Getting the Job Done: Analysis of the Impact and Effectiveness of the SmileTrain Program in Alleviating the Global Burden of Cleft Disease

Perspectives on the state of cleft lip and cleft palate patient care in Africa

PURPOSE OF REVIEW

Patients with cleft lip -palate (CLP) experience morbidity and social stigma, particularly in low-income and middle-income countries (LMICs) such as those of sub-Saharan Africa (SSA). Delays in treatment secondary either to lack of awareness, skills, equipment and consumables; poor health infrastructure, limited resources or a combination of them, has led to SSA having the highest rates of death and second highest rates of disability-adjusted life years in patients with CLP globally. Here we review current perspectives on the state of comprehensive cleft lip and palate repair in Africa.

RECENT FINDINGS

To bridge gaps in government health services, nongovernmental organizations (NGOs) have emerged to provide care through short-term surgical interventions (STSIs). These groups can effect change through direct provision of care, whereas others strengthen internal system. However, sustainability is lacking as there continue to be barriers to achieving comprehensive and longitudinal cleft care in SSA, including a lack of awareness of CLP as a treatable condition, prohibitive costs, poor follow-up, and insufficient surgical infrastructure. With dedicated local champions, a comprehensive approach, and reliable partners, establishing sustainable CLP services is possible in countries with limited resources.

SUMMARY

The replacement of CLP 'missions' with locally initiated, internationally supported capacity building initiatives, integrated into local healthcare systems will prove sustainable in the long-term.

Cleft Lip and Palate Surgery at a Rural African Hospital: A 13-Year Experience From Western Kenya

INTRODUCTION

Most studies on the treatment of cleft lip and palate (CLP) in low-income and middle-income countries have reported on the experience of urban centers or surgical mission trips to rural locations. There is a paucity of literature on the experience of local teams providing orofacial cleft surgery in rural Sub-Saharan Africa. This study reports the efficacy and cost-effectiveness of cleft surgery performed by an all-local team in rural Kenya.

METHODS

A retrospective chart review was performed on all patients who received CLP repair at Kapsowar Hospital between 2011 and 2023. Information regarding patient age, sex, cleft etiology, surgical management, and home location was retrieved. For the most recent year of study (2023), the authors performed a financial audit of all costs related to the performance of unilateral cleft lip surgery. Descriptive statistics were performed.

RESULTS

The authors identified 381 CLP surgeries performed on 311 patients (197 male, 63.3%). The most common etiology of the cleft was left unilateral (28.3%). The average age of primary lip repair decreased from 46.3 months in 2008 to 2009 to 20.2 months in 2022 to 2023 ( P <0.001). The average age of primary cleft palate repair decreased from 38.0 months in 2008 to 2009 to 25.3 months in 2022 to 2023 ( P <0.001). Patients traveled from 23 districts to receive treatment. Age of treatment was not different when distinguished by sex, county poverty level, or travel time from the hospital. The total costs associated with cleft lip repair was $201.6.

CONCLUSIONS

Adequately staffed hospitals in rural locations can meaningfully address a regional CLP backlog more cost-effectively than surgical mission trips.

The Pattern and Profile of Orofacial Clefts in Somaliland: A Review of 40 Consecutive Cleft Lip and Palate Surgical Camps

INTRODUCTION

Somaliland is an autonomously run country that is not internationally recognized. As such, it has been largely excluded by global health development programs despite being the world's fourth poorest country. The purpose of this study was to provide the first known description of the pattern and clinical profile of patients with cleft lip and palate from this nation.

METHODS

The authors performed a retrospective chart review on all patients who received cleft lip and palate repair by a single surgeon in 40 separate surgical camps at Edna Adan University Hospital in Hargeisa, Somaliland, between 2011 and 2024. Information regarding patient age, sex, cleft etiology, surgical management, and home location was retrieved. Descriptive statistical analysis was performed.

RESULTS

A total of 767 patients (495 male, 64.5%) received 787 surgical procedures. The average age of primary surgery was 73.7 months. The most common chief complaint was left cleft lip with cleft palate (316, 41.2%). Males received primary surgery 19.2 months later than did females (73.7 and 54.6 mo, respectively, P <0.001). Patients residing in Hargeisa received their initial procedure an average of 17.8 months younger than those who lived elsewhere in Somaliland (62.9 and 80.7 mo, respectively, P =0.004).

CONCLUSIONS

In this severely economically depressed region, patients received treatment at ages that lagged far beyond recommended guidelines. Our finding of earlier treatment for females than males is rare in the literature and likely relates to cultural sex expectations. Patients from rural locations were especially vulnerable to receiving delayed treatment. Further efforts to decrease the burden of craniofacial deformities in Somaliland should be pursued in earnest.

Predictors of Adverse Outcomes Following Cleft Palate Repair: An Analysis of Over 2500 Patients Using International Smile Train Data

OBJECTIVE

The objective of this study was to use data from Smile Train's global partner hospital network to identify patient characteristics that increase odds of fistula and postoperative speech outcomes.

DESIGN

Multi-institution, retrospective review of Smile Train Express database.

SETTING

1110 Smile Train partner hospitals.

PATIENTS/PARTICIPANTS

2560 patients.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURE(S)

Fistula occurrence, nasal emission, audible nasal emission with amplification (through a straw or tube) only, nasal rustle/turbulence, consistent nasal emission, consistent nasal emission due to velopharyngeal dysfunction, rating of resonance, rating of intelligibility, recommendation for further velopharyngeal dysfunction assessment, and follow-up velopharyngeal dysfunction surgery.

RESULTS

The patients were 46.6% female and 27.5% underweight by WHO standards. Average age at palatoplasty was 24.7 ± 0.5 months and at speech assessment was 6.8 ± 0.1 years. Underweight patients had higher incidence of hypernasality and decreased speech intelligibility. Palatoplasty when under 6 months or over 18 months of age had higher rates of affected nasality, intelligibility, and fistula formation. The same findings were seen in Central/South American and African patients, in addition to increased velopharyngeal dysfunction and fistula surgery compared to Asian patients. Palatoplasty technique primarily involved one-stage midline repair.

CONCLUSIONS

Age and nutrition status were significant predictors of speech outcomes and fistula occurrence following palatoplasty. Outcomes were also significantly impacted by location, demonstrating the need to cultivate longitudinal initiatives to reduce regional disparities. These results underscore the importance of Smile Train's continual expansion of accessible surgical intervention, nutritional support, and speech-language care.

A Systematic Review of the Cost-Effectiveness of Cleft Care in Low- and Middle-Income Countries: What is Needed?

OBJECTIVE

The objective of this paper is to conduct a systematic review that summarizes the cost-effectiveness of cleft lip and/or palate (CL/P) care in low- and middle-income countries (LMICs) based on existing literature.

DESIGN

We searched eleven electronic databases for articles from January 1, 2000 to December 29, 2020. This study is registered in PROSPERO (CRD42020148402). Two reviewers independently conducted primary and secondary screening, and data extraction.

SETTING

All CL/P cost-effectiveness analyses in LMIC settings.

PATIENTS, PARTICIPANTS

In total, 2883 citations were screened. Eleven articles encompassing 1,001,675 patients from 86 LMICs were included.

MAIN OUTCOME MEASURES

We used cost-effectiveness thresholds of 1% to 51% of a country's gross domestic product per capita (GDP/capita), a conservative threshold recommended for LMICs. Quality appraisal was conducted using the Joanna Briggs Institute (JBI) checklist.

