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

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.

Pediatric Surgery Collaboration in Uganda, the Benefits of Long Term Partnerships at Regional Referral Hospitals

Background

In 2022 there were only seven pediatric surgeons in Uganda, but approximately 170 are needed. Consequently, Ugandan general surgeons treat most pediatric surgical problems at regional hospitals. Accordingly, stakeholders created the Pediatric Emergency Surgery Course, which teaches rural providers identification, resuscitation, treatment and referral of pediatric surgical conditions. In order to improve course offerings and better understand pediatric surgery needs we collected admission and operative logbook data from four participating sites. One participating site, Lacor Hospital, rarely referred patients and had a much higher operative volume. Therefore, we sought to understand the causes of this difference and the resulting economic impact.

Methods

Over a four-year period, data was collected from logbooks at four different regional referral hospitals in Uganda. Patients ≤ 18 years old with a surgical diagnosis were included. Patient LOS, referral volume, age, and case type were compared between sites and DALYs were calculated and converted into monetary benefit.

Results

Over four sites, 8,615 admissions, and 5,457 cases were included. Lacor patients were younger, had a longer length of stay, and were referred less. Additionally, Lacor's long-term partnerships with a high-income country institution, a missionary organization, and visiting Ugandan and international pediatric surgeons were unique. In 2018, the pediatric surgery case volume was: Lacor (967); Fort Portal (477); Kiwoko (393); and Kabale (153), resulting in a substantial difference in long-term monetary health benefit.

Conclusion

Long-term international partnerships may advance investments in surgical infrastructure, workforce, and education in low- and middle-income countries. This collaborative model allows stakeholders to make a greater impact than any single institution could make alone.

Understanding pediatric surgical needs in North Korea: a modeling analysis

Background

Sixty-five percent of children worldwide lack access to surgical care, the majority of whom live in low-income and middle-income countries (LMICs). Developing surgical infrastructure requires information on surgical need; however, this information is often limited in LMICs. North Korea (Democratic People's Republic of Korea, DPRK) has a low amount of publicly available data. Here, we analyzed available modeled data to understand the causes of pediatric deaths due to conditions treatable with surgery in DPRK.

Methods

We used World Bank data and models from the Institute for Health Metrics and Evaluation to identify causes of pediatric deaths affecting pediatric patients (age <20 years). We compared mortality of disease between DPRK and countries with similar economic status.

Results

Between 1990 and 2019, the number of overall pediatric deaths has decreased. In 2019, 32.2% of all pediatric deaths in DPRK were caused by surgical conditions. The leading categories of surgical conditions were injuries (53.9%), congenital conditions (34.2%), tumors (8.8%), and abdominal conditions (3.2%). DPRK has a lower relative rate of pediatric deaths compared with other LMICs with similar gross domestic product per capita. However, it has a higher relative rate of pediatric deaths due to conditions requiring treatment with surgery. Transport injuries contribute significantly to the high rate of pediatric deaths in DPRK.

Conclusions

Although DPRK may be allocating overall resources toward pediatric healthcare more efficiently than economic peers, DPRK may benefit from improvement in pediatric surgical capacity. Improved availability of data and close international collaboration could be potential solutions to bridge this gap.

The Pediatric Emergency Surgery Course: Impact on Provider Practice in Rural Uganda

PURPOSE

The Pediatric Emergency Surgery Course (PESC) trains rural Ugandan providers to recognize and manage critical pediatric surgical conditions. 45 providers took PESC between 2018 and 2019. We sought to assess the impact of the course at three regional hospitals: Fort Portal, Kabale, and Kiwoko.

METHODS

We conducted a retrospective cohort study. Diagnosis, procedure, and patient outcome data were collected twelve months before and after PESC from admission and theater logbooks. We also assessed referrals from these institutions to Uganda's two pediatric surgery hubs: Mulago and Mbarara Hospitals. Wilcoxon rank-sum and Pearson's chi-squared tests compared pre- and post-PESC measures. Interrupted time-series-analysis assessed referral volume before and after PESC.

