InciSioN Australasia Position Statement on Global Surgery

Safe, timely and affordable surgical, obstetric and anaesthesia care for all

International Student Surgical Network (InciSioN) Australasia
Australasian Students’ Surgical Association — Global Surgery Committee
Australia and Aotearoa New Zealand

Authors: Gihwan Song, Josephine Oehler, Isaac Lawrence, Joanna Ho, Kristia Paras, Wei Tian Teo, and Audrey Nakagawa

Adopted by: InciSioN Global & Australasian Students' Surgical Association, November 2025
Revised and endorsed: September 2026
Next scheduled review: September 2029
Document owner: InciSioN Australasia Global Surgery Committee

Summary of Positions

  1. Safe, timely and affordable surgical, obstetric and anaesthesia (SOA) care is an essential component of universal health coverage.
  2. Governments in Australasia and the Pacific should embed SOA care in national health planning, with dedicated financing and measurable targets.
  3. Improvements in surgical care for Aboriginal and Torres Strait Islander peoples and Māori must be led by First Nations communities, grounded in self-determination, co-design and Indigenous data sovereignty.
  4. Engagement with Pacific Island health systems must be long-term, reciprocal and led by Pacific institutions and clinicians, with a focus on workforce development.
  5. Student and trainee involvement in global surgery must be ethical, supervised and governed; learners must never practise beyond their competence or in ways that would be unacceptable at home.
  6. Surgical systems should be measured using internationally recognised indicators, adapted to local context and disaggregated to reveal inequity.
  7. The SOA workforce, including anaesthetic, obstetric, nursing and perioperative staff, requires deliberate investment in training, retention and equitable distribution.
  8. Innovation in surgical care should be driven by end users, evaluated responsibly, and designed for climate resilience and environmental sustainability.

1. Purpose and Scope

This statement sets out the positions of InciSioN Australasia on global surgery, the field of study, research, practice and advocacy that seeks to improve health outcomes and achieve health equity for all people who need surgical, obstetric and anaesthesia care.1,2 It is written for governments and health ministries in Australia, Aotearoa New Zealand and the Pacific; for surgical, anaesthetic and obstetric colleges; for universities and medical schools; and for the students and junior doctors who make up our membership. It states what we believe, what we ask of others, and what we commit to doing ourselves. In this statement, ‘the Pacific’ refers to the Pacific Island countries and territories, including Papua New Guinea; ‘First Nations peoples’ refers collectively to Aboriginal and Torres Strait Islander peoples in Australia and to Māori in Aotearoa New Zealand, and we name each specifically where the distinction matters.

Throughout this document, “surgical, obstetric and anaesthesia (SOA) care” refers to the full continuum of care surrounding an operation or procedure: emergency and essential surgery, safe anaesthesia, obstetric intervention, perioperative nursing, and the referral, critical care and rehabilitation systems that make each of these safe. This framing is consistent with the World Health Organization’s integrated approach to emergency, critical and operative (ECO) care, which treats these services as one connected system.3

2. Background

An estimated five billion people cannot access safe, timely and affordable surgical and anaesthesia care when they need it, and about 143 million additional surgical procedures are needed in low- and middle-income countries each year to avert death and disability.4,5 In 2010, conditions requiring surgical care accounted for an estimated 16.9 million deaths worldwide — more than HIV, tuberculosis and malaria combined.4,6 These findings, published by the Lancet Commission on Global Surgery in 2015, reframed surgery from a luxury of wealthy health systems to an indivisible part of universal health coverage.4

The same year, the World Health Assembly adopted resolution WHA68.15, committing member states to strengthen emergency and essential surgical care and anaesthesia as a component of universal health coverage.7 In 2023, resolution WHA76.2 extended this commitment to integrated emergency, critical and operative care, explicitly linking surgical systems to health emergency preparedness, resilience and financial protection.3 In the Western Pacific, Member States adopted a regional Action Framework for Safe and Affordable Surgery (2021–2030) in 2020, on the premise that there can be no universal health coverage without access to safe and affordable surgery.8 The policy mandate for global surgery is therefore settled at the highest level of international health governance. What remains unfinished is implementation. Ten years on from the Commission, progress towards its 2030 targets has been slow and uneven, the unmet need for surgery has grown to at least 160 million operations a year, and most national surgical plans remain unfunded.9

Many Pacific Island countries have surgical and anaesthesia workforce densities far below the thresholds associated with adequate access, and depend on small teams, visiting specialists and overseas referral for complex care.10,11 In a collaborative survey of 14 South Pacific countries, only four met the Lancet Commission benchmark of 20 specialist surgical, anaesthetic and obstetric providers per 100,000 population; a 2020–21 assessment of five Pacific Island countries found specialist densities of 5.0 per 100,000 in Vanuatu, 7.1 in Fiji and 9.9 in Tonga, and a single anaesthetist serving each of Palau and the Cook Islands.12,13 Within Australia and Aotearoa New Zealand, Aboriginal and Torres Strait Islander peoples and Māori communities continue to experience later presentation, delayed and lower intervention rates, differential access to treatment modalities and worse perioperative outcomes across a range of surgical conditions.14–19 Global surgery, properly understood, includes the unfinished work of surgical equity at home.

