Optimal Resources for Children's Surgical Care: Executive Summary

Childhood cancer surgery in low- and middle-income countries

This report summarizes the status of pediatric surgical oncology services in low- and middle-income countries. Factors such as surgical capacity and enablers, and barriers to providing pediatric surgical oncology services are discussed. A review of the literature was conducted to examine the evidence for the capacity of low- and middle-income countries to provide childhood cancer surgery services, focusing on general surgery. Unpublished, ongoing work and initiatives of international organizations are also described.

Adaptation and validation of the Children's Surgical Assessment Tool for Rwandan district hospitals

BACKGROUND/AIMS

Paediatric surgical care is a critical component of child health and basic universal health coverage and therefore should be included in comprehensive evaluations of surgical capacity. This study adapted and validated the Children's Surgical Assessment Tool (CSAT), a tool developed for district and tertiary hospitals in Nigeria to evaluate hospital infrastructure, workforce, service delivery, financing, and training capacity for paediatric surgery, for use in district hospitals in Rwanda.

METHODS

We used a three-round modified Delphi process to adapt the CSAT to the Rwandan context. An expert panel of surgeons, anaesthesiologists, paediatricians, and health systems strengthening experts were invited to participate based on their experience with paediatric surgical or anaesthetic care at district hospitals or with health systems strengthening in the Rwandan context. We used the Content Validity Index to validate the final tool.

RESULTS

The adapted tool had a final score of 0.84 on the Content Validity Index, indicating a high level of agreement among the expert panel. The final tool comprised 171 items across five domains: facility characteristics, service delivery, workforce, financing, and training/research.

CONCLUSION

The adapted CSAT is appropriate for use in district hospitals in Rwanda to evaluate the capacity for paediatric surgery. This study provides a framework for adapting and validating a comprehensive paediatric surgical assessment tool to local contexts in LMICs and used in similar settings in sub-Saharan Africa.

Surgery and the first 8000 days of life: a review

The first 8000 days of life, from birth to adulthood, encompasses critical phases that shape a child's health and development. While global health efforts have focused on the first 1000 days, the next 7000 days (ages 2-21) are equally vital, especially concerning the unmet burden of surgical conditions in low- and middle-income countries (LMICs). Approximately 1.7 billion children globally lack access to essential surgical care, with LMICs accounting for 85% of these unmet needs. Common surgical conditions, including congenital anomalies, injuries, infections, and pediatric cancers, often go untreated, contributing to significant mortality and disability. Despite the substantial need, LMICs face severe workforce and infrastructure shortages, with most pediatric surgical conditions requiring specialized skills, equipment, and tailored healthcare systems. Economic analyses have shown that pediatric surgical interventions are cost-effective, with substantial societal benefits. Expanding surgical care for children in LMICs demands investments in workforce training, infrastructure, and health systems integration, complemented by innovative funding and equitable global partnerships. Prioritizing surgical care within national health policies and scaling up children's surgery through initiatives like the Optimal Resources for Children's Surgical Care can improve health outcomes, align with Sustainable Development Goals, and foster equity in global health. Addressing the surgical care gap in LMICs will reduce preventable mortality, enhance quality of life, and drive sustainable growth, emphasizing surgery as an essential component of universal health coverage for children.

Children's surgery and the emergency, critical, and operative care resolution: Immediate actions to eliminate disparities in surgery, anesthesia, and perioperative care for all children

Around 1.7 billion children lack access to surgical care worldwide. To reinvigorate the efforts to address these disparities and support work to address global challenges in surgery, anesthesia, emergency, and critical care, the World Health Assembly passed World Health Organization Resolution World Health Assembly 76.2: Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies (ECO) in 2023. This resolution highlights the integral role of surgery, anesthesia, and perioperative care in health systems. However, understanding how best to operationalize this resolution is challenging. We review the ECO resolution and highlight points that the pediatric surgical and anesthesia community can leverage to advocate for its recommendations for operative care.

Understanding the Burden of Pediatric Traumatic Injury in Uganda: A Multicenter, Prospective Study

INTRODUCTION

Traumatic injury is responsible for eight million childhood deaths annually. In Uganda, there is a paucity of comprehensive data describing the burden of pediatric trauma, which is essential for resource allocation and surgical workforce planning. This study aimed to ascertain the burden of non-adolescent pediatric trauma across four Ugandan hospitals.

METHODS

We performed a descriptive review of four independent and prospective pediatric surgical databases in Uganda: Mulago National Referral Hospital (2012-2019), Mbarara Regional Referral Hospital (2015-2019), Soroti Regional Referral Hospital (SRRH) (2016-2019), and St Mary's Hospital Lacor (SMHL) (2016-2019). We sub-selected all clinical encounters that involved trauma. The primary outcome was the distribution of injury mechanisms. Secondary outcomes included operative intervention and clinical outcomes.

RESULTS

There was a total of 693 pediatric trauma patients, across four hospital sites: Mulago National Referral Hospital (n = 245), Mbarara Regional Referral Hospital (n = 29), SRRH (n = 292), and SMHL (n = 127). The majority of patients were male (63%), with a median age of 5 [interquartile range = 2, 8]. Chiefly, patients suffered blunt injury mechanisms, including falls (16.2%) and road traffic crashes (14.7%) resulting in abdominal trauma (29.4%) and contusions (11.8%). At SRRH and SMHL, from which orthopedic data were available, 27% of patients suffered long-bone fractures. Overall, 55% of patients underwent surgery and 95% recovered to discharge.

CONCLUSIONS

In Uganda, non-adolescent pediatric trauma patients most commonly suffer injuries due to falls and road traffic crashes, resulting in high rates of abdominal trauma. Amid surgical workforce deficits and resource-variability, these data support interventions aimed at training adult general surgeons to provide emergency pediatric surgical care and procedures.

