HENRY Ford, when unveiling the Model T, was asked why he developed an automobile without consulting public demand. His response, “If I had asked people what they wanted, they would have said faster horses.”

This anecdote highlights the essence of forward-thinking innovation. It is especially pertinent to the debate in Pakistan’s healthcare system about integrating robotic surgical systems in public hospitals. Critics, focusing on economic constraints, advocate for prioritising basic healthcare services. This perspective, while mindful of fiscal responsibility, overlooks the comprehensive nature of healthcare advancement and the diverse benefits of integrating advanced technologies.

Robotic surgery, often perceived as a luxury, is in fact a critical step towards healthcare modernisation. These systems, renowned for their precision and efficiency, promise improved outcomes, quicker recovery, and reduced complications, significantly impacting both individual and economic stability. This technology is a gateway to the digital transformation of surgical practice. With platforms like Proximie, surgeons, even in resource-limited settings, can access global expertise via a smartphone, democratising surgical education and enhancing patient safety. By adopting robotic surgery, Pakistan steps into a future where digital surgery enhances outcomes and broadens access to top-tier medical care.

The trajectory of robotic surgery in neighbouring India offers a compelling narrative for Pakistan. Since acquiring its first robot in 2006, India has established over 76 centres and trained more than 500 surgeons, a stark contrast to Pakistan’s five centres and a handful of trained surgeons since its first acquisition in 2011. India’s recent launch of its own surgical robot, the SSI Mantra, in early 2023 marks a significant milestone in transitioning from technology consumers to creators. A salient point to consider in our discussion on robotic surgery is its unique and well-documented benefits in certain types of surgeries. It’s important to recognise that while robotic surgery may not be a universal solution for all surgical interventions, it is particularly advantageous for specific surgeries routinely performed in tertiary care centres.

Robotic surgery, often perceived as a luxury, is in fact a critical step towards healthcare modernisation.

Robotic surgery excels in navigating challenging and hard-to-reach areas of the body, making it exceptionally beneficial in fields like urology, rectal surgery, gynecological oncology, treatment of other pelvic malignancies and thoracic cancers. For optimal outcomes, these procedures should ideally be conducted in high-volume, reputable centres.

Concentrating robotic surgeries in such settings not only helps in reducing costs and enhancing quality but also plays a crucial role in training the next generation of surgeons. This strategic approach leverages the technology where it’s most needed, ensuring both efficiency and excellence in specialised surgical care.

Criticism of robotic surgery’s cost and perceived modest benefits in high-income countries overlooks its vital role in LMICs, which bear 92% of the global surgical burden yet have limited access to such advanced technologies. Contrasting with the US, which holds 70% of the world’s robotic systems for only 5% of surgical volumes, LMICs’ need for this technology is acute. Robotic surgery in these regions could significantly reduce physician burnout, surgical site infections, and hospital stays, addressing a critical gap in surgical care. Embracing this technology is not just about cost; it’s about bridging a significant healthcare divide, aligning with the goals of global health equity and providing essential surgical care where it’s most needed.

Drawing from global experiences, such as the UK’s National Institute for Health and Care Excellence, one understands the intricate balance required in health technology assessment. NICE’s health technology assessment (HTA) policy, while focused on cost-effectiveness, has also been criticised for stifling innovation and yielding to political influence from authorities in power.

While these global insights are useful, LMICs like Pakistan need to develop their own nuanced approach to HTA, one that considers local healthcare needs and the potential long-term benefits of advanced technologies. Here, the conversation transcends the realms of technology and economics. It calls for examining governance and accountability in healthcare interventions.

The reality regarding maternal and child health in Pakistan is worth considering. The high maternal and child mortality rates in Pakistan have led the government and donors to identify maternal and child health as a priority on the health agenda. Over the last 20 years, a total of $225 million have been spent by foreign funded programmes to improve maternal and child outcomes. However, based on a recent BMJ study by Malik et al. hardly any tangible gains have been made so far. In contrast other South Asian countries like Bangladesh and Nepal have done significantly better.

Now compare this with the success of public sector institutions like NICVD and SIUT, which provide top-notch tertiary care at a fraction of the cost, or no cost at all, as compared to private providers or Western counterparts. These successes stem not from technology alone but from robust governance, stringent accountability, and a commitment to excellence. This demonstrates that the impact of advanced technologies is significantly influenced by the effectiveness of the governance structures within which they are implemented.

Amid debates over the cost of robotic surgery, it’s worth pondering the personal choices one would make when confronted with a serious health condition like prostate cancer. Would the critics of this technology, when faced with the decision for themselves or their loved ones, adhere strictly to their principled stance? Or would the undeniable benefits of minimally invasive, precise, and advanced care offered by robotic surgery sway their choice?

Furthermore, it provokes ethical reflection if critics, blessed with the means, choose to undergo robotic surgery abroad at considerable expense. Such a choice, while valid for an individual, raises an ethical conundrum. How can one justify denying the same advanced medical benefits to their less fortunate countrymen? This scenario highlights a deeper moral question: the responsibility of ensuring equitable access to the best available healthcare, irrespective of one’s economic status. It is a reminder that healthcare decisions, at their core, are not just about economics or technology, but fundamentally about equity and empathy.

The writer is a colorectal surgeon and chief of surgery at Virginia Hospital Centre in the Washington, D.C. area. He specialises in robotic surgery.

Published in Dawn, December 25th, 2023