financial access to life-saving surgical care.
• Workforce development: Training and retaining skilled surgeons, obstetricians, anaesthetists, and allied health workers.
• Infrastructure strengthening: Building and equipping facilities capable of delivering essential surgical care.
• Improving safety and quality: Reducing perioperative mortality through standardised guidelines, protocols, and monitoring systems.
• Financial protection: Preventing patients from falling into poverty due to surgical costs.
• Integration with national policies: Embedding surgical and anaesthesia planning into national health strategies and universal health coverage frameworks.

Core Components of NSOAP

The design of an NSOAP is usually based on six domains that together address the full spectrum of surgical system strengthening:

1. Service delivery – Ensuring facilities are equipped and staffed to provide essential and emergency surgeries, particularly at district hospital level.
2. Workforce – Expanding and distributing the surgical and anaesthesia workforce through training programmes and equitable deployment.
3. Infrastructure – Strengthening hospitals with operating theatres, recovery rooms, sterilisation systems, electricity, and water supply.
4. Information management – Establishing health information systems to monitor surgical outcomes, workforce data, and performance indicators.
5. Financing – Securing sustainable funding mechanisms that support equitable and affordable surgical care.
6. Governance – Creating regulatory frameworks, leadership structures, and accountability mechanisms to oversee implementation.

Implementation and Global Adoption

Since 2015, several countries have adopted or are in the process of developing NSOAPs. Tanzania became the first country to officially launch an NSOAP in 2018, followed by Ethiopia, Zambia, Rwanda, and Nigeria, among others. These plans typically involve multi-stakeholder engagement, including ministries of health, professional associations, academic institutions, and international partners.
Key features of implementation include:

• Baseline assessments of surgical capacity and workforce distribution.
• Costing frameworks to estimate investment needs.
• Integration into health budgets to ensure sustainability.
• Partnerships with global organisations such as the World Health Organization (WHO) and the World Bank.

Advantages and Significance

The NSOAP model brings several advantages to national health systems:

• Provides a comprehensive roadmap to integrate surgery and anaesthesia into health planning.
• Promotes equity by prioritising rural and underserved populations.
• Strengthens resilience of health systems in responding to both routine and emergency surgical needs.
• Contributes to reducing maternal mortality, injury-related deaths, and neglected surgical conditions such as obstetric fistula and congenital anomalies.
• Aligns with universal health coverage goals by addressing both access and financial protection.

Challenges and Criticism

Despite its promise, NSOAP implementation faces challenges:

• Resource constraints: Many LMICs face limited financial resources, with competing health priorities such as infectious diseases.
• Workforce shortages: Retaining trained specialists in rural or resource-poor settings remains difficult.
• Data limitations: Weak health information systems impede effective monitoring of surgical outcomes.
• Political will: Sustained commitment at the highest levels of government is necessary but not always present.
• Equity concerns: Ensuring that marginalised groups truly benefit requires careful policy design and monitoring.

Link with Global Health Goals

The NSOAP framework is closely aligned with several global health agendas:

• Sustainable Development Goal 3.8: Universal health coverage.
• World Health Assembly Resolution 68.15 (2015): Strengthening emergency and essential surgical care.
• Primary Health Care revitalisation: By integrating essential surgery at district hospitals, NSOAPs contribute to strengthening primary healthcare.

Moreover, NSOAPs contribute to reducing mortality from non-communicable diseases, maternal and child health complications, and injuries, which together account for a significant proportion of global disease burden.

Significance for the Future

The National Surgical, Obstetric, and Anaesthesia Plan represents a transformative approach in global health planning by recognising surgery and anaesthesia as fundamental components of universal health coverage. By systematically addressing gaps in access, safety, and affordability, NSOAPs aim to reduce preventable deaths and disabilities while strengthening health systems.