Children's surgery and the emergency, critical, and operative care resolution: immediate actions to eliminate disparities in surgical anesthesia and perioperative care for all children

1.7 billion children lack access to surgical care worldwide. The emergency, critical, and operative care (ECO) resolution represents a call to action to reinvigorate the efforts to address these disparities. We review the ECO resolution and highlight the avenues that may be utilized in advocating for children's surgical care.

A review of twenty-first century developments in paediatric surgery in Africa

This review explores the significant advancements in paediatric surgery in Africa during the twenty-first century, with a particular focus on capacity-building, education, infrastructural development, and research. Historically, paediatric surgery has been an overlooked sector, especially in low-and-middle-income countries in Africa. However, recent years have seen considerable progress. Collaborative efforts such as the Global Initiative for Children's Surgery, and the formation of the Pan African Paediatric Surgery Association, the College of Surgeons of East, Central and Southern Africa and the West African College of Surgeons have facilitated knowledge sharing, collaboration, and advocacy for enhancing surgical standards. Local training programmes, including Master of Medicine programmes and fellowships, have been instrumental in building a skilled workforce. These initiatives have been complemented by infrastructural developments through non-governmental organisations like Kids Operating Room, which have expanded access to paediatric surgical care. Technological advancements, particularly in telemedicine, have further enhanced accessibility. Task-sharing strategies, where non-specialist physicians are trained in paediatric surgical skills, have also been utilised to address the shortage of specialised surgeons. Research in paediatric surgery has experienced an upswing, with local health professionals taking the lead. Research has been crucial for understanding the epidemiology of paediatric surgical conditions, and developing prevention strategies, and is increasingly leading to the inclusion of paediatric surgery in national health plans. Despite the progress, challenges remain, including the need for sustainable funding, continued investment in infrastructure, and training and retention of healthcare professionals. The review emphasises the importance of ongoing efforts in community engagement, innovative technologies, and health systems strengthening for the sustainable development of paediatric surgical services in Africa.

Children's Anaesthesia and perioperative care challenges, and innovations

The 2015 Sustainable Development Goals emphasise good health to all with reduced inequalities, and surgical and anaesthesia care is essential to achieve these. https://sdgs.un.org/goals. However, it has been estimated that 1.7 billion children do not have access to safe anaesthesia and surgery when needed and this disproportionately affects children in low- and middle-income countries (1). It is alarming that 1 in 10 individuals in LMICs do not have access to safe surgical care. Both safe surgery and anaesthesia are essential for ensuring that individuals receive proper medical attention. Economically viable public health initiatives that can avert many disability-adjusted years are needed. (2-4) Morbidity and mortality from surgical disease and anaesthesia care remain high in low-income countries, unlike in high-income countries. The incidence of severe anaesthesia-related critical events and perioperative cardiac arrest is between three and ten times more in LMICs than in HICs (5-7) A baseline POMR that is 100 times higher in LMICs compared to HICs is reported. (8) This perioperative morbidity and mortality gap is more evident in neonates and younger age groups, especially in children with congenital abnormalities. The challenges facing providers of anaesthesia and perioperative care are multifactorial and include but are not limited to the inadequate workforce, inadequate and inappropriate infrastructure, lack of adequate and appropriately sized equipment, including monitors, and safe monitoring capacity, supply chain challenges for medicines and reusable consumables, unreliable supply of oxygen and blood products, lack of data and research for policy formulation, inadequate resource allocation from governments and lack of safety culture among other things. In paediatrics, this is further multiplied by the variability in the sizes of the patients, from neonates to older children (9).

The role of civil society and the voluntary sector in children's global surgery

An unacceptable inequity exists in the burden of pediatric surgical disease and access to surgical and anesthesia care between low- and middle-income countries (LMIC) and high-income countries (HIC). Civil society organizations (CSOs) and the voluntary sector have been integral in addressing this imbalance. This article summarizes the roles that these organizations have played in improving pediatric surgical care globally and how their roles have evolved over the years. CSOs and voluntary organizations have historically provided operations on LMIC patients; however, the focus has shifted to building sustainable surgical systems by training a skilled workforce, improving local infrastructure, and contributing to research and advocacy efforts.

Delivery of Safe Pediatric Anesthesia Care in the First 8000 days: Realities, Challenges, and Solutions in Low- and Middle-Income Countries

BACKGROUND

Worldwide, perioperative mortality has declined over the past 50 years, but the reduction is skewed toward high-income countries (HICs). Currently, pediatric perioperative mortality is much higher in low- and middle-income countries (LMICs) compared to HICs, despite studied cohorts being predominantly low-risk. These disparities must be studied and addressed.

METHODS

A narrative review of the literature was undertaken to identify contributing factors and potential knowledge gaps. Interventions aimed at alleviating the outcomes disparities are discussed, and recommendations are made for future directions.

RESULTS AND CONCLUSIONS

There is a lack of adequately trained pediatric anesthesia providers in LMICs, and the number must be bolstered by making such training available. Essential anesthesia medications and equipment, in pediatric-appropriate sizes, are often not available; neither are essential infrastructure items. Perioperative staff are underprepared for emergent situations that may arise and simulation training may help to ameliorate this. The global anesthesia community has implemented several solutions to address these issues. The World Federation of Societies of Anaesthesiologists (WFSA) and Global Initiative for Children's Surgery have published standards that outline essential items for the provision of safe perioperative pediatric care. Several short educational courses have been developed and introduced in LMICs that either specifically address pediatric patients, or contain a pediatric component. The WFSA also maintains a collection of discrete tutorials for educational purposes. Finally, in Africa, large-scale, prospective data collection is underway to examine pediatric perioperative outcomes. More work needs to be done, though, to improve perioperative outcomes for pediatric patients in LMICs.

Changing patterns in the burden of paediatric injuries during the COVID-19 pandemic: a study in Mozambique's central hospitals

INTRODUCTION

There is a substantial body of knowledge on the effects of the COVID-19 pandemic on injuries showing frequent but inconsistent reductions in both volume and pattern. Yet, studies specifically addressing children are less common, not least from low- and middle-income countries. This study investigated whether changes in the pattern and outcome of paediatric injury admissions to Mozambique's four regional referral hospitals during 2020.