RESULTS

1534 admissions and 2148 cases were documented across the three regional hospitals. Kiwoko made 539 referrals, while pediatric surgery hubs received 116 referrals. There was a statistically significant immediate increase in the number of referrals from Fort Portal, from 0.5 patients/month pre-PESC to 0.8 post-PESC (95 % CI 0.03-1.51). Moving averages of the combined number of pyloromyotomy, intussusception reductions, and hernia repairs at the rural hospitals also increased post-course. Neonatal time to referral and referred patient age were significantly lower after PESC delivery.

CONCLUSION

Our data suggest that PESC increased referrals to tertiary centers and operative volume of selected cases at rural hospitals and shortened time to presentation at sites receiving referrals. PESC is a locally-driven, validated, clinical education intervention that improves timely care of pediatric surgical emergencies and merits further support and dissemination.

TYPE OF STUDY

Retrospective Cohort Study.

LEVEL OF EVIDENCE

III.

Global children's surgery: Economic and policy priorities

An estimated two-thirds of the world's children and adolescents, most of whom live in low- and middle- income countries lack access to safe, quality, and timely surgical care. While much efforts have been made in the last decade to advocate for children' surgery, several economic and policy gaps remain, hampering progress and investments. These gaps range from lack of adequate data on costs and cost-effectiveness, high rate of out-of-pocket payments and limited health insurance coverage, to non-inclusion of children's surgical care in public child health policies and surgical plans. Given the magnitude of the limitations, actions and initiatives need to be prioritised to facilitate coordinated investments. Urgent investments are required to generate reliable and convincing data on costs of children's surgical care, as well as costs of equipment and supplies. To support actions and initiatives, children's surgery should be included in any existing and planned child public health initiatives and surgical plans. Integration of injury prevention and early identification of surgical conditions into school health initiatives would also strengthen care. The overall return on investment in children's surgical care are enormous with implications for child survival, family, and society stability as well as country workforce and economy. Investments should be well coordinated at country, regional and global levels to avoid waste of resources and duplication of efforts, while encouraging convergence of efforts.

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.

Impact of new dedicated pediatric operating rooms on surgical volume in Africa: Evidence from Nigeria

BACKGROUND

There is a large unmet children's surgical need in low- and middle-income countries (LMICs). This study examines the impact of installing dedicated pediatric operating rooms (ORs) on surgical volume at National Hospital Abuja, a hospital in Abuja, Nigeria.

METHODS

A Non-Governmental Organization installed two pediatric ORs in August 2019. We assessed changes in volume from July 2018 to September 2021 using interrupted time series analysis.

RESULTS

Total surgical volume increased by 13 cases (p = 0.01) in 1-month post-installation, with elective operations making up 85% (p = 0.02) of cases. There was an increase in elective volume by about 1 case per month (p = 0.01) post-installation and the difference between pre-and post-trends was 1.23 cases per month (p = 0.009). The baseline volume of neonatal surgeries increased by 9 cases per month (p < 0.001) post-installation and this difference between pre- and post-trends was statistically significant (p = 0.001). Similarly, one-month post-installation, the cases classified as ASA class >2 increased by 14 (p < 0.001). There was no significant difference between pre-and post-installation mortality rate at about 2% per month.

CONCLUSIONS

There were significant changes in surgical volume after OR installation, primarily composed of elective operations, reflecting an increased capacity to address surgical backlogs and/or perform more specialized surgeries. Despite a significant increase in volume and higher ASA class, there was no significant difference in mortality. This study supports the installation of surgical infrastructure in LMICs to strengthen capacity without increasing postoperative mortality.

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.

Does community-based health insurance protect women from financial catastrophe after cesarean section? A prospective study from a rural hospital in Rwanda

BACKGROUND

The implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the > 79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%. However, 55.5% of the population is below the international poverty line meaning that even this copay can have a significant impact on a family's financial health. The aim of this study was to estimate the burden of OOP payments for cesarean sections in the context of CBHI and determine if having it reduces catastrophic health expenditure (CHE).

METHODS

This study is nested in a larger randomized controlled trial of women undergoing cesarean section at a district hospital in Rwanda. Eligible patients were surveyed at discharge to quantify household income and routine monthly expenditures and direct and indirect spending related to the hospitalization. This was used in conjunction with hospital billing records to calculate the rate of catastrophic expenditure by insurance group.

