Analysis of Financial Risk Protection Indicators in Myanmar for Paediatric Surgery

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.

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.

Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa

BACKGROUND

Out-of-pocket healthcare costs leading to catastrophic healthcare expenditure pose a financial threat for families of children undergoing surgery in Sub-Saharan African countries, where universal healthcare coverage is often insufficient.

METHODS

A prospective clinical and socioeconomic data collection tool was used in African hospitals with dedicated pediatric operating rooms installed philanthropically. Clinical data were collected via chart review and socioeconomic data from families. The primary indicator of economic burden was the proportion of families with catastrophic healthcare expenditures. Secondary indicators included the percentage who borrowed money, sold possessions, forfeited wages, and lost a job secondary to their child's surgery. Descriptive statistics and multivariate logistic regression were performed to identify predictors of catastrophic healthcare expenditure.

RESULTS

In all, 2,296 families of pediatric surgical patients from 6 countries were included. The median annual income was $1,000 (interquartile range 308-2,563), whereas the median out-of-pocket cost was $60 (interquartile range 26-174). Overall, 39.9% (n = 915) families incurred catastrophic healthcare expenditure, 23.3% (n = 533) borrowed money, 3.8% (n = 88%) sold possessions, 26.4% (n = 604) forfeited wages, and 2.3% (n = 52) lost a job because of the child's surgery. Catastrophic healthcare expenditure was associated with older age, emergency cases, need for transfusion, reoperation, antibiotics, and longer length of stay, whereas the subgroup analysis found insurance to be protective (odds ratio 0.22, P = .002).

CONCLUSION

A full 40% of families of children in sub-Saharan Africa who undergo surgery incur catastrophic healthcare expenditure, shouldering economic consequences such as forfeited wages and debt. Intensive resource utilization and reduced insurance coverage in older children may contribute to a higher likelihood of catastrophic healthcare expenditure and can be insurance targets for policymakers.

Financing Pediatric Surgery: A Provider's Perspective from the Global Initiative for Children's Surgery

BACKGROUND

Half the world's population is at risk of catastrophic health expenditure (CHE, out-of-pocket spending of more than 10% of annual expenditure) should they require surgery. Protection against CHE is a key indicator of successful health care delivery and has been identified as a priority area by the Global Initiative for Children's Surgery (GICS). Data specific to pediatric surgical patients is limited. This study examines the financial risks for pediatric surgical patients and their families from a provider's perspective.

METHODS

We surveyed GICS members about the existing financial protection mechanisms and estimated expenditures for their patients. Questions were structured based on the National Surgical, Obstetric and Anesthesia Planning Surgical Indicators and finalized based on multi-institutional consensus between high-income country and low-and middle-income country (LMIC) providers. Chi-squared test, Fisher's exact test and student's t-test were used as appropriate.

RESULTS

Among 107 respondents, 72.4% were from low income or lower-middle income (LIC/LMIC) countries, and 55.1% were attending or consultant physicians. Families were most likely to decline surgery in LIC/LMIC due to inability to afford treatment (mean Likert = 3.77 ± 1.06). The odds of incurring CHE after children's surgery are up to 17 times greater in LIC/LMIC (P = 0.001, unadjusted OR 17.28, 95%CI 2.13-140.02). Over 50% of families of children undergoing major surgery in these settings face CHE. An estimated 5.1% of providers in LIC/LMIC and 56.2% (P < 0.001) of providers in UMIC/HIC reported that families are able to pay for their direct medical costs with the assistance available to them and were more likely to sell assets (74.4% vs. 33.3%, P = 0.005).

CONCLUSION

Patients in LMICs are at greater risk for CHE and have less financial risk protection than their HIC counterparts. Given this disparity, intervention is needed to make safe surgery affordable for children worldwide.

Long-Term Impact of a Low-Cost Paediatric Intussusception Air Enema Reduction Simulation-Based Education Programme in a Low-Middle Income Country

INTRODUCTION

Intussusception is one of the commonest causes of bowel obstruction in infants. Most infants in Low- and Middle-Income Countries (LMICs) undergo an invasive operative intervention. Supported by simulation-based education (SBE), the Air Enema (AE) non-operative technique was introduced in 2016 in Myanmar. This study assesses the long-term outcomes.

METHODS

Mixed methods study design over 4 years including clinical outcomes and surgeon's attitudes towards the AE technique and SBE. Prospectively collected clinical outcomes and semi-structured interview with reflexive thematic analysis (RTA). Primary outcome measure was a long-term shift to non-operative intervention.

SECONDARY OUTCOMES

Length of Stay (LoS), recurrence rates, intestinal resection rates, compared to the operative group. The data was analysed according to intention to treat. Quantitative data analysis with Mann-Whitney U test, Fisher's exact test, Student's T-Test or Wilcoxon Signed-Rank Test utilised. A p-value of <.05 was considered significant.

RESULTS

A total of 311 infants with intussusception were included. A sustained shift to AE was revealed with high success rates (86.1-91.2%). AE had a reduced LoS (4 vs. 7 days p ≤ 0.0001), Duration of Symptoms (DoS) was lower with AE (1.9/7 vs. 2.5/7, p = 0.002). Low recurrence rates (0-5.8%) and intestinal resection rates stabilised at 30.5-31.8% vs.15.3% pre-intervention. Four RTA themes were identified: Expanding conceptions of healthcare professional education and training; realising far reaching advantages; promoting critical analysis and reflective practice of clinicians; and adapting clinical practice to local context. RTA revealed an overall positive paradigm shift in attitudes and application of SBE.

CONCLUSIONS

A sustained change in clinical outcomes and appreciation of the value of SBE was demonstrated following the intervention.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report

BACKGROUND

Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally.

METHODS AND FINDINGS

The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees.

CONCLUSIONS

To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.