METHODS

Clinical charts of paediatric patients presenting to the targeted hospitals with acute injuries were reviewed using a set of child, injury, and outcome characteristics during each of two consecutive restriction periods in 2020 using as a comparator the same periods in 2019, the year before the pandemic. Differences between 2020 and 2019 proportions for any characteristic were examined using the t-test (significance level 0.05).

RESULTS

During both restriction periods, compared with the previous year, reductions in the number of injuries were noticed in nearly all aspects investigated, albeit more remarkably during the first restriction period, in particular, greater proportions of injuries in the home setting and from burns (7.2% and 11.5% respectively) and a reduced one of discharged patients (by 2.5%).

CONCLUSION

During the restrictions implemented to contend the pandemic in Mozambique in 2020, although each restriction period saw a drop in the volume of injury admissions at central hospitals, the pattern of child, injury and outcome characteristics did not change much, except for an excess of home and burn injuries in the first, more restrictive period. Whether this reflects the nature of the restrictions only or, rather, other mechanisms that came into play, individual or health systems related, remains to be determined.

Assessment of essential surgical and anaesthesia care capacity: a cross-sectional study in five Pacific Island Countries

Background

Pacific Island Countries (PICs) face unique challenges in providing surgical care. We assessed the surgical care capacity of five PICs to inform the development of National Surgical, Obstetric and Anaesthesia Plans (NSOAP).

Methods

We conducted a cross-sectional survey of 26 facilities in Fiji, Tonga, Vanuatu, Cook Islands, and Palau using the World Health Organization - Program in Global Surgery and Social Change Surgical Assessment Tool.

Findings

Eight referral and 18 first-level hospitals containing 39 functioning operating theatres, 41 post-anaesthesia care beds, and 44 intensive care unit beds served a population of 1,321,000 across the five countries. Most facilities had uninterrupted access to electricity, water, internet, and oxygen. However, CT was only available in 2/8 referral hospitals, MRI in 1/8, and timely blood transfusions in 4/8. The surgical, obstetric, and anaesthetist specialist density per 100,000 people was the highest in Palau (49.7), followed by Cook Islands (22.9), Tonga (9.9), Fiji (7.1), and Vanuatu (5.0). There were four radiologists and 3.5 pathologists across the five countries. Surgical volume per 100,000 people was the lowest in Vanuatu (860), followed by Fiji (2,247), Tonga (2,864), Cook Islands (6,747), and Palau (8,606). The in-hospital peri-operative mortality rate (POMR) was prospectively monitored in Tonga and Cook Islands but retrospectively measured in other countries. POMR was below 1% in all five countries.

Interpretation

Whilst PICs share common challenges in providing specialised tertiary services, there is substantial diversity between the countries. Strategies to strengthen surgical systems should incorporate both local contextualisation within each PIC and regional collaboration between PICs.

Funding

None.

Strategic partnerships to improve surgical care in the Asia-Pacific region: proceedings

Emergency and essential surgery is a critical component of universal health coverage. Session three of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region focused on strategic partnerships. During this session, a range of partner organisations, including intergovernmental organisations, professional associations, academic and research institutions, non-governmental organisations, and the private sector provided an update on their work in surgical system strengthening in the Asia-Pacific region. Partner organisations could provide technical and implementation support for National Surgical, Obstetric, and Anaesthesia Planning (NSOAP) in a number of areas, including workforce strengthening, capacity building, guideline development, monitoring and evaluation, and service delivery. Participants emphasised the importance of several forms of strategic collaboration: 1) collaboration across the spectrum of care between emergency, critical, and surgical care, which share many common underlying health system requirements; 2) interprofessional collaboration between surgery, obstetrics, anaesthesia, diagnostics, nursing, midwifery among other professions; 3) regional collaboration, particularly between Pacific Island Countries, and 4) South-South collaboration between low- and middle-income countries (LMICs) in mutual knowledge sharing. Partnerships between high-income countries (HIC) and LMIC organisations must include LMIC participants at a governance level for shared decision-making. Areas for joint action that emerged in the discussion included coordinated advocacy efforts to generate political view, developing common monitoring and evaluation frameworks, and utilising remote technology for workforce development and service delivery.

Met and Unmet Need for Pediatric Surgical Access in Uganda: A Country-Wide Prospective Analysis

INTRODUCTION

Children's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation.

MATERIALS AND METHODS

Surgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated.

RESULTS

A total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need.

CONCLUSIONS

This investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda.

Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania

Introduction

Paediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ).

Methods

Data from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons.

Results

Similar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied-more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water.

Conclusions

With no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs.

Assessing the inclusion of children's surgical care in National Surgical, Obstetric and Anaesthesia Plans: a policy content analysis

OBJECTIVE

While National Surgical, Obstetric and Anaesthesia Plans (NSOAPs) have emerged as a strategy to strengthen and scale up surgical healthcare systems in low/middle-income countries (LMICs), the degree to which children's surgery is addressed is not well-known. This study aims to assess the inclusion of children's surgical care among existing NSOAPs, identify practice examples and provide recommendations to guide inclusion of children's surgical care in future policies.

DESIGN

We performed two qualitative content analyses to assess the inclusion of children's surgical care among NSOAPs. We applied a conventional (inductive) content analysis approach to identify themes and patterns, and developed a framework based on the Global Initiative for Children's Surgery's Optimal Resources for Children's Surgery document. We then used this framework to conduct a directed (deductive) content analysis of the NSOAPs of Ethiopia, Nigeria, Rwanda, Senegal, Tanzania and Zambia.

RESULTS

Our framework for the inclusion of children's surgical care in NSOAPs included seven domains. We evaluated six NSOAPs with all addressing at least two of the domains. All six NSOAPs addressed 'human resources and training' and 'infrastructure', four addressed 'service delivery', three addressed 'governance and financing', two included 'research, evaluation and quality improvement', and one NSOAP addressed 'equipment and supplies' and 'advocacy and awareness'.

