Despite the high population of children, increasing surgical disease burden and shortage of pediatric surgeons, as well as limited infrastructure, children's surgical care in low- and middle-income ...countries (LMICs) has been neglected for decades. This has contributed to unacceptably high morbidity and mortality, long term disabilities and economic loss to families. The work of the global initiative for children's surgery (GICS) has raised the profile and visibility of children's surgery in the global health space. This has been achieved a philosophy of inclusiveness, LMIC participation, focus on LMIC needs and high income country (HIC) support, and driven by implementation to change on the ground situations. Children's operating rooms are being installed to strengthen infrastructure and children's surgery is being gradually included in national surgical plans to provide the policy framework to support children's surgical care. In Nigeria, pediatric surgery workforce has increased from 35 in 2003 to 127 in 2002, but the density remains low at 0.14 per 100,000 population <15 years. Education and training have been strengthened with the publication of a pediatric surgery textbook for Africa and creation of a Pan Africa pediatric surgery e-learning platform. However, financing children's surgery in LMICs remains a barrier as many families are at risk of catastrophic healthcare expenditure. The success of these efforts provides encouraging examples of what can be collectively achieve by appropriate and mutually beneficial global north-south collaborations. Pediatric surgeons need to commit their time, knowledge and skills, as well as experience and voices to strengthen children's surgery globally to impact more lives, for the overall good of more.
In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast ...and cervical cancer. The provision of safe and affordable surgical and anaesthesia care when needed not only reduces premature death and disability, but also boosts welfare, economic productivity, capacity, and freedoms, contributing to long-term development.
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).
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.
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.
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.
Background
National surgical policies have been increasingly adopted by African countries over the past decade. This report is intended to provide an overview of the current state of adoption of ...national surgical healthcare policies in Africa, and to draw a variety of lessons from representative surgical plans in order to support transnational learning.
Methods
Through a desk review of available African national surgical healthcare plans and written contributions from a committee comprising six African surgical policy development experts, a few key lessons from five healthcare plans were outlined and iteratively reviewed.
Results
The current state of national surgical healthcare policies across Africa was visually mapped, and lessons from a few compelling examples are highlighted. These include the power of initiative from Senegal; regional leadership from Zambia; contextualization, and renewal of commitment from Ethiopia; multidisciplinary focus and creation of multiple implementation entry points from Nigeria; partnerships and involvement of multiple stakeholders from Rwanda; and the challenge of surgical policy financing from Tanzania. The availability of global expertise, the power of global partnerships, and the critical role of health ministries and Ministers of Health in planning and implementation have also been highlighted.
Conclusions
Strategic planning for surgical healthcare improvement is at various stages across the continent, with potential for countries to learn from one another. Convenings of stakeholders and Ministers of Health from countries at various stages of strategic surgical plan development, execution, and evaluation can enhance African surgical policy development through the exchange of ideas, lessons, and experiences.
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. 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. 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.
Efforts from the developed world to improve surgical, anesthesia and obstetric care in low- and middle-income countries have evolved from a primarily volunteer mission trip model to a sustainable ...health system strengthening approach as private and public stakeholders recognize the enormous health toll and financial burden of surgical disease. The National Surgical, Obstetric and Anesthesia Plan (NSOAP) has been developed as a policy strategy for countries to address, in part, the health burden of diseases amenable to surgical care, but these plans have not developed in isolation. The NSOAP has become a phenomenon of globalization as a broad range of partners - individuals and institutions - help in both NSOAP formulation, implementation and financing. As the nexus between policy and action in the field of global surgery, the NSOAP reflects a special commitment by state actors to make progress on global goals such as Universal Health Coverage and the United Nations Sustainable Development Goals. This requires a continued global commitment involving genuine partnerships that embrace the collective strengths of both national and global actors to deliver sustained, safe and affordable high-quality surgical care for all poor, rural and marginalized people.
Abstract Most of the world is in a surgical workforce crisis. While a lack of human resources is only one component of the myriad issues affecting surgical care in resource-poor regions, it is ...arguably the most consequential. This article examines the current state of the pediatric surgical workforce in low- and middle-income countries (LMICs) and the reasons for the current shortfalls. We also note progress that has been made in capacity building and discuss priorities going forward. The existing literature on this subject has naturally focused on regions with the greatest workforce needs, particularly sub-Saharan Africa (SSA). However, wherever possible we have included workforce data and related literature from LMICs worldwide. The pediatric surgeon is of course critically dependent on multi-disciplinary teams. Surgeons in high-income countries (HICs) often take for granted the ready availability of excellent anesthesia providers, surgically trained nurses, radiologists, pathologists, and neonatologists among many others. While the need exists to examine all of these disciplines and their contribution to the delivery of surgical services for children in LMICs, for the purposes of this review, we will focus primarily on the role of the pediatric surgeon.
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