RESULTS

Primary CL/P repair was cost-effective at the threshold of 51% of a country's GDP/capita across all studies. However, only 1 study met at least 70% of the JBI criteria. There is a need for context-specific cost and health outcome data for primary CL/P repair, complications, and existing multidisciplinary management in LMICs.

CONCLUSIONS

Existing economic evaluations suggest primary CL/P repair is cost-effective, however context-specific local data will make future cost-effectiveness analyses more relevant to local decision-makers and lead to better-informed resource allocation decisions in LMICs.

Global Smile Foundation's Cleft Surgical Outreach Program: Clinical and Economic Impact During the Past 14 Years

Clefts of the lip and/or palate can result in significant morbidity as well as economic and psychosocial distress for patients and families. Global Smile Foundation is a non-profit organization committed to providing comprehensive cleft care to patients with cleft of the lip/palate around the world. Primary cleft lip and primary cleft palate repairs performed by the Global Smile Foundation in the last decade were reviewed. Averted disability-adjusted life years were estimated and assessed for their economic value. A total of 15,310 disability-adjusted life years were averted. The financial gain was estimated between $78,323,624 and $152,906,604, with an average financial benefit of $48,021 to $93,750 per patient.

The Case for Investing in Psychosocial Care and Rights of Children with Chronic Medical Conditions in India

This narrative review paper aims to build a common understanding of the vulnerabilities of children with chronic medical conditions who face exceptional challenges due to nature of the illness, deformity, injury, and traumatic healthcare encounters which could potentially lead to long-term psychological effects. The presence of chronic medical diagnoses in children and the subsequent impacts including social stigma, as well as their age and developmental level, may amplify adjustment challenges in parenting considerations, school, peer relations, career, and future relationships. Children may be traumatized by unfamiliar and painful healthcare experiences. Hospitalization can lead to increased feelings of isolation, fear, and self-doubt when children do not receive emotionally safe psychological support necessary to minimize the accompanying stress and anxiety. School experiences and parenting children with chronic illnesses have additional intersecting socialization characteristics. This paper highlights a vision for furthering the groundwork within Indian pediatric settings to promote emotional safety and psychosocial care. Principles from the United Nations Convention on the Rights of the Child and the World Health Organization's definition of health create an impetus for giving a voice to children with chronic medical conditions. While there are sporadic psychosocial services for children with chronic needs, they lack consistency, and this indicates a need and an opportunity for developing a unique career for human development and psychology professionals to address these concerns. As exemplars, two psychosocial care programs in India that help foster resilience in these children are highlighted. Although limited, extant research regarding the experiences of children with chronic medical conditions in India is discussed, and implications for future research and academic initiatives are interwoven within this paper.

International pediatric surgery partnerships in sub-Saharan Africa: a scoping literature review

Background

Sub-Saharan Africa (SSA) faces a critical shortage of pediatric surgical providers. International partnerships can play an important role in pediatric surgical capacity building but must be ethical and sustainable.

Objective

The purpose of this study is to perform a scoping literature review of international pediatric surgery partnerships in SSA from 2009 to 2019. We aim to categorize and critically assess past partnerships to aid in future capacity-building efforts.

Methods

We performed a scoping literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. We searched the PubMed and Embase databases for articles published from 2009 to 2019 using 24 keywords. Articles were selected according to inclusion criteria and assessed by two readers. Descriptive analyses of the data collected were conducted in Excel.

Results

A total of 2376 articles were identified. After duplicates were removed, 405 articles were screened. In total, 83 articles were assessed for eligibility, and 62 were included in the review. The most common partnership category was short-term surgical trip (28 articles, 45%). A total of 35 articles (56%) included education of host country providers as part of the partnership. Only 45% of partnerships included follow-up care, and 50% included postoperative outcomes when applicable.

Conclusions

To increase sustainability, more partnerships must include education of local health-care providers, and short-term surgical trips must be integrated into long-term partnerships. More partnerships need to report postoperative outcomes and ensure follow-up care. Educating peri-operative providers, training general surgeons in common pediatric procedures, and increasing telehealth use are other goals for future partnerships.

A global view of pediatric urology

Over the course of approximately 60 years, the field of pediatric urology has evolved as a convergence of pediatric surgery, urology, and plastic surgery to address congenital anomalies of the urinary tract and genitalia in children. Guidelines for training and certification are narrowing in high-income countries (HICs) at the same time as the fertility rate is declining and the prevalence of complex genitourinary (GU) conditions is decreasing. In low-and middle-income countries (LMICs), health systems for large populations are currently in a state of stress. Here we briefly review the history of pediatric urology as a surgical subspecialty, identify unmet needs especially in LMICs and place the field in the context of a global surgical ecosystem.

METHODS

The English language literature on workforce trends in pediatric urology, pediatric surgery and urology was reviewed as well as development of the emerging field of global surgery. Global surgery looks at the social, economic and political context of health systems as well as unmet clinical need. World trends in fertility rates were reviewed to identify regions of workforce surplus and gaps, supply chain needs, infrastructure and systems strengths and weaknesses.

RESULTS

The proliferation of training programs in pediatric surgery and specialties in high-income countries (HICs) coupled with declining birth rates has led to a saturation of specialists and declining surgical case load. In LMICs, while the birth rate has also been declining, surgical specialization has not progressed. In the lowest income countries, especially in sub-Saharan Africa, training in pediatric surgical specialties and urology is rare. The broad workforce that supports surgical care, such as anesthesia, intensivist pediatrics, radiology, laboratory, and nursing face similar challenges. Supply chains for specialized pediatric urological surgery are weak.

CONCLUSION

There is an evolving maldistribution of pediatric surgical and pediatric urological workforce globally, with too few practitioners in LMICs and too many in HICs. The high cost of specialized equipment limits access to quality care, and the supply chain for consumables and medication is patchy. In LIC's, basic community-based infrastructure for health including reliable electricity is lacking. Recent experience with Covid and environmental disasters has highlighted that even in HICs surgical resilience can be challenged. This is an opportunity to consider the state of children's urological care globally and to build resilience by identifying and addressing strengths and gaps.

Barriers and Resources to Cleft Lip and Palate Speech Services Globally: A Descriptive Study

BACKGROUND

Although a number of international cleft organizations and cleft professionals in low- and middle-income countries (LMICs) have built and supported comprehensive cleft care and speech therapy models to address the shortage of speech services in LMICs, the specific speech needs of individuals with cleft lip and palate (CLP) in such countries remain unknown. The objective of this study was to evaluate the barriers to accessing speech services for patients with CLP as well as the resources and models of speech services that are currently available for individuals with CLP in LMICs, with the goal of better understanding the needs of this population.

METHODS

Qualitative and quantitative methods consisted of Smile Train partner surveys that were distributed June 25th to July 31st, 2018 worldwide. Surveys were distributed through Smile Train's online medical database, Smile Train Express, which every Smile Train partner uses to report their Smile Train sponsored treatment outcomes. A total of 658 Smile Train partners responded to the surveys. Respondents included surgeons, speech therapists, orthodontists, administrators and nurses who represented non-governmental organizations, hospitals (private or public), hospital groups, and private clinics.

RESULTS

Results indicated that lack of resources, including access to local speech providers and language materials, as well as financial constraints such as patient travel and speech treatment costs, are the most commonly reported barriers to accessing speech services across all geographic regions surveyed.

CONCLUSIONS

Improving access to CLP speech services in LMICs may require strategies that address lack of speech providers, language materials, and financial constraints.