CONCLUSIONS

Additional focus must be placed on the development of surgical healthcare systems for children in LMICs. This requires a focus on children's surgical care separate from adult surgical care in the scaling up of surgical healthcare systems, including children-focused needs assessments and the inclusion of children's surgery providers in the process. This study proposes a framework for evaluating NSOAPs, highlights practice examples and suggests recommendations for the development of future policies.

Picture Cards Versus Physical Examination: A Proof-of-Concept Study to Improve the SOSAS Survey Tool

INTRODUCTION

The Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool is used to determine the unmet surgical needs in the community and has been validated in several countries. A major weakness is the absence of an objective assessment to verify patient-reported surgically treatable conditions. The goal of this study was to determine whether a picture portfolio, a tool previously shown to improve parental recognition of their child's congenital deformity, could improve the accuracy of the SOSAS tool by how it compares with physical examination. This study focused on children as many surgical conditions in them require prompt treatment but are often not promptly diagnosed.

METHODS

We conducted a descriptive cross-sectional community-based study to determine the prevalence of congenital and acquired surgical conditions among children and adults in a mixed rural-urban area of Lagos, Southwest Nigeria. The picture portfolio was administered only to children and the surgical conditions to be assessed were predetermined using an e-Delphi process among pediatric surgeons. The modified The Surgeons OverSeas Assessment of Surgical Needs-Nigeria Survey Tool (SOSAS-NST) was administered to household members to collect other relevant data. Data were analyzed using the REDCap analytic tool.

RESULTS

Eight hundred and fifty-six households were surveyed. There were 1984 adults (49.5%) and 2027 children (50.5%). Thirty-six children met the predetermined criteria for the picture portfolio-hydrocephalus (n = 1); lymphatic malformation (n = 1); umbilical hernia (n = 14); Hydrocele (n = 5); inguinal hernia (n = 10) and undescended testes (n = 5). The picture portfolio predicted all correctly except a case of undescended testis that was mistaken for a hernia. The sensitivity of the picture portfolio was therefore 35/36 or 97.2%.

CONCLUSIONS

The SOSAS-NST has improved on the original SOSAS tool and within the limits of the small numbers, the picture portfolio has a high accuracy in predicting diagnosis in children in lieu of physical examination.

Essential equipment and services for otolaryngology care: a proposal by the Global Otolaryngology-Head and Neck Surgery Initiative

PURPOSE OF REVIEW

To highlight the need for comprehensive resource lists to provide baseline care of otolaryngologic conditions; to present a proposed list of essential equipment and services that may be applied toward surgical systems research, policymaking, and charitable efforts in global otolaryngology-head and neck surgery.

RECENT FINDINGS

To provide effective and high-quality surgical care across care settings, there must be a global standard for equipment and ancillary services necessary to provide baseline care. Though there have been efforts to devise resource standards via equipment lists and appraisal tools, these have been limited in scope to general surgery, emergency care, and a few other subspecialty surgical contexts. Recent efforts have brought attention to the significant burden imposed by otolaryngologic conditions such as hearing loss, otitis media, head and neck cancer, head and neck trauma, and upper airway foreign bodies. Yet, there has not been a comprehensive list of resources necessary to provide baseline care for common otolaryngologic conditions.

SUMMARY

Through an internal survey of its members, the Global Otolaryngology-Head and Neck Surgery Initiative has compiled a list of essential equipment and services to provide baseline care of otolaryngologic conditions. Our efforts aimed to address common otolaryngologic conditions that have been previously identified as high-priority with respect to prevalence and burden of disease. This expert-driven list of essential resources functions as an initial framework to be adapted for internal quality assessment, implementation research, health policy development, and economic priority-setting.

Voyaging through the paediatric surgical maze: A multi-centre analysis of inter-hospital referrals to Johannesburg, South Africa

INTRODUCTION

Paediatric surgery is a centralised service that is provided at only three public sector hospitals in Johannesburg, South Africa. These centres receive an overwhelming number of referrals from over fifty lower-level hospitals. The aim of this study was to analyse referrals to these specialist centres in order to quantify the unmet referred burden of disease and to identify ways in which paediatric surgical access in the region can be improved.

METHODS

A prospective descriptive study was conducted over a 1-year period (01/06/21-31/05/22). All inter-hospital referrals from lower-level hospitals to the three Johannesburg-based specialist centres were analysed.

RESULTS

2394 unique referrals to 3 hospitals were recorded. Five main diagnoses were responsible for 68% of all referrals: neonatal surgical conditions, burns, acute abdomen/bowel obstruction, trauma and symptomatic hernias. 59.7% of all referred patients met criteria for emergency transfer to a specialist unit. 26.7% of these patients, however, were unable to be transferred owing to a lack of bedspace at specialist centres. Transferred patients experienced significant time delays between referral and arrival. Four lower-level hospitals have been identified as possible sites for service expansion.

CONCLUSION

A large unmet paediatric surgical burden of disease has been identified. Lower-level hospitals have been identified that may be suitable for the implementation of decentralisation efforts to improve access to paediatric surgery within the region.

LEVEL OF EVIDENCE

V.

A Journey Undertaken by Families to Access General Surgical Care for their Children at Muhimbili National Hospital, Tanzania; Prospective Observational Cohort Study

BACKGROUND

A majority of the 2 billion children lacking access to safe, timely and affordable surgical care reside in low-and middle-income countries. A barrier to tackling this issue is the paucity of information regarding children's journey to surgical care. We aimed to explore children's journeys and its implications on accessing general paediatric surgical care at Muhimbili National Hospital (MNH), a tertiary centre in Tanzania.

METHODS

A prospective observational cohort study was undertaken at MNH, recruiting patients undergoing elective and emergency surgeries. Data on socio-demographic, clinical, symptoms onset and 30-days post-operative were collected. Descriptive statistics and Mann-Whitney, Kruskal-Wallis and Fisher's exact tests were used for data analysis.

