Cleft Care Can Strengthen Entire Health Systems

Ernest Gaie, Senior Advisor Global Business Operations, Operation Smile

Operation Smile
6 min readJan 29, 2021

In 2015, the Lancet Global Health medical journal published a report that revealed an alarming five billion people do not have access to safe surgical care when they need it. Additionally, 17 million lives are lost every year from surgically treatable conditions.

Surgery is a critical component of an effective and responsive health care system. However, it remains unattainable to more than 80% of the world’s population.

Nine out of 10 people in low- and middle-income countries cannot access basic surgical care.

The global need for stronger surgical health care systems cannot be overemphasized. The unprecedented effect of COVID-19 in countries perceived to have sophisticated health systems like the U.S., Italy or China, proved that no health system is strong or complete without investment in building resilient and responsive systems.

The pandemic revealed that many countries lack the structure to respond to infectious disease outbreaks, without disruptions in the provision of other essential health care services like surgery.

Unfortunately for millions of children throughout the world, this includes cleft care.

Cleft Surgery is Essential Surgery

Even before COVID-19, the volume of patients requiring surgical care for cleft conditions was staggering. We estimate that there are between 3 and 5 million children waiting for surgery in the 34 countries where we currently work. Cleft surgery is not elective surgery.

Failure to correct cleft conditions at an early age can result in malnutrition, stunted growth and even starvation.

An infant with a cleft lip looks into the camera.
Our research has shown that infants born with cleft conditions have nine times the risk of dying within the first year of life.

Unfortunately, based on my field experience, I’ve found that health systems in the majority of low-and middle-income countries (LMICs) aren’t built to diagnose, manage and treat children born with cleft lip and cleft palate.

Because of this, children with cleft conditions are often overlooked or are not properly diagnosed or referred to a specialist.

In many LMICs where the incidence and prevalence of cleft remain high, the condition is often considered a form of spiritual retribution or curse from ancestors or gods. These beliefs further victimize mothers who are already enduring shame and stigma.

Therefore, the children do not get surgery. They don’t attend school or have the opportunity grow up to pursue a career or participate in society.

The Economic Impact of a Lack of Access to Surgery

The economic impact of an untreated cleft condition should be a huge motivator for government bodies to prioritize investments in surgical health system strengthening. But cleft conditions are only one of the many neglected surgically treatable conditions that occur in LMICs.

Empirical research has shown how such investment could enhance social, economic and political development for individuals and the communities they live in. Consider:

  • A child born with a cleft lip in a country where they don’t receive treatment may grow up to be stigmatized in their community. For that reason, they may drop out of school. Their potential to get an education and skills to contribute to the economy is lost in part because they did not receive surgical care.
  • Similarly, someone is severely injured in a road traffic accident who does not receive quality and affordable surgical care may become disabled. As a result, they are unable to continue working to provide for their self or their family.

Thousands of such cases at a national level have drastic effects on economic growth. I assert that when a government invests in strengthening surgical systems in their country, economic growth will follow.

A group of children raise their hands in a classroom.
We have made significant progress in improving access to surgery for children with cleft in the countries where we work. Enabling kids like Nazifa to return to school and pursue a brighter future.

Cleft Care Provision Can Help Build National Health Policy

A national health policy defines the health priorities of a country’s government. They are intentional statements that identify the current gaps in a health system and define a plan to address those gaps at a national level.

Engaging and partnering with countries at a health policy level presents Operation Smile with opportunities to expand the impact of our work to entire populations. We use our almost 40 years of experience and influence in these partnerships to demonstrate the significance of investing in cleft care as a tool for strengthening entire surgical health systems.

By making investments to identify, prevent and treat cleft conditions, we are investing in systems to identify, prevent and treat other surgically treatable conditions. By prioritizing cleft, governments are prioritizing the entire health system.

Strengthening The Health Care Workforce Through Cleft Care

This focus on strengthening health systems through cleft surgeries isn’t a change in the way we work, it’s an expansion and deepening of our approach.

We have long focused on innovating and building the capacities of national health systems and workforces in the countries where we work. We know the value of these investments because we’ve seen the impact they can create:

  • Global essential surgery projects in Nicaragua and Vietnam that aim to strengthen the capacity of hospitals to deliver ongoing surgical care to the community.
  • Partnerships with the governments of Rwanda and the Federal Republic of Ethiopia to create hands-on educational training programs for surgery and anesthesiology residents.
Medical professionals observe a surgeon during an operation.
We prioritize training and education because one of our core beliefs is that today’s students are tomorrow’s leaders.
  • A partnership with the American Heart Association that has trained more than 10,000 healthcare workers in basic life support.
  • Collaborating with the Madagascar Ministry of Public Health to implement a National Surgical, Obstetric and Anesthesia Plan (NSOAP) that was launched in May 2020. It’s the first policy in Madagascar that comprehensively aims to improve access to quality surgical care for all citizens.

Cleft Care Changes The Way Health Systems Work

One of the core building blocks of the health system is financing. To successfully strengthen health systems, organizations must integrate efforts nationally. Scaling up surgical systems requires significant resources.

The Lancet estimates that about $300 billion is needed to scale up surgical systems in developing countries by the year 2030.

That is a lot of money.

To put this in perspective, between 2007 and 2013 all charitable organizations in the U.S. focused on surgical care delivery and health systems strengthening, including Operation Smile, spent about $2.5 billion.

A crowd of families waiting for a health screening at an Operation Smile mission in the Philippines
The need is great, but we’re committed to working until every child with a cleft condition has access to the surgical care they deserve.

It’s time for a radical paradigm shift in the way health care systems are structured and surgical care is provided, because if nothing changes, traditional health systems will never be able to meet existing surgical needs. It’s time for a coalition of governmental and nongovernmental organizations to invest in surgery as a fundamental component of the universal health coverage.

We call on international development colleagues, global philanthropists, corporate manufacturers of pharmaceuticals and medical equipment and devices, leaders from developing countries, and corporations to join Operation Smile and increase their financial support to help build stronger surgical health systems around the world.

Headshot of Ernest Gaie, Senior Advisor Global Business Operations, Operation Smile
Ernest Gaie, Senior Advisor Global Business Operations, Operation Smile

Ernest brings 20 years of field-based experience working with nonprofit organizations primarily in Sub Saharan Africa. He brings extensive expertise in designing, implementing and managing complex and diverse teams; regional and country programs; and strategy evaluation, development and improvement. Ernest is a proud recipient of the Clinton Global Health Initiative for his outstanding leadership and management of Africare’s response to the Ebola epidemic in Liberia, that spread internationally, claiming nearly 16,000 lives between 2014 and 2015. Ernest also supported Liberia’s Ministry of Health and other partners to rebuild its health system post war. He was a lead contributor in the design of Liberia’s national health policy and championed the implementation of its decentralization policy. Ernest is an expert in cultivating strategic relationships with national governments, ministries of health and regulatory bodies as well as strategic partners including bilateral (USG, Irish Aid, DfID, Japanese International Cooperation Agency, Canadian International Development Agency), multilateral (World Bank, African Development Bank, relevant UN Agencies) and international charitable foundations. At Africare, Ernest lead regional development efforts, raising $40 million USD in just four years. Ernest is also a proud member of Rotary International



Operation Smile

We are a global nonprofit bridging the gap in access to essential surgeries & healthcare, starting with cleft surgery and comprehensive care.