Mobile Surgical Scouts Increase Surgical Access for Patients with Cleft Lip and Palate in Nepal

Background: In Nepal's remote regions, challenging topography prevents patients with cleft lip and palate (CLP) from seeking care. Objective: To measure the effect of a mobile surgical scout program on CLP surgical care in remote regions of Nepal. Methods: Forty-four lay people were trained as mobile surgical scouts and over 5 months traversed remote districts of Nepal on foot to detect and refer CLP patients for surgical care. Surgical patients from remote districts were compared with matched time periods in the year before intervention. Diagnostic accuracy of the surgical scouts was assessed. Findings: Mobile surgical scouts accurately diagnosed (90%) and referred (82%) patients for cleft surgery. Before the intervention, CLP surgeries from remote districts represented 3.5% of cleft surgeries performed. With mobile surgical scouting, patients from remote districts comprised 8.2% of all cleft surgeries (p = 0.007). When transportation and accompaniment was provided in addition to mobile surgical scouts, patients from remote districts represented 13.5% (p ≤ 0.001) of all cleft surgeries. Conclusion: Task-shifting the surgical screening process to trained scouts resulted in accurate diagnoses, referrals, and increased access to cleft surgery in remote districts of Nepal.

The Current State of Cleft Care in Sub-Saharan Africa: A Narrative Review

OBJECTIVE

To identify practices and limitations of cleft care in sub-Saharan Africa (SSA).

DESIGN

A retrospective narrative nonsystematic literature review was performed.

SETTING

Literature exploring the management practices of cleft lip and/or palate across regions in SSA was included.

PARTICIPANTS

Full text case reports, retrospective studies, prospective studies, clinical trials, and review articles written and published in English between 1966 and February 1, 2021, were included in this analysis utilizing PubMed, MEDLINE, EMBASE, and Google scholar databases.

MAIN OUTCOME MEASURES

Qualitative themes identified in analysis were clinical practice patterns, current infrastructure and limitations of cleft repair, training and interdisciplinary teams, economic analyses, and international partnerships.

RESULTS

Significant barriers to care identified in SSA include lack of hospital resources, craniofacial training, access to multidisciplinary specialists, and public awareness. These problems make the entire care journey difficult for patients. Increasing public education has the power to diminish late presentations to hospitals. Providing adequate hospital resources and craniofacial training through international and organizational partnerships can ensure that more patients will receive care. Increasing the availability and number of multidisciplinary specialists is crucial to follow up care which aims at improving functional outcomes.

CONCLUSION

This narrative review highlights current practices and limitations in cleft care, emphasizing the importance of effective and timely repair of clefts in SSA. Targeted efforts aimed at establishing sustainable infrastructure for cleft care in SSA can have significant individual and community health and economic benefits.

Assessing Performance in Simulated Cleft Palate Repair Using a Novel Video Recording Setup

OBJECTIVE

To test the feasibility of implementing a high-fidelity cleft palate simulator during a workshop in Santiago, Chile, using a novel video endoscope to assess technical performance.

DESIGN

Sixteen cleft surgeons from South America participated in a 2-day cleft training workshop. All 16 participants performed a simulated repair, and 13 of them performed a second simulated repair. The repairs were recorded using a low-cost video camera and a newly designed camera mouth retractor attachment. Twenty-nine videos were assessed by 3 cleft surgeons using a previously developed cleft palate objective structured assessment of technical skill (CLOSATS with embedded overall score assessment) and global rating scale. The reliability of the ratings and technical performance in relation to minimum acceptable scores and previous experience was assessed.

RESULTS

The video setup provided acceptable recording quality for the purpose of assessment. Average intraclass correlation coefficient for the CLOSATS, global, and overall performance score was 0.69, 0.75, and 0.82, respectively. None of the novice surgeons passed the CLOSATS and global score for both sessions. One participant in the intermediate group, and 2 participants in the advanced group passed the CLOSATS and global score for both sessions. There were highly experienced participants who failed to pass the CLOSATS and global score for both sessions.

CONCLUSIONS

The cleft palate simulator can be practically implemented with video-recording capability to assess performance in cleft palate repair. This technology may be of assistance in assessing surgical competence in cleft palate repair.

A Qualitative Analysis of Factors Impacting Comprehensive Cleft Lip and Palate Care in Ghana

OBJECTIVE

The objective of this study was to examine practices regarding cleft lip and palate (CLP) among medical professionals and caregivers of children with CLP and to identify barriers and facilitators to comprehensive CLP care at a hospital in West Africa.

DESIGN

Qualitative methods used consisted of individual semistructured interviews with caregivers of children with CLP and one focus group with CLP team members.

SETTING

A majority of the interviews took place in the hospital, with some occurring during home visits. The focus group was conducted in the same hospital.

PARTICIPANTS

Forty-five caregivers of children with CLP and 1 adult with CLP completed an interview. Additionally, 2 of the caregivers had CLP and completed an interview from their perspective. The focus group consisted of 13 CLP team members from a comprehensive CLP team in Ghana.

INTERVENTIONS

Interviews consisted of semistructured, open-ended questions, and the focus group relied on a discussion guide. Line-by-line coding was used to identify common themes regarding barriers and facilitators to CLP care.

RESULTS

Barriers to CLP care that were consistent across caregiver interviews and the focus group were lack of knowledge regarding CLP, stigma and cultural beliefs surrounding CLP, transportation, financial, and feeding/nutrition issues. Barriers to care identified in the interviews and focus group were similar; however, facilitators to care varied greatly between the 2.

CONCLUSIONS

Two different qualitative methods provided unique perspectives on barriers and facilitators to CLP care. However, patients and caregivers continue to face substantial barriers to obtaining care.

Repurposing NGO data for better research outcomes: a scoping review of the use and secondary analysis of NGO data in health policy and systems research

Background

Non-governmental organisations (NGOs) collect and generate vast amounts of potentially rich data, most of which are not used for research purposes. Secondary analysis of NGO data (their use and analysis in a study for which they were not originally collected) presents an important but largely unrealised opportunity to provide new research insights in critical areas, including the evaluation of health policy and programmes.

Methods

A scoping review of the published literature was performed to identify the extent to which secondary analysis of NGO data has been used in health policy and systems research (HPSR). A tiered analytical approach provided a comprehensive overview and descriptive analyses of the studies that (1) used data produced or collected by or about NGOs; (2) performed secondary analysis of the NGO data (beyond the use of an NGO report as a supporting reference); and (3) analysed NGO-collected clinical data.

Results

Of the 156 studies that performed secondary analysis of NGO-produced or collected data, 64% (n = 100) used NGO-produced reports (mostly to a limited extent, as a contextual reference or to critique NGO activities) and 8% (n = 13) analysed NGO-collected clinical data. Of these studies, 55% (n = 86) investigated service delivery research topics and 48% (n = 51) were undertaken in developing countries and 17% (n = 27) in both developing and developed countries. NGOs were authors or co-authors of 26% of the studies. NGO-collected clinical data enabled HPSR within marginalised groups (e.g. migrants, people in conflict-affected areas), albeit with some limitations such as inconsistent and missing data.

Conclusion

We found evidence that NGO-collected and produced data are most commonly perceived as a source of supporting evidence for HPSR and not as primary source data. However, these data can facilitate research in under-researched marginalised groups and in contexts that are hard to reach by academics such as conflict-affected areas. NGO–academic collaboration could help address issues of NGO data quality to facilitate their more widespread use in research. The use of NGO data use could enable relevant and timely research in the areas of programme evaluation and health policy and advocacy to improve health and reduce health inequalities, especially in marginalised groups and developing countries.