Students and junior doctors have played a visible role in the global surgery movement since its beginning, through advocacy, research and education. That involvement carries obligations, because the duty of justice — one of the four principles of biomedical ethics20 — is inseparable from the goals of the movement. This statement sets out how we believe it should be done.

3. Guiding Principles

  • Equity. Access to safe surgical care should not depend on geography, income, Indigenous status or ethnicity. National averages that conceal inequity are not success.
  • Local leadership. Communities and health systems define their own priorities. External partners and governments contribute to locally led plans.
  • Safety and quality. Expanding access without safety causes harm.21,22 Volume, safety and quality must improve together.
  • Reciprocity. Partnerships must benefit both parties on terms both parties set, with honest accounting of who bears the costs and who benefits.
  • Accountability. Positions and commitments mean little without measurement, reporting and review. We apply this standard to ourselves as well as to others.
  • Sustainability. Surgical systems must be financially, environmentally and workforce-sustainable, and resilient to climate-related and other shocks.

4. Positions

Position 1: Surgical care is essential to universal health coverage

InciSioN Australasia holds that SOA care is a core component of universal health coverage and of the health-related Sustainable Development Goals.4,7 Health systems that cannot deliver a caesarean section, a laparotomy or the management of an open fracture (the Lancet Commission’s three Bellwether procedures) safely and promptly are not providing universal coverage, whatever their other strengths.4 Surgery is sometimes described as too expensive or too complex for resource-limited settings. The evidence shows the opposite, essential surgical care is among the more cost-effective health investments available.23,24

Position 2: National planning and financing

We call on governments in the region to embed SOA care within national health strategies, using mechanisms such as National Surgical, Obstetric and Anaesthesia Plans (NSOAPs)25,26 or equivalent integrated planning processes, and to attach dedicated budget lines to them. Plans without financing are aspirations.9 In the Pacific, planning processes should be owned by national ministries, with development partners, including Australia and Aotearoa New Zealand, aligning support behind them.8 A review of the national health plans of ten Pacific Island countries, Papua New Guinea and Timor-Leste found only limited reference to surgical and anaesthesia care and no surgical outcome metrics; the Western Pacific Action Framework now offers a regional template for correcting this.8,27

Position 3: First Nations surgical equity and self-determination

Surgical inequity experienced by Aboriginal and Torres Strait Islander peoples and by Māori is a global surgery issue within our own health systems. We hold that closing these gaps requires more than “equity considerations” appended to mainstream programmes. It requires First Nations leadership and co-design at every stage, consistent with the United Nations Declaration on the Rights of Indigenous Peoples,28 the Priority Reforms of the National Agreement on Closing the Gap29 and the Crown’s obligations under Te Tiriti o Waitangi30; investment in First Nations surgical, anaesthetic and perioperative workforces; culturally safe perioperative care;31 and respect for Indigenous data sovereignty,32–34 so that data about First Nations peoples are governed by First Nations peoples. Reporting of surgical access and outcomes should be disaggregated by Indigenous status or ethnicity as a matter of routine, under governance arrangements agreed with the communities concerned.14 Research and audit involving First Nations patients should follow published guidance on Indigenous governance of surgical research and on the reporting of research involving Indigenous peoples.35,36

Position 4: Pacific partnership

Australasian engagement with Pacific surgical systems has a long history, including sustained specialist training partnerships alongside shorter-term visiting programmes.37–39 We take the position that the future of this engagement must be Pacific-led.8 Priorities, models of care and training pathways should be determined by Pacific institutions, regional bodies and clinicians. External contributions are most valuable when they build permanent local capacity — accredited training positions, retention support, equipment maintenance, referral systems — and least valuable when they deliver episodic services that displace or demoralise local providers. Short-term surgical visits can have a place, but only within long-term relationships, at the invitation of local services, and with follow-up arrangements agreed in advance.40

Position 5: Ethical engagement by students and trainees

Student enthusiasm for global surgery is an asset, but it has sometimes been expressed in ways that cause harm: electives treated as adventure tourism, learners performing procedures abroad that they would never be permitted to perform at home, and partnerships in which all the benefit flows to the visitor.41–43 InciSioN Australasia does not support these practices in any form.