RESULTS

About 94% of the 340 women met the World Bank definition of extreme poverty. Of the 330 (97.1%) with any type of health insurance, the majority (n = 310, 91.2%) have CBHI. The average OOP expenditure for a cesarean section and hospitalization was $9.36. The average cost adding transportation to the hospital was $19.29. 164 (48.2%) had to borrow money and 43 (12.7%) had to sell possessions. The hospital bill alone was a CHE for 5.3% of patients. However, when including transportation costs, 15.4% incurred a CHE and including lost wages, 22.6%.

CONCLUSION

To ensure universal health coverage (UHC), essential surgical care must be affordable. Despite enrollment in universal health insurance, cesarean section still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although CBHI protects against CHE from the cost of healthcare, when adding in the cost of transportation, lost wages and caregivers, cesarean section is still often a catastrophic financial event. Further innovation in financial risk protection is needed to provide equitable UHC.

Building towards equitable access to safe surgery for every child

Kids Operating Room (KidsOR) is a global health charity focused entirely on helping transform surgical care for children around the world. KidsOR corroborates and puts into practice the argument of the Lancet Commission on Global Surgery that surgical care is a valuable investment and should be incorporated as an essential component of a functioning health care system. Moreover, by investing in local capacities, we distance ourselves from the status quo of international health aid, more specifically short-term medical missions and specific disease interventions. Our focus is to integrate the capabilities inherent to the country in the development of human resources that fosters greater local empowerment. As a result, despite the challenges of the time, we have shipped a pristine Operating Room to a partner hospital on average once every 12 days. Our strategy also includes a funding programme that supports the development and training of local surgeons and anaesthetists. By 2030 we have committed to open 120 new Operating Rooms in Africa, and we expect to achieve 1.2 million years averted of Disability Adjusted Life Years (DALYs) for every year of full activity in our Operating Rooms as well as to strengthen the economies across sub-Saharan Africa economies by a combined total of 2.5 billion US dollars a year. We also look to the future and advocate for a new aid model for the 21st century in consonance with the principles encouraged by the 1978 Alma Ata Declaration and aiming to make health for all more than a slogan. LEVEL OF EVIDENCE: : IV.

Cost-effectiveness of paediatric surgery: an economic evaluation of World Paediatric Project surgical interventions in St. Vincent and the Grenadines (2002–2019)

Objectives

The purpose of this study is to examine the cost-effectiveness of six types of surgical interventions as part of a sustained paediatric surgical programme in St.Vincent and the Grenadines from 2002 to 2019.

Design

In this economic model, six paediatric surgical interventions (ophthalmic, orthopaedic, plastic, general, urology, neurosurgery) were compared with no surgery in a deterministic cost-effectiveness model. We assessed health benefits as averted disability-adjusted life-years (DALYs). Costs were included from the programme perspective and measured using standard micro-costing methods. Incremental cost-effectiveness ratios (ICERs) were calculated for each type of surgical intervention. Interventions with ICERs of <50% of gross domestic product (GDP) per capita were considered cost-effective. Costs are reported in 2019 US$. Univariate sensitivity analyses were conducted to assess the effect of uncertainty.

Results

The average cost per procedure was US$16 685 (range: US$9791.78–US$72 845.76). The cumulative discounted 18-year health impact was 5815 DALYs averted with a cost per DALY averted of US$2622. Most paediatric surgical interventions were cost-effective, yielding cost per DALY estimates less than 50% of GDP per capita of St. Vincent and the Grenadines. When undiscounted, only orthopaedic surgeries had cost per DALY more than 50% GDP per capita. When considering discounting, orthopaedic and urology surgeries exceeded the adopted threshold for cost-effectiveness.

Conclusions

We found that short-term, recurrent surgical interventions could yield substantial economic benefits in this limited resource setting. This research indicates that investment in paediatric surgical interventions is cost-effective for the majority of specialties. These findings are of clinical significance given the large burden of disease attributable to surgically treatable diseases. This work demonstrates that scaling up dedicated surgical programmes for children is a cost-effective and essential component to improve paediatric health.