The History and Mission of Smile Train, a Global Cleft Charity

Cleft lip and/or palate (CLP) is a common congenital anomaly with a global impact. One organization attempting to decrease global burden of CLPs is Smile Train. Since 1999, Smile Train has empowered local medical providers to provide comprehensive and sustainable cleft care. Partner surgeons have performed more than 1.5 million operations for patients with CLPs in more than 90 countries. This article outlines the history and mission of Smile Train and details the organization's efforts to increase hospital-wide safety, provide education and training opportunities for partners, and use technology to improve the delivery of cleft care on a global scale.

Bridging the gap: an economic case study of the impact and cost effectiveness of comprehensive healthcare intermediaries in rural Mexico

BACKGROUND

In rural settings where patients face significant structural barriers to accessing healthcare services, the formal existence of government-provided health coverage does not necessarily translate to meaningful care delivery. This paper analyses the effectiveness of an innovative approach to overcome these barriers, the Right to Health Care programme offered by Compañeros en Salud in Chiapas, Mexico. This programme provides comprehensive free coverage of all additional direct and indirect medical costs as well as accompaniment through the medical system. Over 550 patients had participated from 2013 until November 2018.

METHODS

Focusing on ten of the most frequently treated conditions, including hernias, cataracts and congenital heart defects, we performed a retrospective case study analysis of the quality-adjusted life years (QALYs) gained from treatment and the cost per QALY for 69 patients. This analysis used disability weights and uncertainty intervals from the Global Burden of Disease study and organisational micro-costing data for each patient. Each patient was compared to their own hypothetical counterfactual health outcome had they not received the secondary and tertiary care required for the specific condition. A mixed methods approach is used to establish this counterfactual baseline, drawing on pre-intervention observations, qualitative interviews and established literature precedent.

RESULTS

The programme was found to deliver an average of 14.4 additional QALYs (95% uncertainty interval 12.4-15.8) without time discounting. The mean cost per QALY over these conditions was $388 USD (95% UI $262-588) at purchasing power parity.

CONCLUSIONS

These numbers compare favourably with studies of other health services and international cost per QALY guidelines. They reflect the on-treatment effect for the ten conditions analysed and are presented as a case study indicative of the promise of healthcare intermediaries rather than a definitive assessment of cost-effectiveness. Nonetheless, these results show the potential feasibility and cost effectiveness of a more comprehensive approach to healthcare provision in a resource-limited rural setting.

TRIAL REGISTRATION

This study involves economic analysis of a programme facilitating access to public healthcare services. Thus, there was no associated clinical trial to be registered.

Funding paediatric surgery procedures in sub-Saharan Africa

Background

In sub-Saharan Africa, there is a growing awareness of the burden of paediatric surgical diseases. This has highlighted the large discrepancy between the capacity to treat and the ability to afford treatment, and the effect of this problem on access to care. This review focuses on the sources and challenges of funding paediatric surgical procedures in sub-Saharan Africa.

Methods

We undertook a search for studies published between January 2007 and November 2016 that reported the specific funding of paediatric surgical procedures and were conducted in sub-Saharan Africa. Abstract screening, full-text review and data abstraction were completed and resulting data were analysed using Statistical Package for Social Sciences (SPSS) software.

Results

Thirty-five studies met our inclusion criteria and were reviewed. The countries that were predominantly emphasized in the publications reviewed were Nigeria, South Africa, Kenya, Ghana and Uganda. The paediatric surgical procedures involved general paediatric surgery/urology, cardiac surgery, neurosurgery, oncology, plastics, ophthalmology, orthopaedics and otorhinolaryngology. The mean cost of these procedures ranged from 60 to 21,140 United States Dollars (USD). The source of funding for these procedures was mostly out-of-pocket payments (OOPs) by the patient's family in 32 studies, (91.4%) and medical mission/non-governmental organizations (NGOs) in 21 (60%) studies. This pattern did not differ appreciably between the articles published in the initial and latter 5 years of the study period, although there was a trend towards a reduction in OOP funding. Improvements in healthcare funding by individual countries supported by international organizations and charities were the predominant suggested solutions to challenges in funding.

Conclusion

While considering the potential limitations created by diversity in study design, the reviewed publications indicate that funding for paediatric surgical procedures in sub-Saharan Africa is mostly by OOPs made by families of the patients. This may result in limited access to some procedures. Coordinated efforts, and collaboration between individual countries and international agencies, may help to reduce OOP funding and thus improve access to critical procedures.

The Economic Value of the Delivery of Primary Cleft Surgery in Timor Leste 2000-2017

BACKGROUND

Plastic and reconstructive surgical teams visiting from Australia, a high-income country, have delivered cleft surgical services to Timor Leste since 2000 on a volunteer basis. This paper aims to estimate the economic benefit of correcting cleft deformities in this new nation as it evolved its healthcare delivery service from independence in 1999.

METHODS

We have utilised a prospective database of all cleft surgical interventions performed during 44 plastic surgical missions over the last 18 years. The disability-adjusted life year (DALY) framework was used to calculate the total DALYs averted by primary cleft lip and palate repair. The 2004 global burden of disease disability weights were used. Economic benefits were calculated using the gross national income (GNI) and the value of a statistical life (VSL) methods for Timor Leste. Estimates were adjusted for treatment effectiveness, counterfactual cases, and complications. Cost estimates included the local hospitalisation costs, the foregone salaries of the visiting surgeons and nurses, other costs associated with providing surgical care, and an estimate for foregone wages of the patients or their carers. Sensitivity analysis was performed with income elasticity set to 0.55, 1.0, and 1.5.

RESULTS

During 44 visiting plastic surgical missions to Timor Leste, 1500 procedures were performed, including 843 primary cleft lip and palate operations. The cleft procedures resulted in the aversion of 842 DALYs and an economic return to Timor Leste of USD 2.2 million (GNI-based) or USD 197,917 (VSL-based). Our programme cost USD 705 per DALY averted. The economic return on investment was 0.3:1 (VSL-based) or 3.8:1 (GNI-based).

CONCLUSION

A sustained and consistent visiting team approach providing repair of cleft lip and palate defects has resulted in considerable economic gain for Timor Leste over an 18-year period. The training of a local surgeon and multidisciplinary team with ongoing support to the in-country cleft service is expected to reduce the cost per DALY averted once the surgeon and team are able to manage clefts independently.

Developing Metrics to Define Progress in Children's Surgery

There is a need for relevant, valid, and practical metrics to better quantify both need and progress in global pediatric surgery and for monitoring systems performance. There are several existing surgical metrics in use, including disability-adjusted life years (DALYs), surgical backlog, effective coverage, cost-effectiveness, and the Lancet Commission on Global Surgery indicators. Most of these have, however, not been yet applied to children's surgery, leaving therefore significant data gaps in the burden of disease, infrastructure, human resources, and quality of care assessments in the specialty. This chapter reviews existing global surgical metrics, identifies settings where these have been already applied to children's surgery, and highlights opportunities for further inquiry in filling the knowledge gaps. Directing focused, intentional knowledge translation efforts in the identified areas of deficiency will foster the maturation of global pediatric surgery into a solid academic discipline able to contribute directly to the cause of improving the lives of children around the world.

Impact of short-term reconstructive surgical missions: a systematic review

Introduction

Short-term missions providing patients in low-income countries with reconstructive surgery are often criticised because evidence of their value is lacking. This study aims to assess the effectiveness of short-term reconstructive surgical missions in low-income and middle-income countries.

