Operation Smile Eradication “Mega Mission in Nicaragua November 2016”

Project location: NICARAGUA, Managua and Esteli
Project start date: March 2016 - Project end date: December 2016
Project number: 2016-010
Beneficiary: Fondazione Operation Smile Italia Onlus

Only 4% of an estimated 234 million surgical procedures performed each year go to the poorest third of the global population.

More than one-quarter of the world's death and disability could be alleviated through surgical intervention. The potential impact of surgery starkly illuminates the suffering of those who lack access to it: a family without income after a hand injury, a mother succumbing to an enlarging breast mass, or burn victims shunned for their disfigurement. In low and middle income countries (LMICs), it is believed that the surgical burden of disease is even higher and it is estimated that approximately two billion people lack access to surgery. The facts are staggering: each year more people die because of lack of access to surgical care than from HIV/AIDS, tuberculosis, and malaria combined.

Even when surgical care is available in LMICs, safety is a serious problem. Unsafe surgery causes an estimated one million deaths and seven million complications each year. Going into surgery in a resource poor environment means that a person's risk of anesthesia-related mortality is 100 to 1,000 times higher than if that procedure were performed in a high income country. This points to significant lack of equitable access to safe anesthesia and safe surgical care.

Surgery has historically been a neglected area of investment in global public health, as it has incorrectly been assumed to be an expensive, complex intervention that is difficult to deliver. This has created the misperception that surgery is merely a luxury in resource-limited environments. In the last decade, however, clinicians, public health experts, policy makers and researchers have realized that surgery is a cost-effective intervention and a critical strategy for improving health in LMICs. Together, we must dispel the belief that surgery is a luxury in resource limited environments. Otherwise, the consequence will be death and disability for millions who remain without access to essential surgical care.

Over the last 33 years, Operation Smile has learned that if we break surgery down into its component parts (ie. The surgeon, anesthesiologist, nurses - operating, pre-operative post-operative, the equipment, etc.), then we can manage, educated, and deliver a high quality product with relative ease. Our knowledge base comes from the combination of working directly in the field, caring for over 250,000 patients, and the experience of our collective staff and medical volunteers, as opposed to an approach which is purely academic.

Operation Smile is wholly dedicated to serving all individuals in need of high quality treatment - that's why the organization's Global Standards of Care ensure quality care to every child, every time, and are rigorously followed by medical volunteers during each program. They include requirements for screening, anesthesia equipment and supplies, surgical equipment and pre- and post-operative protocols. Our volunteer team will include plastic surgeons, anaesthesiologists, paediatricians, nurses, speech pathologists and other credentialed health professionals.

Over the past 30 years, OS have worked to reimagine what the world would look like if every child in a resource poor environment had access to surgical care. From the beginning, we had the audacity to believe that it was possible to bring high quality surgical care to places where many individuals had never even visited a doctor. That work continues today, as we deliver much needed surgical care for cleft lip and cleft palate to those in need.

Operation Smile recognizes the implications of all this on patients and the critical need to address the barriers that prevent someone from receiving surgery. Indeed, since 1982, we have worked to improve the global availability of equipment and supplies, as well as deliver hands-on training and educational programs for local medical professionals so they can provide treatment within their own communities and share their expertise. By supporting local health systems, our objective is to mitigate financial, social and geographic obstacles, such as transportation costs and lodging expenses, which hinder a patient's ability to seek care.
Operation Smile has the expertise to create a lasting impact for the patients it serves and influence global healthcare. By taking a patient-centric approach, we focus on three key areas to increase access to patient care in resource- poor environments.

BACKLOG ERADICATION
Operation Smile understands the consequences of living life with a cleft condition and the dramatic difference it can make to receive this intervention earlier in life as a child. While we are capable of addressing the new caseload of patients each year in many of our mission and care center-based locations, these efforts are not capable of providing care for the backlog of patients who need surgery. We will implement prevalence studies to determine the unmet need of surgical care, utilize national registries to schedule patients for care, and will deploy large-scale missions and surgical programs to eradicate this backlog. We are devoted to expanding resources over the next five years to eradicate the patient backlog in seven target countries, including Cambodia, Thailand, Vietnam, Dominican Republic, Guatemala, Honduras and Nicaragua.

INCREASING SURGICAL CAPACITY
As leaders in the provision of surgery in resource-poor environments, we understand that a focus solely on cleft will create an unbalanced health system for the communities and patients we serve. With our strong medical volunteer network and stringent focus on safety through our Global Standards of Care, Operation Smile is well-positioned to increase the surgical capacities for the countries in which we work. Through training and education programs, partnering with local hospitals, governments, and Ministries of Health, and through expanding our focus beyond cleft, more local medical professionals will be able to provide critical, life-changing surgeries to those who have the most need, elevating the surgical capacities of countries on a global scale.


SUSTAINED ACTIVITY

Operation Smile mobilizes thousands of credentialed medical volunteers to provide effective treatment programs in more than 60 countries. For more than 30 years, this work has demonstrated that the organization is adept at leveraging core competencies to provide care for the most marginalized patients. Expanded resources will ensure these efforts continue to restore hope for the life of our patients worldwide.

