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