Methods

A systematic review was conducted according to PRISMA guidelines. We searched five medical databases from inception up to 2 July 2018. Original studies of short-term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients and sustainability. Data were combined to generate overall outcomes, including overall complication rates.

Results

Of 1662 identified studies, 41 met full inclusion criteria, which included 48 546 patients. The overall study quality according to Oxford CEBM and GRADE was low. Ten studies reported a minimum of 6 months’ follow-up, showing a follow-up rate of 56.0% and a complication rate of 22.3%. Twelve studies that did not report on duration or follow-up rate reported a complication rate of 1.2%. Fifteen out of 20 studies (75%) that reported on follow-up also reported on sustainable characteristics.

Conclusions

Evidence on the patient outcomes of reconstructive surgical missions is scarce and of limited quality. Higher complication rates were reported in studies which explicitly mentioned the duration and rate of follow-up. Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions. This review indicates that missions should develop towards sustainable partnerships. These partnerships should provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems.

PROSPERO registration number

CRD42018099285.

Delayed access to care and unmet burden of pediatric surgical disease in resource-constrained African countries

BACKGROUND

The purpose of this study was to estimate the unmet burden of surgically correctable congenital anomalies in African low- and middle-income countries (LMICs).

METHODS

We conducted a chart review of children operated for cryptorchidism, isolated cleft lip, hypospadias, bladder exstrophy and anorectal malformation at an Ethiopian referral hospital between January 2012 and July 2016 and a scoping review of the literature describing the management of congenital anomalies in African LMICs. Procedure numbers and age at surgery were collected to estimate mean surgical delays by country and extrapolate surgical backlog. The unmet surgical need was derived from incidence-based disease estimates, established disability weights, and actual surgical volumes.

RESULTS

The chart review yielded 210 procedures in 207 patients from Ethiopia. The scoping review generated 42 data sets, extracted from 36 publications, encompassing: Benin, Egypt, Ghana, Ivory Coast, Kenya, Nigeria, Madagascar, Malawi, Togo, Uganda, Zambia, and Zimbabwe. The largest national surgical backlog was noted in Nigeria for cryptorchidism (209,260 cases) and cleft lip (4154 cases), and Ethiopia for hypospadias (20,188 cases), bladder exstrophy (575 cases) and anorectal malformation (1349 cases).

CONCLUSION

These data support the need for upscaling pediatric surgical capacity in LMICs to address the significant surgical delay, surgical backlog, and unmet prevalent need.

TYPE OF STUDY

Retrospective study and review article LEVEL OF EVIDENCE: III.

A Bibliometric Analysis of the Most Cited Articles in Global Reconstructive Surgery

BACKGROUND

A substantial global inequality exists between surgical need and the availability of safe, affordable surgical care. Low- and middle-income countries have the greatest burden of untreated surgical disease and addressing this inequity is the goal of the Global Surgery movement. Reconstructive surgery is a fundamental component of Global Surgery as it is central to the appropriate treatment of trauma, burns, wounds, and congenital malformations. The objective of this study was to analyze the most frequently cited articles in the field of global reconstructive surgery to understand the main publication trends.

METHODS

The 25 most cited articles relating to global reconstructive surgery were identified from all available journals through the Web of Science online database. The following data were extracted from each included article: title, source journal, publication year, total citations, average citations per year, authors, main subject, reconstructive surgery subspecialty, country, and institution of origin.

RESULTS

The average number of citations per article was 21.7 (median, 19; range, 10-40). Most articles originated from the United States, and only 1 originated from a low-income country. The majority of the articles focused on cleft lip and palate (CLP) (72%), with few articles discussing burns or trauma. The main discussion themes were the quality of care provided in low- and middle-income countries both by local and visiting teams, the burden of diseases in relation to global reconstructive surgery, and the impact of surgical interventions economically and on patients.

CONCLUSIONS

The number of research articles and citations related to global reconstructive surgery are limited. Despite having a lower incidence than burns or trauma, there is a preponderance of reports focusing on missions treating CLP. These findings suggest that more research funding could be invested in global reconstructive surgery for conditions other than CLP.

Disability Weights for Pediatric Surgical Procedures: A Systematic Review and Analysis

BACKGROUND

Metrics to measure the burden of surgical conditions, such as disability weights (DWs), are poorly defined, particularly for pediatric conditions. To summarize the literature on DWs of children's surgical conditions, we performed a systematic review of disability weights of pediatric surgical conditions in low- and middle-income countries (LMICs).

METHOD

For this systematic review, we searched MEDLINE for pediatric surgery cost-effectiveness studies in LMICs, published between January 1, 1996, and April 1, 2017. We also included DWs found in the Global Burden of Disease studies, bibliographies of studies identified in PubMed, or through expert opinion of authors (ES and HR).

RESULTS

Out of 1427 publications, 199 were selected for full-text analysis, and 30 met all eligibility criteria. We identified 194 discrete DWs published for 66 different pediatric surgical conditions. The DWs were primarily derived from the Global Burden of Disease studies (72%). Of the 194 conditions with reported DWs, only 12 reflected pre-surgical severity, and 12 included postsurgical severity. The methodological quality of included studies and DWs for specific conditions varied greatly.

INTERPRETATION

It is essential to accurately measure the burden, cost-effectiveness, and impact of pediatric surgical disease in order to make informed policy decisions. Our results indicate that the existing DWs are inadequate to accurately quantify the burden of pediatric surgical conditions. A wider set of DWs for pediatric surgical conditions needs to be developed, taking into account factors specific to the range and severity of surgical conditions.

A Sustainable and Scalable Approach to the Provision of Cleft Care: A Focus on Safety and Quality

BACKGROUND

A global health model based on partnering with local hospitals and surgical teams, providing education and training for local providers, and mandating adherence to safety and quality standards to ensure safe surgery and anesthesia care can build local surgical capacity and strengthen existing health care systems in low- and middle-income countries. Smile Train uses this sustainable partnership model to provide responsible humanitarian aid while maintaining a bidirectional exchange with its international partners.

METHODS

A voluntary online survey is administered annually to Smile Train's global partners. One portion of this survey focuses on how Smile Train can best support providers' adherence to the Smile Train Safety and Quality Protocol and Anesthesia Guidelines for cleft care.

RESULTS

In 2014 and 2015, 1132 health care providers responded to Smile Train's annual partner survey (77 percent response rate). When asked how Smile Train could best support partners to continually meet the safety and quality standards, most partners reported that they could benefit from additional financial support (59.6 percent) and medical professional education and training opportunities (59.2 percent).

CONCLUSIONS

The results from the partner survey yield important insights into the programmatic needs of Smile Train partners. Smile Train uses this information to efficiently allocate and distribute resources and to strategically plan and implement training opportunities where needed. The partner survey helps to ensure that Smile Train patients around the world consistently receive safe and high-quality cleft surgery and anesthesia care.

Burden of Orofacial Clefting in India, 2016: A Global Burden of Disease Approach

Background:

In the recent past, there have been inconsistent reports of India witnessing a decreasing trend in the incidence of orofacial clefts (OFC). To date, little comprehensive evidence has been published. To identify the prevalence, associated burden in terms of epidemiological parameters and to estimate the “unmet” OFC treatment needs, the present study was undertaken.

