Identifying critical gaps in research to advance global surgery by 2030: a systematic mapping review

Abstract Progress on surgical system strengthening has been slow due to a disconnect between evidence generation and the information required for effective policymaking. This systematic mapping review sought to assess critical research gaps in the field of global surgery guided by the World Health Organisation Health Systems building block framework, analysis of authorship and funding patterns, and an exploration of emerging research partnership networks. Literature was systematically mapped to identify, screen, and synthesize results of publications in the global surgery field between 2015 and March 2022. We searched four databases and included literature published in seven languages. A social network analysis determined the network attributes of research institutions and their transient relationships in shaping the global surgery research agenda. We identified 2,298 relevant studies out of 92,720 unique articles searched. Research output increased from 453 in 2015-16 to 552 in 2021-22, largely due to literature on Covid-19 impacts on surgery. Sub-Saharan Africa (792/2298) and South Asia (331/2298) were the most studied regions, although high-income countries represented a disproportionate number of first (42%) and last (43%) authors. Service delivery received the most attention, including the surgical burden and quality and safety of services, followed by capacity-building efforts in low- and middle-income countries. Critical research in economics and financing, essential infrastructure and supplies, and surgical leadership necessary to guide policy decisions at the country level were lacking. Global surgical systems remain largely under-researched. Knowledge diffusion requires an emphasis on developing sustainable research partnerships and capacity across low- and middle-income countries. A renewed focus must be given to equipping countries with tools for effective decision-making to enhance investments in high-quality surgical services

The Power of the Weak: How Informal Power-Sharing Shapes the Work of the UN Security Council

To what extent is the work of international organizations shaped by their most powerful members? Can minor powers influence the decisions taken by these organizations? This dissertation presents the argument that great powers engage in power-sharing in order to attain unanimity inside international organizations, which enhances compliance and increases the effect of the signals these organizations convey to the public. The pursuit of unanimity lends weight even to votes that are not needed for the adoption of a proposal under the formal rules. It enables minor powers to exert more influence inside international organizations than they could if the formal rules and/or the balance of material power between member states determined the outcome of decision-making in international organizations. An analysis of the UN Security Council tests this argument. The dissertation identifies a series of informal power-sharing practices in the Security Council, which systematically depart from the organization's formal rules, and which promote consensus and augment minor powers' influence far beyond what one would expect on the basis of the material capabilities and voting power of these states. In turn, these informal power-sharing practices are motivated by great powers' desire to attain unanimous support for the policies enacted in the Security Council, irrespective of the body's formal voting rules. Survey experiments demonstrate the rationale behind great powers' pursuit of unanimity. They show that a policy's endorsement by a united Security Council has a much larger signaling effect on public opinion than the policy's approval by a divided Council. Qualitative case studies and novel design-based causal inference that exploits natural experiments show that minor powers strongly influence the deployment of UN peace operations and UN counter-terrorism sanctions, and that minor powers also use their influence in the Council to attain side-payments. Minor powers' influence is particularly strong during crises, when great powers are most eager to secure small states' votes through power-sharing. Interviews with diplomats in seven countries and quantitative analyses of exogenous variation in minor powers' representation on the Security Council under pre-determined rotation rules trace minor powers' influence to informal power-sharing practices in the Council