RESULT

We recruited 154 children with a median age of 36 months. The majority were referred from regional hospitals due to a lack of paediatric surgery expertise. The time taken to seeking care was significantly greater in those who self-referred (p = 0.0186). Of these participants, 68.4 and 31.1% were able to reach a referring health facility and MNH, respectively, within 2 h of deciding to seek care. Overall insurance coverage was 75.32%. The median out of pocket expenditure for receiving care was $69.00. The incidence of surgical site infection was 10.2%, and only 2 patients died.

CONCLUSION

Although there have been significant efforts to improve access to safe, timely and affordable surgical care, there is still a need to strengthen children's surgical care system. Investing in regional hospitals may be an effective approach to improve access to children surgical care.

An OxPLORE Initiative Evaluating Children's Surgery Resources Worldwide: A Cross-sectional Implementation of the OReCS Document

BACKGROUND

The Global Initiative for Children's Surgery (GICS) group produced the Optimal Resources for Children's Surgery (OReCS) document in 2019, listing standards of children's surgical care by level of healthcare facilities within low resource settings. We have previously created and piloted an audit tool based on the OReCS criteria in a high-income setting. In this study, we aimed to validate its use in identifying gaps in children's surgery provision worldwide.

METHODS

Our OReCS audit tool was implemented in 10 hospitals providing children's surgery across eight countries. Collaborators were recruited via the Oxford Paediatrics Linking Our Research with Electives (OxPLORE) international network of medical students and trainees. The audit tool measured a hospital's current capacity for children's surgery. Data were analysed firstly to express the percentage of 'essential' criteria met for each specialty. Secondly, the 'OxPLORE method' was used to allocate each hospital specialty a level based on procedures performed and resources available. A User Evaluation Tool (UET) was developed to obtain feedback on the ease of use of the tool.

RESULTS

The percentage of essential criteria met within each category varied widely between hospitals. The level given to hospitals for subspecialties based on OReCS criteria often did not reflect their self-defined level. The UET indicated the audit tool was practicable across multiple settings.

CONCLUSIONS

We recommend the use of the OReCS criteria to identify areas for local hospital improvement and inform national children's surgical plans. We have made informed suggestions to increase usability of the OReCS audit tool.

Infrastructure Availability for the Care of Congenital Heart Disease Patients and Its Influence on Case Volume, Complexity and Access Among Healthcare Institutions in 17 Middle-Income Countries

The care for patients with congenital heart disease (CHD) is multi-disciplinary and resource intensive. There is limited information about the infrastructure available among programs that care for CHD patients in low and middle-income countries (LMIC). A survey covering the entire care-pathway for CHD, from initial assessment to inpatient care and outpatient follow-up, was administered to institutions participating in the International Quality Improvement Collaborative for Congenital Heart Disease (IQIC). Surgical case complexity-mix was collected from the IQIC registry and estimated surgical capacity requirement was based on population data. The statistical association of selected infrastructure with case volume, case-complexity and percentage of estimated case-burden actually treated, was analyzed. Thirty-seven healthcare institutions in seventeen countries with median annual surgical volume of 361 (41-3503) operations completed the survey. There was a median of two (1-16) operating room/s (OR), nine (2-80) intensive care unit (ICU) beds, three (1-20) cardiac surgeons, five (3-30) OR nurses, four (2-35) anesthesiologists, four (1-25) perfusionists, 28 (5-194) ICU nurses, six (0-30) cardiologists and three (1-15) interventional cardiologists. Higher surgical volume was associated with higher OR availability (p = 0.007), number of surgeons (p = 0.002), OR nurses (0.008), anesthesiologists (p = 0.04), perfusionists (p = 0.001), ICU nurses (p < 0.001), years of experience of the most senior surgeon (p = 0.03) or cardiologist (p = 0.05), and ICU bed capacity (p = 0.001). Location in an upper-middle income country (P = 0.04), OR availability (p = 0.02), and number of cardiologists (p = 0.004) were associated with performing a higher percentage of complex cases. This study demonstrates an overall deficit in the infrastructure available for the care of CHD patients among the participating institutions. While there is considerable variation across institutions surveyed, deficits in infrastructure that requires long-term investment like operating rooms, intensive care capacity, and availability of trained staff, are associated with reduced surgical capacity and access to CHD care.

Access to paediatric surgery: the geography of inequality in Nigeria

Background

About 96.3 million children and adolescents aged 0–19 years reside in Nigeria, comprising 54% of the population. Without adequate access to surgery for commonly treatable diseases, many face disability and increased risk of mortality. Due to this population’s unique perioperative needs, increasing access to paediatric surgical care requires a situational evaluation of the distribution of paediatric surgeons and anaesthesiologists. This study’s aim is to identify the percentage of Nigerian youth who reside within 2 hours of paediatric surgical care at the state and national level.

Methods

The Association of Paediatric Surgeons of Nigeria and the Nigeria Society of Anaesthetists provided surgical and anaesthesia workforce data by state. Health facilities with paediatric surgeons were converted to point locations and integrated with ancillary geospatial layers and population estimates from 2016 and 2017. Catchment areas of 2 hours of travel time around a facility were deployed as the benchmark indicator to establish timely access.

Results

Across Nigeria’s 36 states and Federal Capital Territory, the percentage of Nigeria’s 0–19 population residing within 2 hours of a health facility with a paediatric surgical and anaesthesia workforce ranges from less than 2% to 22.7%–30.5%. In 3 states, only 2.1%–4.8% of the population can access a facility within 2 hours, 12 have 4.9%–13.8%, and 8 have 13.9%–22.6%.

Conclusion

There is significant variation across Nigerian states regarding access to surgical care, with 69.5%–98% of Nigeria’s 0–19 population lacking access. Developing paediatric surgical services in underserved Nigerian states and investing in the training of paediatric surgical and anaesthesia workforce for those states are key components in improving the health of Nigeria’s 0–19 population and reducing Nigeria’s burden of surgical disease, in line with Nigeria’s National Surgical, Obstetrics, Anaesthesia and Nursing Plan.