Materials and Methods:

Using the Global Burden of Diseases 2016 approach and its assumptions, an attempt was made to estimate the prevalence to quantify the burden of OFC in India as disability-adjusted life years (DALYs), years of life lost (YLL), and years lived with disability (YLD) as well as death due to OFC. The results from such an approach are presented. Using previous estimates of “unmet” OFC treatment needs, an attempt was made to estimate the current volume of “unmet” OFC treatment needs.

Results:

In the present study, it was estimated that a total of 0.033% of all Indian population suffers from OFC. In 2016, the estimated prevalence rate/100,000 was 33.27 for males, 31.01 for females, and 32.18 combined for both genders. It was estimated that for all ages, the DALYs lost were 2.05 for 100,000 males, 2.66 for females and 2.34 for both sexes. The OFC birth prevalence model revealed that the birth prevalence (as a proportion) in 2016 in India showed an odds ratio of 0.48 (1.56–1.65) and fixed factor of nonrecording 0.83 (0.15–6.63), underreporting 0.97 (0.88–1), gender 1.09 (1.02–1.16), chromosomal diagnoses included 1.22 (1.22–1.22), and stillbirth 1.22 (1.22–1.22). The total unmet cleft treatment need was estimated at 79,430 or 18.76% of the total Indian cleft population with OFC.

Conclusions:

Within the constraints of the mathematical modeling and based on all available surveys, literature, and reported data, the overall birth prevalence and the prevalence of OFC in India are presented. Till reliable data emerges, the present estimates could serve as a robust estimate of the prevalence and burden of OFC in India. The present enterprise highlights the need for well-designed, high-quality Pan-India, community-based, observational studies to accurately estimate the burden of OFC in India.

What Is the Role of Plastic Surgery in Global Health? A Review

There is growing awareness of the substantial global burden of surgical disease. Conditions treated effectively by plastic and reconstructive procedures make a large proportion of the global surgical diseases, and disproportionately affect individuals at the lower end of the economic spectrum. This article reviews the role of plastic surgery in global health, highlights the ongoing need for plastic and reconstructive surgery globally, and increasing efforts that have been made to meet these needs. There global shortage of plastic surgeons in low and middle income countries, but plastic surgery has a long tradition of humanitarian aid, has been a leader in global surgery development. Plastic and reconstructive surgical care has increasingly been shown to be cost effective and to have an immense impact on the economy of a region, delivering a substantial return on investment. More sustainable global surgical care is essential in future, requiring ongoing efforts from the plastic surgery community, greater recognition of the problems that can be addressed at policy level, and research to help guide policy-makers when facing the decision of allocating scarce resources. There is a fundamental role of plastic surgery in global health.

A Cost-Effectiveness Analysis of a Pediatric Operating Room in Uganda

This study examines the cost-effectiveness of constructing a dedicated pediatric operating room (OR) in Uganda, a country where access to surgical care is limited to 4 pediatric surgeons serving a population of over 20 million children under 15 years of age.

METHODS

A simulation model using a decision tree template was developed to project the cost and disability-adjusted life-years saved by a pediatric OR in a low-income setting. Parameters are informed by patient outcomes of the surgical procedures performed. Costs of the OR equipment and a literature review were used to calculate the incremental cost-effectiveness ratio of a pediatric OR. One-way and probabilistic sensitivity analysis were performed to assess parameter uncertainty. Economic monetary benefit was calculated using the value of a statistical life approach.

RESULTS

A pediatric OR averted a total of 6,447 disability-adjusted life-years /year (95% uncertainty interval 6,288-6,606) and cost $41,182/year (UI 40,539-41,825) in terms of OR installation. The pediatric operating room had an incremental cost-effectiveness ratio of $6.39 per disability-adjusted life-year averted (95% uncertainty interval of 6.19-6.59), or $397.95 (95% uncertainty interval of 385.41-410.67) per life saved based on the country's average life expectancy in 2015. These values were well within the WHO guidelines of cost-effectiveness threshold. The net economic benefit amounted to $5,336,920 for a year of operation, or $16,371 per patient. The model remained robust with one-way and probabilistic sensitivity analyses.

CONCLUSION

The construction of a pediatric operating room in Uganda is a cost-effective and worthwhile investment, endorsing future decisions to enhance pediatric surgical capacity in the resource-limited settings of Sub-Saharan Africa.

A Model of the Unmet Need for Cleft Lip and Palate Surgery in Low- and Middle-Income Countries

BACKGROUND

There is a significant unmet need for the cleft lip and/or palate (CL/P) care in low- and middle-income countries (LMICs) ; however, country-level estimates that can be used to inform local and international cleft care program strategies are lacking.

METHODS

Using data from Operation Smile surgical programs in twelve LMICs and country-level indicators from the World Health Organization and World Bank, we developed a model to estimate the proportion of individuals with CL/Ps older than respective surgery age targets for cleft lip and cleft palate surgery (1 and 2 years, respectively). After extrapolating this model to other LMICs with available indicator data, we combined these findings with estimates of CL/P prevalence among live births to estimate the total number of unrepaired CL/P cases in LMICs worldwide.

RESULTS

The models were constructed from a total of 887 cases of cleft palate and 576 cases of cleft lip across the twelve countries. From these, we estimated that there are 616,655 cases of unrepaired CL/P (95 % CI 564,893-678,503) in the 113 countries with available data for extrapolation. The rate of unrepaired CL/Ps ranged from 2.5 per 100,000 population in Romania to 28.5 per 100,000 in Cambodia, respectively (median rate 10.7 per 100,000 population).

CONCLUSIONS

Our model provides marked insight into the global surgical backlog due to cleft lip and palate. While the most populated LMICs have the largest number of unrepaired CL/Ps, low-income countries with relatively less healthcare infrastructure have exceptionally high rates (e.g., Cambodia, Afghanistan, and Nepal). These estimates can be used by local and international cleft care organizations to set program priorities, estimate resource requirements, and inform strategies to support cleft care.

The impact and cost-effectiveness of the Amref Health Africa-Smile Train Cleft Lip and Palate Surgical Repair Programme in Eastern and Central Africa

Introduction

Cleft lip with or without cleft palate (CLP) is a congenital malformation that causes significant morbidity in low and middle income countries. Amref Health Africa has partnered with Smile Train to provide CLP surgeries since 2006.

Methods

We analyzed anonymized data of 37,274 CLP patients from the Smile Train database operated on in eastern and central Africa between 2006 and 2014. Cases were analyzed by age, gender, country and surgery type. The impact of cleft surgery was determined by measuring averted Disability-Adjusted Life Years (DALYs) and delayed averted DALYs. We used mean Smile Train costs to calculate cost-effectiveness. We calculated economic benefit using the human capital approach and Value of Statistical Life (VSL) methods.

Results

The median age at time of primary surgery was 5.4 years. A total of 207,879 DALYs were averted at a total estimated cost of US$13 million. Mean averted DALYs per patient were 5.6, and mean cost per averted DALY was $62.8. Total delayed burden of disease from late age at surgery was 36,352 DALYs. Surgical correction resulted in $292 million in economic gain using the human capital approach and $2.4 billion using VSL methods.

Conclusion

Cleft surgery is a cost-effective intervention to reduce disability and increase economic productivity in eastern and central Africa. Dedicated programs that provide essential CLP surgery can produce substantial clinical and economic benefits.

Estimate of Unmet Need for Cleft Lip and/or Palate Surgery in India

IMPORTANCE

The unmet need for cleft lip and/or palate (CL/P) care in India is significant. However, estimates required for CL/P care program planning are lacking.