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.

Best Buy in Public Health or Luxury Expense?: The Cost-effectiveness of a Pediatric Operating Room in Uganda From the Societal Perspective

OBJECTIVE

To determine the cost-effectiveness of building and maintaining a dedicated pediatric operating room (OR) in Uganda from the societal perspective.

BACKGROUND

Despite the heavy burden of pediatric surgical disease in low-income countries, definitive treatment is limited as surgical infrastructure is inadequate to meet the need, leading to preventable morbidity and mortality in children.

METHODS

In this economic model, we used a decision tree template to compare the intervention of a dedicated pediatric OR in Uganda for a year versus the absence of a pediatric OR. Costs were included from the government, charity, and patient perspectives. OR and ward case-log informed epidemiological and patient outcomes data, and measured cost per disability adjusted life year averted and cost per life saved. The incremental cost-effectiveness ratio (ICER) was calculated between the intervention and counterfactual scenario. Costs are reported in 2015 US$ and inflated by 5.5%.

FINDINGS

In Uganda, the implementation of a dedicated pediatric OR has an ICER of $37.25 per disability adjusted life year averted or $3321 per life saved, compared with no existing operating room. The ICER is well below multiple cost-effectiveness thresholds including one times the country's gross domestic product per capita ($694). The ICER remained robust under 1-way and probabilistic sensitivity analyses.

CONCLUSION

Our model ICER suggests that the construction and maintenance of a dedicated pediatric operating room in sub-Saharan Africa is very-cost effective if hospital space and personnel pre-exist to staff the facility. This supports infrastructure implementation for surgery in sub-Saharan Africa as a worthwhile investment.

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.

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.

Burden of Surgical Infections in a Tertiary-Care Pediatric Surgery Service in Uganda

Background: Delayed presentation of surgical disease often leads to infection in low- and middle-income countries (LMICs). In addition, many primary infections require surgical intervention. The burden of infection in children's surgery in LMICs is poorly defined and may tax the limited availability of surgical resources. Methods: A prospective surgical database was reviewed for all children presenting to a Ugandan tertiary referral hospital from January 2012 to August 2016. All patients presenting with infection were included and analyzed by operative intervention and survival. Results: Of the 3,494 children admitted over the time period, 712 (20.4%) presented with infection. A total of 455 patients (64%) with an infection underwent an operation, with an in-hospital mortality rate of 12.5%. Operations involving infections represented 20% of the volume of the children's surgery department. Common conditions were abscesses (n = 308; 43.4%), typhoid intestinal perforations (n = 85; 12.0%), appendicitis (n = 78; 11.0%) and perforated bowel caused by ileocolic intussusception (n = 37; 5.2%). Patients with esophageal atresia presenting with aspiration pneumonia had an in-hospital mortality rate of 78.6%, those with abdominal sepsis a 67% mortality rate, and neonatal infants with necrotizing enterocolitis a 50% mortality rate. Conclusion: There is a high volume of infection in children requiring surgery, contributing to a high mortality rate. Resource allocation for children's surgical care in LMIC should be directed toward timely diagnosis and surgical intervention of these conditions.

Burden and Outcomes of Neonatal Surgery in Uganda: Results of a Five-Year Prospective Study

BACKGROUND

Ninety-four percent of congenital anomalies occur in low- and middle-income countries. In Uganda, only three pediatric surgeons and three pediatric anesthesiologists serve more than 20 million children. This study estimates burden, outcomes, coverage, and economic benefit of neonatal surgical conditions in Uganda.

METHODS

A prospectively collected database was reviewed for neonatal surgical admissions from January 1, 2012, to December 31, 2017, at the only two sites with specialist pediatric surgical coverage. Outcomes were compared with high-income countries. Met and unmet need were estimated using disability-adjusted life years. Economic benefit was estimated using a value of statistical life-year approach.

RESULTS

For 1313 neonatal admissions, the median age of presentation was 3 d, overall mortality was 36%, and median distance traveled was 40 km. Anorectal malformations were most common (18%). Postoperative mortality was 24%. Mortality was significantly associated with surgical intervention (P < 0.0001). Met need was 4181 disability-adjusted life years per year, which corresponds to a $3.5 million net economic benefit to Uganda, with a potential additional benefit of $153 million if unmet need were fully addressed. Approximately 2% of the total need is met by the health care system.