Pediatric Central Nervous System Cancers in the Democratic People's Republic of Korea

Purpose:

Central nervous system (CNS) cancers rank as the most frequent solid tumors and the leading cause of cancer-related deaths in children and adolescents. There is less information available about pediatric brain and CNS tumors in low-income and middle-income countries, suggesting a lack of surgical accessibility or limited capacity to treat these conditions. In this study, we chose to study the epidemiology of CNS cancers in the Democratic People's Republic of Korea (DPRK).

Methods:

We extracted the prevalence, incidence, deaths, and disability-adjusted life years (DALYs) associated with CNS cancers in individuals under the age of 20 from the 2017 Global Burden of Disease study from the Institute for Health Metrics and Evaluation. DALYs, which signify the number of healthy life years lost due to ill health, disability, or early death. Economic impact was calculated from DALYs.

Conclusions:

Given the large burden of brain and CNS cancers among all pediatric cancers in the DPRK, scaling up and strengthening surgical services for children is an essential component to improving care of pediatric CNS cancers in the DPRK. Childhood cancers are time sensitive, and early diagnosis and treatment are vital in ensuring improved survival for the vulnerable pediatric cancer patient population. As surgical treatment can often prolong lives and even prevent premature deaths from these cancers, further analysis of current surgical capacity can inform the path to meeting these critical pediatric surgical needs.

Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study

INTRODUCTION

As childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs).

METHODS

A multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ² analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A p<0.05 was deemed significant.

RESULTS

1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis.

CONCLUSION

Mortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.

Online action planning forums to develop a roadmap to mitigate the impact of COVID-19 on the delivery of global children’s surgical care

PURPOSE

We aimed to understand the challenges facing children's surgical care providers globally and realistic interventions to mitigate the catastrophic impact of COVID-19 on children's surgery.

METHODS

Two online Action Planning Forums (APFs) were organized by the Global Initiative for Children's Surgery (GICS) with a geographically diverse panel representing four children's surgical, anesthesia, and nursing subspecialties. Qualitative analysis was performed to identify codes, themes, and subthemes.

RESULTS

The most frequently reported challenges were delayed access to care for children; fear among the public and patients; unavailability of appropriate personal protective equipment (PPE); diversion of resources toward COVID-19 care; and interruption in student and trainee hands-on education. To address these challenges, panelists recommended human resource and funding support to minimize backlog; setting up international, multi-center studies for systematic data collection specifically for children; providing online educational opportunities for trainees and students in the form of large and small group discussions; developing best practice guidelines; and, most importantly, adapting solutions to local needs.

CONCLUSION

Identification of key challenges and interventions to mitigate the impact of the COVID-19 pandemic on global children's surgery via an objective, targeted needs assessment serves as an essential first step. Key interventions in these areas are underway.

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

BACKGROUND

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

METHODS

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

FINDINGS

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality.

INTERPRETATION

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

FUNDING

Wellcome Trust.

Geospatial analysis of pediatric surgical need and geographical access to care in Somaliland: a cross-sectional study

BACKGROUND

The global burden of disease in children is large and disproportionally affects low-income and middle-income countries (LMICs). Geospatial analysis offers powerful tools to quantify and visualise disparities in surgical care in LMICs. Our study aims to analyse the geographical distribution of paediatric surgical conditions and to evaluate the geographical access to surgical care in Somaliland.

METHODS

Using the Surgeons OverSeas Assessment of Surgical Need survey and a combined survey from the WHO's (WHO) Surgical Assessment Tool-Hospital Walkthrough and the Global Initiative for Children's Surgery Global Assessment in Paediatric Surgery, we collected data on surgical burden and access from 1503 children and 15 hospitals across Somaliland. We used several geospatial tools, including hotspot analysis, service area analysis, Voronoi diagrams, and Inverse Distance Weighted interpolation to estimate the geographical distribution of paediatric surgical conditions and access to care across Somaliland.

RESULTS

Our analysis suggests less than 10% of children have timely access to care across Somaliland. Patients could travel up to 12 hours by public transportation and more than 2 days by foot to reach surgical care. There are wide geographical disparities in the prevalence of paediatric surgical conditions and access to surgical care across regions. Disparities are greater among children travelling by foot and living in rural areas, where the delay to receive surgery often exceeds 3 years. Overall, Sahil and Sool were the regions that combined the highest need and the poorest surgical care coverage.

CONCLUSION

Our study demonstrated wide disparities in the distribution of surgical disease and access to surgical care for children across Somaliland. Geospatial analysis offers powerful tools to identify critical areas and strategically allocate resources and interventions to efficiently scale-up surgical care for children in Somaliland.

Global and regional overview of the inclusion of paediatric surgery in the national health plans of 124 countries: an ecological study

OBJECTIVE

This study evaluates the priority given to surgical care for children within national health policies, strategies and plans (NHPSPs).

PARTICIPANTS AND SETTING

We reviewed the NHPSPs available in the WHO's Country Planning Cycle Database. Countries with NHPSPs in languages different from English, Spanish, French or Chinese were excluded. A total of 124 countries met the inclusion criteria.

PRIMARY AND SECONDARY OUTCOME MEASURES

We searched for child-specific and surgery-specific terms in the NHPSPs' missions, goals and strategies using three analytic approaches: (1) count of the total number of mentions, (2) count of the number of policies with no mentions and (3) count of the number of policies with five or more mentions. Outcomes were compared across WHO regional and World Bank income-level classifications.

RESULTS

We found that the most frequently mentioned terms were 'child*', 'infant*' and 'immuniz*'. The most frequently mentioned surgery term was 'surg*'. Overall, 45% of NHPSPs discussed surgery and 7% discussed children's surgery. The majority (93%) of countries did not mention selected essential and cost-effective children's procedures. When stratified by WHO region and World Bank income level, the West Pacific region led the inclusion of 'pediatric surgery' in national health plans, with 17% of its countries mentioning this term. Likewise, low-income countries led the inclusion of surg* and 'pediatric surgery', with 63% and 11% of countries mentioning these terms, respectively. In both stratifications, paediatric surgery only equated to less than 1% of the total terms.