OBJECTIVE

To estimate the unmet need for CL/P surgery in India at the state level.

DESIGN, SETTING, AND PARTICIPANTS

To determine the proportion of individuals with CL/P who presented for care in India, data were used from patients who received care at Operation Smile programs in 12 low- and middle-income countries from June 1, 2013, to May 31, 2014. The resulting model describes the prevalent unmet need for cleft surgery in India by state and includes patients older than the surgery target ages of 1 and 2 years for cleft lip and cleft palate repair, respectively. Next, the total number of unrepaired CL/P cases in each state was estimated using state-level economic and health system indicators.

MAIN OUTCOMES AND MEASURES

Prevalent unmet need for CL/P repair.

RESULTS

In the 28 states with available data, an estimated 72 637 cases of unrepaired CL/P (uncertainty interval, 58 644-97 870 cases) were detected. The percentage of individuals with unrepaired CL/P who were older than the respective target ages ranged from 37.0% (95% CI, 30.6%-43.8%) in Goa to 65.8% (95% CI, 60.3%-70.9%) in Bihar (median, 57.9%; interquartile range, 52.6%-63.4%). The rate of unrepaired CL/Ps ranged from less than 3.5 per 100 000 population in Kerala and Goa to 10.9 per 100 000 population in Bihar (median rate, 5.9 [interquartile range, 4.6-7.3] per 100 000 population).

CONCLUSIONS AND RELEVANCE

An estimated 72 000 cases of unrepaired CL/P are found in India. Poor states with less health care infrastructure have exceptionally high rates (eg, Bihar). These estimates are useful for informing international and national CL/P care strategies, allocating resources, and advocating for individuals and families affected by CL/P more broadly.

LEVEL OF EVIDENCE

NA.

Establishing disability weights for congenital pediatric surgical conditions: a multi-modal approach

BACKGROUND

Burden of disease (BoD) as measured by Disability-Adjusted Life Years (DALYs) is one of the criteria for priority-setting in health care resource allocation. DALYs incorporate disability weights (DWs), which are currently expert-derived estimates or non-existent for most pediatric surgical conditions. The objective of this study is to establish DWs for a subset of key pediatric congenital anomalies using a range of health valuation metrics with caregivers in both high- and low-resource settings.

METHOD

We described 15 health states to health professionals (physicians, nurses, social workers, and therapists) and community caregivers in Kenya and Canada. The health states summaries were expert- and community-derived, consisting of a narrated description of the disease and a functional profile described in EQ-5D-5 L style. DWs for each health state were elicited using four health valuation exercises (preference ranking, visual analogue scale (VAS), paired comparison (PC), and time trade-off (TTO)). The PC data were anchored internally to the TTO and externally to existing data to yield DWs for each health state on a scale from 0 (health) to 1 (dead). Any differences in DWs between the two countries were analyzed.

RESULTS

In total, 154 participants, matched by profession, were recruited from Kijabe, Kenya (n = 78) and Hamilton, Canada (n = 76). Overall calculated DWs for 15 health states ranged from 0.13 to 0.77, with little difference between countries (intra-class coefficient 0.97). However, DWs generated in Kenya for severe hypospadias and undescended testes were higher than Canadian-derived DWs (p = 0.04 and p < 0.003, respectively).

CONCLUSIONS

We have derived country-specific DWs for pediatric congenital anomalies using several low-cost methods and inter-professional and community caregivers. The TTO-anchored PC method appears best suited for future use. The majority of DWs do not appear to differ significantly between the two cultural contexts and could be used to inform further work of estimating the burden of global pediatric surgical disease. Care should be taken in comparing the DWs obtained in the current study to the existent list of DWs because methodological differences may impact on their compatibility.

Economic Valuation of the Global Burden of Cleft Disease Averted by a Large Cleft Charity

BACKGROUND

This study attempts to quantify the burden of disease averted through the global surgical work of a large cleft charity, and estimate the economic impact of this effort over a 10-year period.

METHODS

Anonymized data of all primary cleft lip and cleft palate procedures in the Smile Train database were analyzed and disability-adjusted life years (DALYs) calculated using country-specific life expectancy tables, established disability weights, and estimated success of surgery and residual disability probabilities; multiple age weighting and discounting permutations were included. Averted DALYs were calculated and gross national income (GNI) per capita was then multiplied by averted DALYs to estimate economic gains.

RESULTS

548,147 primary cleft procedures were performed in 83 countries between 2001 and 2011. 547,769 records contained complete data available for the study; 58 % were cleft lip and 42 % cleft palate. Averted DALYs ranged between 1.46 and 4.95 M. The mean economic impact ranged between USD 5510 and 50,634 per person. This corresponded to a global economic impact of between USD 3.0B and 27.7B USD, depending on the DALY and GNI values used. The estimated cost of providing these procedures based on an average reimbursement rate was USD 197M (0.7-6.6 % of the estimated impact).

CONCLUSIONS

The immense economic gain realized through procedures focused on a small proportion of the surgical burden of disease highlights the importance and cost-effectiveness of surgical treatment globally. This methodology can be applied to evaluate interventions for other conditions, and for evidence-based health care resource allocation.

Economic valuation of the impact of a large surgical charity using the value of lost welfare approach

Background

The assessment of the economic burden of surgical disease is integral to determining allocation of resources for health globally. We estimate the economic gain realised over an 11-year period resulting from a vertical surgical programme addressing cleft lip (CL) and cleft palate (CP).

Methods

The database from a large non-governmental organisation (Smile Train) over an 11-year period was analysed. Incidence-based disability-adjusted life years (DALYs) averted through the programme were calculated, discounted 3%, using disability weights from the Global Burden of Disease (GBD) study and an effectiveness factor for each surgical intervention. The effectiveness factor allowed for the lack of 100% resolution of the disability from the operation. We used the value of lost welfare approach, based on the concept of the value of a statistical life (VSL), to assess the economic gain associated with each operation. Using income elasticities (IEs) tailored to the income level of each country, a country-specific VSL was calculated and the VSL-year (VSLY) was determined. The VSLY is the economic value of a DALY, and the DALYs averted were converted to economic gain per patient and aggregated to give a total value and an average per patient. Sensitivity analyses were performed based on the variations of IE applied for each country.

Results

Each CL operation averted 2.2 DALYs on average and each CP operation 3.3. Total averted DALYs were 1 325 678 (CP 686 577 and CL 639 102). The economic benefit from the programme was between US$7.9 and US$20.7 billion. Per patient, the average benefit was between US$16 133 and US$42 351. Expense per DALY averted was estimated to be $149.

Conclusions

Addressing basic surgical needs in developing countries provides a massive economic boost through improved health. Expansion of surgical capacity in the developing world is of significant economic and health value and should be a priority in global health efforts.

Economic Analysis of Children's Surgical Care in Low- and Middle-Income Countries: A Systematic Review and Analysis

Background

Understanding the economic value of health interventions is essential for policy makers to make informed resource allocation decisions. The objective of this systematic review was to summarize available information on the economic impact of children’s surgical care in low- and middle-income countries (LMICs).

Methods

We searched MEDLINE (Pubmed), Embase, and Web of Science for relevant articles published between Jan. 1996 and Jan. 2015. We summarized reported cost information for individual interventions by country, including all costs, disability weights, health outcome measurements (most commonly disability-adjusted life years [DALYs] averted) and cost-effectiveness ratios (CERs). We calculated median CER as well as societal economic benefits (using a human capital approach) by procedure group across all studies. The methodological quality of each article was assessed using the Drummond checklist and the overall quality of evidence was summarized using a scale adapted from the Agency for Healthcare Research and Quality.