Operation Smile has learned a great deal over the past three decades. We have grown into a truly global organization, increasingly aware of the challenges facing those without access to surgical services and cognizant of the incredible amount of disability that results. We have learned to listen to our patients, acknowledging the complex environments in which the poor live and understanding that increasing access to healthcare only truly matters if it is congruent with and responsive to the needs of patients and delivered in a manner consistent with patients' needs, culture and constraints. Operation Smile is committed to providing patient-centered care, ensuring that our services are delivered in a way that creates equitable access and addresses barriers that so often leaves those with facial deformities marginalized and unable to gain access to much needed care.

As leaders in the provision of surgery in resource-poor environments, we understand that a focus solely on cleft will create an unbalanced health system for the communities and patients we serve. With our strong medical volunteer network and stringent focus on safety through our Global Standards of Care, Operation Smile is well-positioned to increase the surgical capacities for the countries in which we work. Through training and education programs, partnering with local hospitals, governments, and Ministries of Health, and through expanding our focus beyond cleft, more local medical professionals will be able to provide critical, life-changing surgeries to those who have the most need, elevating the surgical capacities of countries on a global scale.
For many of the smaller countries that Operation Smile operates in, as Nicaragua, our investment in missions, education and training, and centers has contributed to developing a health care system that is adequate for meeting the needs of new caseload (e.g. babies born every year with cleft lip and cleft palate), but is not capable of addressing the backlog of patients who have not received care. Our organizational approach for countries like Nicaragua is to eradicate the backlog of cleft lip and cleft palate patients in the next 5 years.

Our first step towards eradicating the backlog is to understand what the backlog is. This will be achieved by conducting "Prevalence Studies" that will allow is to develop national models of how many patients are still waiting for treatment and will also give insight into the specific challenges they have in accessing care. Once the backlog is measured, we will conduct large programs that utilize the global resources of Operation Smile. The program models will include "Mega missions" where up to 1.000 patients can be treated in a short period of time, establishing temporary hospitals, or building temporary centers of care.
Our proposed organizational approach for these countries is to eradicate the backlog of cleft lip and cleft palate patients in the next five years. Operation Smile will conduct appropriately scaled programs that utilize the global resources of Operation Smile to ensure that patients in need of care receive treatment from experts in this field, both within Nicaragua and around our world. The goal is that once the backlog has been eradicated the national health infrastructure, inclusive of Operation Smile, will take care of the new caseload and address any ongoing health needs of the treated population.

NICARAGUA

Nicaragua is one of four countries in the Latin and Central America region that has been targeted for cleft eradication. Recent meetings with the Nicaraguan Ambassador and the foundation's Board of Directors have escalated this initiative to the top leadership circles within Nicaragua, so that cleft eradication may take the national stage. The eradication strategy is comprised of several key initiatives, including education programs, prevalence studies, national registries, and large scale surgical programs.

The summit for the adoption of the post-2015 development agenda held from September 25th to 27th in New York represents a peculiar moment in Operation Smile history. It was convened as a high-level plenary meeting of the United Nations General Assembly (UNGA) and represented a unique opportunity to advocate for the importance of access to surgery as a global public health priority and to highlight the ongoing work of Operation Smile and the government of Nicaragua. During the summit, the Nicaraguan Ambassador to the UN publicly stated the importance of increasing access to safe surgical care. Operation Smile continues to lobby for support of the ratification of the Sustainable Development Goals (SDGs) and the inclusion of surgery as a component of Universal Health Coverage amongst its strongest partner countries.

The Nando and Elsa Peretti Foundation has awarded a grant for this project. Working together, OS believes that it is possible to ensure that every child with a cleft lip and/or palate in Nicaragua has access to care.

Operation Smile's programmatic capabilities represent knowledge developed from conducting programs across the globe. The implementation science of Operation Smile is extraordinarily valuable to understand future program innovations of Operation Smile as well as valuable to other organizations that are trying to develop programs. Our ability to measure and describe our implantation science will benefit many people in need.

In Nicaragua, Operation Smile plans to screen around 800 patients, provide them with free medical examinations and upwards of 200 patients receiving surgery with the help of a team of several international volunteers. Our volunteer team will include plastic surgeons, anaesthesiologists, paediatricians, nurses, speech pathologists and other credentialed health professionals.

Operation Smile's experience in delivering surgical care in diverse and challenging settings has resulted in robust strategy for creating, utilizing and managing documentation including medical records. The diverse geography and environments in which medical missions are conducted and the associated legal requirements and cultural sensitivities have helped define Operation Smile's documentation solutions. In the near future, these solutions will also integrate various technologies including electronic health records, encryption and other digital strategies.
Operation Smile continues to develop and review prospective and retrospective data collection and analysis approaches for this standard.

- Fact Finding Checklist
- Biomed Report

In accordance with the World Health Organization, Operation Smile believes that the delivery of safe surgical care is an essential health service that should be accessible through any functioning health system. Together with Operation Smile's patients, it seeks to become a leader in advocating for the increased availability of safe surgery. Over and over again we see the dramatic need for surgery being outpaced by available capacity. Those excluded from care are often marginalized and voiceless and through an advocacy platform Operation Smile seeks to make our patients' voices heard.OS's  experience has not only demonstrated the dramatic need for surgery, but also offers a viable, cost-effective platform for the scale up of surgical services worldwide. The lack of political commitment by low and middle income country governments may be the single most important factor related to why surgical services have been a neglected health priority, and Operation Smile is committed to advocating for the inclusion of safe surgery as an essential health care service.


Fondazione Operation Smile Italia Onlus
think global, act local
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