Elsevier

Journal of Pediatric Surgery

Volume 47, Issue 12, December 2012, Pages 2305-2311
Journal of Pediatric Surgery

Independent review article
The burden of pediatric surgical conditions in low and middle income countries: A call to action

https://doi.org/10.1016/j.jpedsurg.2012.09.030Get rights and content

Abstract

Recently, the role of surgery in global health has gained greater attention, although pediatric surgery has received little specific emphasis. This paper highlights pediatric surgical conditions as a part of global public health, and identifies gaps in knowledge and possible areas of action for the global pediatric surgical community. The burden of disease concept is discussed with examples of its application to pediatric surgery, and further information required to improve measurement of the global burden of pediatric surgical conditions. In addition, selected tools to measure access to surgical care and the unmet need for surgery in low and middle-income countries (LMICs) are reviewed, with recent innovative approaches and other possible adaptations to pediatric surgery. Finally, some of the strategies used to improve access to care for pediatric surgical conditions are discussed, with possible future directions.

Section snippets

Why pediatric surgery and global public health?

There are multiple reasons why pediatric surgery has an important role to play in global public health. First, the global burden of surgical conditions is significant, and injuries and congenital anomalies, which disproportionately affect children, predominate among them [5]. Secondly, the global volume of surgical procedures is considerable (234 million/year), and unacceptable disparities exist between high and LMICs in the proportion of procedures performed and access to care [6]. Thirdly,

The global burden of disease and pediatric surgery

The burden of disease (BoD) concept was introduced in 1990 and proposed the unique health metric termed the DALY (“disability-adjusted-life-year”), including not only mortality, but morbidity as well [11]. Subsequent DALY estimates increased to 140 conditions, their sequelae, and risk factors. By the most recent 2006 estimate, 11% of the global BoD is secondary to surgical conditions — led by injuries, complications of childbirth, congenital anomalies, and non-communicable diseases (See Fig. 1)

Access to pediatric surgery and unmet need in LMICs

Few studies have measured access to pediatric surgery in LMICs. Most are retrospective single-institution reports, typically relying on data retrieved from hospital logbooks. Such studies from Malawi, Uganda, and Tanzania have reported limited surgical output per population compared to higher income countries [23], [24], [25]. The Ugandan study, the only one specific to children, found only 172 operations performed per 100,000 population, with the majority supported by externally funded groups

Barriers to access

A skilled workforce and adequate infrastructure are required to deliver surgical services. A recent study has emphasized the significant shortage of pediatric surgeons in Africa, with tens of millions of children served by either no or one pediatric surgeon [30]. Other reports have cited perhaps the greatest workforce barrier—lack of personnel trained to provide pediatric anesthesia [31]. In addition, many factors such as cost of transport, broken referral systems, the traditional healer

Strategies to improve access to Care

Access can be increased by improving the infrastructure, the workforce, or by addressing the social barriers listed above. Strengthening the capacity of existing training programs is critical, and while partnerships can help, existing models have not yet been critically analyzed [41], [42]. Voluntary efforts such as those coordinated by the Global Pediatric Surgery Network can temporarily improve the workforce shortage, and useful educational and training resources for pediatric surgery in

Conclusions

The burden of disease and disparities in access to the surgical care of children in LMICs are of great importance to the global pediatric surgery community and deserve greater attention. Some prior and recent efforts have called attention to this issue [4], [48]. This paper has reviewed several concepts in BoD and has discussed tools to improve calculations and strategies for access to pediatric surgical care. It is the authors' hope that this will inform global development in the specialty,

Acknowledgments

The authors would like to acknowledge Richard Gosselin, MD of the Institute for Global Orthopedics and Traumatology (IGOT) and faculty member at the University of California at Berkeley, School of Public Health for providing critical feedback on the manuscript.

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