CONCLUSION

The low prevalence of children's surgical search terms in NHPSPs indicates that the influence of surgical care for this population remains low in the majority of countries. Increased awareness of children's surgical needs in national health plans might constitute a critical step to scale up surgical system in these countries.

Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals

BACKGROUND

Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity.

METHODS

Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered.

RESULTS

From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society.

CONCLUSION

This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.

Inclusion of Children's Surgery in National Surgical Plans and Child Health Programmes: the need and roadmap from Global Initiative for Children's Surgery

About 1.7 billion children and adolescents, mostly in low- and middle-income countries (LMICs) lack access to surgical care. While some of these countries have developed surgical plans and others are in the process of developing theirs, children's surgery has not received the much-needed specific emphasis and focus in these plans. With the significant burden of children's surgical conditions especially in low- and middle-income countries, universal health coverage and the United Nations' (UN) Sustainable Development Goals (SDG) will not be achieved without deliberate efforts to scale up access to children's surgical care. Inclusion of children's surgery in National Surgical Obstetric and Anaesthesia Plans (NSOAPs) can be done using the Global Initiative for Children's Surgery (GICS)-modified Children's Surgical Assessment Tool (CSAT) tool for baseline assessment and the Optimal Resources for Children Surgical Care (OReCS) as a foundational tool for implementation.

Children at the Heart of Global Cardiac Surgery: An Advocacy Stakeholder Analysis

One in a hundred babies, or 1.3 million per year around the world, are born with congenital heart defects (CHD), of which over 70% will require medical or surgical treatment within their first year of life. In low- and middle-income countries, the majority does not receive the treatment they need or receive suboptimal care. Despite a higher pediatric cardiac surgical disease burden, low-income countries only have 0.07 pediatric cardiac surgeons per million pediatric population, compared to 9.51 per million in high-income countries. Here, we perform a stakeholder analysis of existing advocacy bodies within the field of pediatric global cardiac surgery and identify gaps and opportunities in advocating for cardiac care for children with CHD. We propose a framework to optimize civil society messaging in order to more effectively advocate domestically and internationally to hold national and international policy makers accountable for existing gaps and disparities in CHD care around the world.

Barriers to Surgical Care Among Children in Somaliland: An Application of the Three Delays Framework

BACKGROUND

There are complex barriers that increase delays to surgical care in low- and middle-income countries, particularly among the vulnerable population of children. Understanding these barriers to surgical care can result in targeted and strategic intervention efforts to improve care for children. The three-delay model is a widely used framework in global health for evaluating barriers associated with seeking (D1), reaching (D2), and receiving health care (D3). The goal of our study is to evaluate reasons for delays in the surgical care for children in Somaliland using the three-delay framework.

METHODS

Data were collected in a cross-sectional study in Somaliland from 1503 children through a household survey. Among children with a surgical need, we quantified the number of children seeking, reaching, and receiving care along the surgical care continuum, according to the three-delay framework. We evaluated predictors of the three delays through a multivariate logistic regression model, including the child's age, gender, village type, household income level, region, and household size.

RESULTS

Of the 196 children identified with a surgical condition, 50 (27.3%) children had a delay in seeking care (D1), 28 (20.6%) children had a delay in reaching care (D2), and 84 (71.2%) children had a delay in receiving care (D3), including 10 children who also experienced D1 and D2. The main reasons cited for D1 included seeking a traditional healthcare provider, while lack of money and availability of care were main reasons cited for D2. Significant predictors for delays included household size for D1 and D3 and condition type and region for D2.

CONCLUSION

Children in Somaliland experience several barriers to surgical care along the entire continuum of care, allowing for policy guidance tailored to specific local challenges and resources. Since delays in surgical care for children can substantially impact the effectiveness of surgical interventions, viewing delays in surgical care under the lens of the three-delay framework can inform strategic interventions along the pediatric surgical care continuum, thereby reducing delays and improving the quality of surgical care for children.

Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study

BACKGROUND

The unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions.

METHODS

In this cross-sectional nationwide study, the WHO's Surgical Assessment Tool-Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region.

RESULTS

The healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection.

CONCLUSION

We found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.

Waiting Too Long: The Contribution of Delayed Surgical Access to Pediatric Disease Burden in Somaliland

BACKGROUND

Delayed access to surgical care for congenital conditions in low- and middle-income countries is associated with increased risk of death and life-long disabilities, although the actual burden of delayed access to care is unknown. Our goal was to quantify the burden of disease related to delays to surgical care for children with congenital surgical conditions in Somaliland.

METHODS

We collected data from medical records on all children (n = 280) receiving surgery for a proxy set of congenital conditions over a 12-month time period across all 15 surgically equipped hospitals in Somaliland. We defined delay to surgical care for each condition as the difference between the ideal and the actual ages at the time of surgery. Disability-adjusted life years (DALYs) attributable to these delays were calculated and compared by the type of condition, travel distance to care, and demographic characteristics.

RESULTS

We found long delays in surgical care for these 280 children with congenital conditions, translating to a total of 2970 attributable delayed DALYs, or 8.4 avertable delayed DALYs per child, with the greatest burden among children with neurosurgical and anorectal conditions. Over half of the families seeking surgical care had to travel over 2 h to a surgically equipped hospital in the capital city of Hargeisa.

CONCLUSIONS

Children with congenital conditions in Somaliland experience substantial delays to surgical care and travel long distances to obtain care. Estimating the burden of delayed surgical care with avertable delayed DALYs offers a powerful tool for estimating the costs and benefits of interventions to improve the quality of surgical care.