We hold that all student and trainee involvement in global surgical settings must meet the following minimum standards, consistent with published ethical guidance for global health training:43–45

  • Learners practise only within their competence, under supervision, and to the same standard of consent and safety that would apply in their home institution.
  • Placements occur within established institutional partnerships with defined governance.
  • Pre-departure preparation covers clinical limits, ethics, cultural safety and the history and politics of the setting; structured debriefing follows.
  • Reciprocity is built in, including bidirectional exchange, authorship and credit for local collaborators, and priorities set by the host institution.
  • The costs imposed on host institutions (supervision time, infrastructure, patient goodwill) are acknowledged and, where appropriate, compensated.

Position 6: Measurement that reveals inequity

We support the use of internationally recognised surgical system indicators, including timely access to essential surgery, workforce density, surgical volume, perioperative mortality,46 and protection against impoverishing and catastrophic expenditure,47 as a shared language for assessing progress.4,48 These indicators are most useful when adapted to local context and interpreted together. Wherever they are collected, they should be disaggregated by geography, income and Indigenous status, because system-level averages routinely conceal the inequities this movement exists to address. Reporting of these indicators remains sparse and uneven worldwide, yet the Pacific has already shown that collaborative collection across small island states is feasible.12,49

Position 7: Workforce

A surgical system depends on its whole workforce: surgeons, anaesthesia, obstetrics, nursing and perioperative staff.10,11,50 We call for deliberate investment in training and retaining this whole team, with particular attention to rural and remote distribution, to Pacific-based training pathways that allow clinicians to qualify without permanent emigration,38 and to the workforce aspirations of First Nations communities. Recruitment of clinicians from Pacific health systems by wealthier neighbours, whether through active recruitment or through the pull of better-resourced systems, should be honestly acknowledged as a cost to those systems and managed in line with the WHO Global Code of Practice on the International Recruitment of Health Personnel.51,52 Seven Pacific Island countries (Kiribati, the Federated States of Micronesia, Papua New Guinea, Samoa, Solomon Islands, Tuvalu and Vanuatu) appear on the WHO Health Workforce Support and Safeguards List, which discourages active international recruitment from the countries listed.53

Position 8: Responsible innovation and climate resilience

Innovation in surgical care, whether in devices, techniques, digital tools, should begin with the problems defined by the clinicians and patients who will live with the solutions, and should be evaluated through staged, transparent frameworks before wide adoption.54,55 We are cautious about technologies designed elsewhere and deployed into low-resource settings without local evidence, maintenance pathways or exit plans. Surgical systems must also be planned for a changing climate: resilient to extreme weather and supply disruption,56,57 and attentive to the significant environmental footprint of surgical and anaesthetic care itself.58,59

5. Calls to Action

To the governments of Australia and Aotearoa New Zealand

  • Embed SOA care explicitly in bilateral and regional health assistance to the Pacific, aligned behind nationally owned plans.60
  • Fund long-term workforce partnerships, including regional training positions and retention support, in preference to episodic service delivery.38,40
  • Report disaggregated surgical access and outcomes for First Nations peoples routinely, under Indigenous data governance arrangements.29,33

In support of Pacific governments and regional bodies

  • We support the continued assertion of national ownership of surgical system planning, and will hold ourselves and other external partners to alignment with it.8
  • We support the inclusion of SOA indicators in national health information systems, adapted to local priorities.12,49

To surgical, anaesthetic and obstetric colleges

  • Sustain and expand accredited training pathways in and for the Pacific, co-governed with Pacific institutions.38
  • Set and enforce standards for member participation in short-term international surgical activity.40,45
  • Grow First Nations membership and leadership within the surgical professions through funded, accountable programmes.

To universities and medical schools

  • Require structured pre-departure training, supervision agreements and debriefing for all international clinical placements, with specific emphasis on ethical conduct.43,44
  • Decline to recognise, for academic credit, placements arranged outside accountable institutional partnerships.
  • Support global surgery teaching and research that includes, and fairly credits, collaborators in partner institutions.

What InciSioN Australasia commits to

  • Advocating consistently for the positions in this statement in national and regional forums.
  • Educating our members on ethical engagement and declining to promote opportunities that fall short of the standards in Position 5.
  • Partnering with First Nations and Pacific student and clinician organisations on their terms, including shared platforms and credit.

6. Implementation and Review

The statement will be formally reviewed no later than September 2029, or earlier if a major change in international policy warrants it. The review will assess both the currency of the positions and our own performance against the commitments in Section 5.

Declaration of interests and funding

The authors hold committee roles within InciSioN Australasia and/or the Australasian Students’ Surgical Association Global Surgery Committee. No additional competing interests relevant to this statement were declared. No funding was received for the preparation of this statement.

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