Findings

We identified 86 articles that met inclusion criteria, spanning 36 groups of surgical interventions. The procedure group with the lowest median CER was inguinal hernia repair ($15/DALY). The procedure group with the highest median societal economic benefit was neurosurgical procedures ($58,977). We found a wide range of study quality, with only 35% of studies having a Drummond score ≥ 7.

Interpretation

Our findings show that many areas of children’s surgical care are extremely cost-effective in LMICs, provide substantial societal benefits, and are an appropriate target for enhanced investment. Several areas, including inguinal hernia repair, trichiasis surgery, cleft lip and palate repair, circumcision, congenital heart surgery and orthopedic procedures, should be considered “Essential Pediatric Surgical Procedures” as they offer considerable economic value. However, there are major gaps in existing research quality and methodology which limit our current understanding of the economic value of surgical care.

Partnership in fellowship: Comparative analysis of pediatric surgical training and evaluation of a fellow exchange between Canada and Kenya

BACKGROUND

In pediatric surgery, significant differences in education and practice exist between developed and developing nations. We compared the training of senior fellows in a Canadian and a Kenyan pediatric surgery training program, and evaluated a fellow exchange between the programs.

METHODS

The study was performed six years after creation of the exchange program. Areas studied included case volume and distribution, length of training, curriculum, work hours, and an estimate of service to education ratio. Perceived strengths and challenges of the exchange were investigated using questionnaires.

RESULTS

Fellows at each site performed approximately 450 cases/year. Significant differences in case distribution were noted, with plastic surgery, urology and neurosurgery procedures being significantly more frequent in the Kenyan center, and neonatal, minimally invasive, and vascular access procedures being significantly more frequent in the Canadian center. All participants identified educational value in the exchange, although logistical challenges were significant.

CONCLUSION

Differences exist in the training experiences of pediatric surgical fellows in Canada and Kenya, reflecting the differences in health care environment, education, and surgical practice in the two countries. The exchange program of pediatric surgical fellows tapped into this rich diversity and may be applicable to other medical and surgical specialty training programs.

Alveolar Bone Graft: Clinical Profile and Risk Factors for Complications in Oral Cleft Patients

OBJECTIVE

The aim of this study was to investigate clinical aspects and predisposing factors for alveolar bone graft complications in persons born with oral clefts.

DESIGN

A total of 105 patients, aged 7 to 57 years old, who received alveolar bone graft at the Cranio-maxillofacial Surgery Center in the National Institute of Traumatology and Orthopedics (INTO), Rio de Janeiro (RJ) from 2009 to 2014 were selected. Data were collected concerning the type of oral cleft, family history of cleft, medical and dental exam, donor area, type of graft material, repaired surgical treatment done, and postoperative follow-up examinations.

RESULTS

Postoperative complications developed in 31 patients (32.9%). The mean age at grafting was 16.79 years for the group without complications (n = 63) and 20.13 years for the group with postoperative complications (n = 31). There was a positive association between age and type of graft and cases with alveolar bone graft complications. Patients aged 12 years or more had a four times more chance of developing alveolar bone graft complications. Particulate bone graft from iliac crest demonstrated better results compared with block graft or mixed graft.

CONCLUSION

Patients with cleft lip and palate who were 12 years or older had a greater chance of developing complications after grafting the alveolar bone. Furthermore, particulate alveolar graft from iliac crest had significantly better outcomes.

Measuring and Comparing the Cost-Effectiveness of Surgical Care Delivery in Low-Resource Settings: Cleft Lip and Palate as a Model

Cleft lip and palate (CLP) care is the longest sustained global effort in humanitarian surgical care. However, the relative cost-effectiveness of surgical delivery approaches remains largely unknown. We assessed the cost-effectiveness of two strategies of CLP surgical care delivery in low resource settings: medical mission and comprehensive care center. We evaluated the medical records and costs for 17 India-based medical missions and a Comprehensive Cleft Care Center in Guwahati, India, from Operation Smile, a humanitarian nongovernmental organization. Age, sex, diagnosis, and procedures were extracted and cost/Disability-Adjusted Life Year (DALY) averted was calculated using a provider's perspective. The disability weights for CLP from the Global Burden of Disease (GBD) 2010 update were used as the reference case. Sensitivity analysis was performed using various disability weights, age-weighting, discounting, and cost perspective. The medical missions treated 3503 patients for first-time cleft procedures and averted 6.00 DALYs per intervention with a cost-effectiveness of $247.42/DALY. The care center cohort included 2778 patients with first-time operations for CLP and averted a mean of 5.96 DALYs per intervention with a cost-effectiveness of $189.81/DALY. The Incremental Cost-Effectiveness Ratio (ICER) of choosing medical mission over care center is $462.55. The care center provides cleft care with a higher cost-effectiveness, although both models are highly cost-effective in India, in accordance with WHO guidelines. Compared to other global health interventions, cleft care is very cost-effective and investment in cleft surgery might be realistic and achievable in similar resource-constrained environments.

An investment in knowledge: Research in global pediatric surgery for the 21st century

The body of literature addressing surgical and anesthesia care for children in low- and middle-income countries (LMICs) is small. This lack of research hinders full understanding of the nature of many surgical conditions in LMICs and compromises potential efforts to alleviate the significant health, welfare and economic burdens surgical conditions impose on children, families and countries. This article will evaluate the need for improved global pediatric surgery research by (1) presenting the current state of surgical research for children in LMICs and (2) discussing methods and opportunities for improvement within the political context of current global health priorities.

Pediatric surgery as an essential component of global child health

Recent initiatives in global health have emphasized universal coverage of essential health services. Surgical conditions play a critical role in child health in resource-poor areas. This article discusses (1) the spectrum of pediatric surgical conditions and their treatment; (2) relevance to recent advances in global surgery; (3) challenges to the prioritization of surgical care within child health, and possible solutions; (4) a case example from a resource-poor area (Uganda) illustrating some of these concepts; and (5) important child health initiatives with which surgical services should be integrated. Pediatric surgery providers must lead the effort to prioritize children's surgery in health systems development.

The burden of pediatric surgical disease in low-resource settings: Discovering it, measuring it, and addressing it

Global surgery has come of age as an emerging discipline poised to impact health care worldwide with a concerted plan of action and wide stakeholder support. Much less can be said about global pediatric surgery, despite a growing awareness of the global burden of pediatric surgical disease. The author describes his exposure to this burden of disease as a pediatric surgeon working in resource-limited countries in Africa and outlines his personal journey from recognizing the burden to measuring it and eventually attempting to address it. The article, based on the Hugh Greenwood International Lecture at the 2015 BAPS Congress, reviews what is known so far within global pediatric surgery, what is currently happening, and what lies ahead.

Developing pediatric surgery in low- and middle-income countries: An evaluation of contemporary education and care delivery models

There are several different models of education and care delivery models in low- and middle-income countries (LMICs), and many endeavors combine more than one of the described models. This article summarizes the burden of pediatric surgical disease and discusses the benefits and shortcomings of the following: faith-based missions; short-term surgical trips; partnerships, twinning, and academic collaborations; teaching workshops, "train the trainer," and pediatric surgery camps; specialty treatment centers; online conferences, telemedicine, and mobile health; specific programs for exchange and education; and training in high-income countries (HICs), fellowships, and observorships. It then addresses ethical concerns common to all humanitarian pediatric surgical efforts.