CONCLUSIONS

Neonatal surgery is associated with improved survival for most conditions. Despite increases in workforce and infrastructure, a limited proportion of the need for neonatal surgery is currently being met. This is multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial.

Global children's surgery: recent advances and future directions

PURPOSE OF REVIEW

Two-thirds of the world's population lacks access to surgical care, many of them being children. This review provides an update on recent advances in global children's surgery.

RECENT FINDINGS

Surgery is being increasingly recognized as an essential component of global and child health. There is a greater focus on sustainable collaborations between high-income countries (HICs) and low-and-middle-income countries (HICs and LMICs). Recent work provides greater insight into the global disease burden, perioperative outcomes and effective context-specific solutions. Surgery has continued to be identified as a cost-effective intervention in LMICs. There have also been substantial advances in research and advocacy for a number of childhood surgical conditions.

SUMMARY

Substantial global disparities persist in the care of childhood surgical conditions. Recent work has provided greater visibility to the challenges and solutions for children's surgery in LMICs. Capacity-building and scale up of children's surgical care, more robust implementation research and ongoing advocacy are needed to increase access to children's surgical care worldwide.

Barriers to Pediatric Surgical Care in Low-Income Countries: The Three Delays' Impact in Uganda

BACKGROUND

We sought to understand the challenges in accessing pediatric surgical care in the context of the "three delays" model at the Pediatric Surgery Outpatient Clinic (PSOPC) at a tertiary hospital in Kampala, Uganda.

MATERIALS AND METHODS

An outpatient database was established at the weekly PSOPC. A survey regarding prior healthcare visits and barriers to care was additionally administered to clinic patients and inpatients.

RESULTS

Patients first sought healthcare a median of 56 d before the current visit to the PSOPC. A majority (52%) of patients first sought care at another health facility, and 17% of those surveyed had presented to the PSOPC three or more times for their current medical issue. Of 240 patients with a new issue or due for their next surgery, 10% were admitted to the ward, with only 54% receiving definitive care. Included in the most commonly needed surgeries for PSOPC patients were herniotomy (16% inguinal; 14.9% umbilical), orchiopexy (6.3%), posterior sagittal anorectoplasty (6.3%), and colostomy closure (4.4%), with the range of patient ages at the time of presentation reflecting delays in care. Patient expenditures associated with travel to the hospital showed inpatients coming from significantly further away, with higher costs of travel and need to borrow or sell assets to cover travel costs, when compared with PSOPC patients.

CONCLUSIONS

Patients face significant delays in accessing and receiving definitive surgical care. Associated burdens associated with these delays place patients at risk for catastrophic health expenditures. Infrastructure and capacity development are necessary for improvement in pediatric surgical care.

Global paediatric surgery: meeting an unmet need—the response of the British Association of Paediatric Surgeons

AIM

Outline the response from an organisation regarding the unmet needs in global children's surgery METHOD: The burden of global surgical disease, whilst daunting, is becoming increasingly better defined as agencies, surgical colleges and professional specialty associations all attempt to increase capacity in terms of manpower, support education and find sustainable solutions to the deficit of health in treating women and children. However, definition of the problem does not in itself create change and similarly, humanitarian activities including volunteering by established surgical practitioners and other non-governmental organisations (NGOs) make only marginal improvement in the standards of care on offer at a global level.

RESULTS

The International Affairs Committee, British Association of Paediatric Surgeons (BAPS) has had its target firmly set on investing in potential leaders within paediatric surgery in low- and middle-income countries (LMICs), and sharing elements of the educational programme made available for training within the UK and Ireland with the aim of contributing to the solutions of inequity in the surgical standards available to the world's children.

CONCLUSION

This article outlines some of the practical steps that have been deployed by BAPS by way of sharing the responsibility for problem-solving at a global level. It also highlights the need for clarity in advocacy and the route through which effective communication can translate into wider and more effective delivery of surgical care for children.