Pediatric Anesthesia Specialty Societies and Multi-Institutional Collaborations

Pediatric anesthesiology is a subspecialty of anesthesiology that deals with the high-risk pediatric population. The specialty has made significant advancement in large collaborative efforts to study and increase patient safety, including the creation of international societies, a dedicated journal, special committees and interest groups, and multi-institution databases for research and quality improvement. Readily available resources were created to help with the education of future pediatric anesthesiologists as well as continuing medical education. Conclusions: Specialty societies and collaborations in pediatric anesthesia are crucial for continuous improvement in the care of children. They promote research, education, quality improvement, and advocacy at the local, national, and international level.

Burden of Neonatal Surgical Conditions in Northern Ghana

Background

Congenital anomalies have risen to become the fifth leading cause of under-five mortality globally. The majority of deaths and disability occur in low- and middle-income countries including Ghana. This 3-year retrospective review aimed to define, for the first time, the characteristics and outcomes of neonatal surgical conditions in northern Ghana.

Methods

A retrospective study was conducted to include all admissions to the Tamale Teaching Hospital (TTH) neonatal intensive care unit (NICU) with surgical conditions between January 2014 and January 2017. Data were collected on demographics, diagnosis and outcomes. Descriptive analysis was performed on all data, and logistic regression was used to predict determinants of neonatal mortality. p < 0.05 was deemed significant.

Results

Three hundred and forty-seven neonates were included. Two hundred and sixty-one (75.2%) were aged 7 days or less at presentation, with males (n = 177, 52%) slightly higher than females (n = 165, 48%). The majority were delivered by spontaneous vaginal delivery (n = 247, 88%); 191 (58%) were born in hospital. Congenital anomalies accounted for 302 (87%) of the neonatal surgical cases and 45 (96%) deaths. The most common anomalies were omphalocele (n = 48, 13.8%), imperforate anus (n = 34, 9.8%), intestinal obstruction (n = 29, 8.4%), spina bifida (n = 26, 7.5%) and hydrocephalus (n = 19, 5.5%). The overall mortality rate was 13.5%. Two-thirds of the deaths (n = 30) from congenital anomalies were conditions involving the digestive system with gastroschisis having the highest mortality of 88%. Omphalocele (n = 11, 23.4%), gastroschisis (n = 7, 14.9%) and imperforate anus (n = 6, 12.8%) contributed to the most deaths. On multivariate analysis, low birthweight was significantly associated with mortality (OR 3.59, CI 1.4–9.5, p = 0.009).

Conclusion

Congenital anomalies are a major global health problem associated with high neonatal mortality in Ghana. The highest burden in terms of both caseload and mortality is attributed to congenital anomalies involving the digestive system, which should be targeted to improve outcomes.

Electronic supplementary material

The online version of this article (10.1007/s00268-019-05210-9) contains supplementary material, which is available to authorized users.

Top 10 Resources in Global Surgery

This resource list could serve to orient those interested in global surgery and could be supplemented with resources advocating for global surgery from clinical, population health, or policy perspectives.

Lessons from developing, implementing and sustaining a participatory partnership for children's surgical care in Tanzania

Global surgery is an essential component of Universal Health Coverage. Surgical conditions account for almost one-third of the global burden of disease, with the majority of patients living in low-income and middle-income countries (LMICs). Children account for more than half of the global population; however, in many LMIC settings they have poor access to surgical care due to a lack of workforce and health system infrastructure to match the need for children's surgery. Surgical providers from high-income countries volunteer to visit LMICs and partner with the local providers to deliver surgical care and trainings to improve outcomes. However, some of these altruistic efforts fail. We aim to share our experience on developing, implementing and sustaining a partnership in global children's surgery in Tanzania. The use of participatory methods facilitated a successful 17-yearlong partnership, ensured a non-hierarchical environment and encouraged an understanding of the context, local needs, available resources and hospital capacity, including budget constraints, when codesigning solutions. We believe that participatory approaches are feasible and valuable in developing, implementing and sustaining global partnerships for children's surgery in LMICs.

Adaptations in pediatric anesthesia care and airway management in the resource-poor setting

The need for safe and quality pediatric anesthesia care in low- and middle-income countries (LMICs) is huge. An estimated 1.7 billion children do not have access to surgical care, and the majority are in LMICs. In addition, most LMICs do not have the requisite surgical workforce including anesthesia providers. Surgery is usually performed at three levels of facilities: district, provincial, and national referral hospitals. Unfortunately, the manpower, equipment, and other resources available to provide surgical care for children vary greatly at the different level facilities. The majority of district level hospitals are staffed solely by non-physician anesthesia providers with variable training and little support to manage complicated pediatric patients. Airway and respiratory complications are known to account for a large portion of pediatric perioperative complications. Management of the difficult pediatric airway pathology is a challenge for anesthesia providers regardless of setting. However, in the low-resource setting poor infrastructure, lack of transportation systems, and crippled referral systems lead to late presentation. There is often a lack of pediatric-sized anesthesia equipment and resources, making management of the local pathology even more challenging. Efforts are being made to offer these providers additional training in pediatric anesthesia skills that incorporate low-fidelity simulation. Out of necessity, anesthesia providers in this setting learn to be resourceful in order to manage complex pathologies with fewer, less ideal resources while still providing a safe anesthetic.

Global surgery

This article outlines the global surgery activities held at the 66th Annual International Meeting of the British Association of Paediatric Surgeons (BAPS) in 2019. For the first time BAPS introduced a plenary session on global surgery. Topics that were covered include management of birth defects in Low-Middle Income Countries (LMIC), mostly gastroschisis, and community-based involvement in children's surgery, knowing that 2.5 billion children worldwide do not have access to surgical care. The presentation on financial burden for families with children needing surgical care highlighted the route to poverty in the absence of governmental support. The Hugh Greenwood lecture covered the involvement of a global organisation, namely Global Initiative for Children's Surgery (GICS) advocating and working towards children's surgery, as this was ignored at the Lancet Commission held in 2015. LEVEL OF EVIDENCE: Level V.