Search

Congenital conditions comprise a significant portion of the global burden of surgical conditions in children. In Somaliland, over 250,000 children do not receive required surgical care annually, although the estimated costs and benefits of scale-up of children's surgical services to address this disease burden is not known.We developed a Markov model using a decision tree template to project the costs and benefits of scale-up of surgical care for children across Somaliland. We used a proxy set of congenital anomalies across Somaliland to estimate scale-up costs using three different scale-up rates. The cost-effectiveness ratio and net societal monetary benefit were estimated using these models, supported by disability weights in existing literature.Overall, we found that scale-up of surgical services at an aggressive rate (22.5%) over a 10-year time horizon is cost effective. Although the scale-up of surgical care for most conditions in the proxy set was cost effective, scale-up of hydrocephalus and spina bifida are not as cost effective as other conditions.Our analysis concludes that it is cost effective to scale-up surgical services for congenital anomalies for children in Somaliland.

There are complex barriers that increase delays to surgical care in low- and middle-income countries, particularly among the vulnerable population of children. Understanding these barriers to surgical care can result in targeted and strategic intervention efforts to improve care for children. The three-delay model is a widely used framework in global health for evaluating barriers associated with seeking (D1), reaching (D2), and receiving health care (D3). The goal of our study is to evaluate reasons for delays in the surgical care for children in Somaliland using the three-delay framework. Data were collected in a cross-sectional study in Somaliland from 1503 children through a household survey. Among children with a surgical need, we quantified the number of children seeking, reaching, and receiving care along the surgical care continuum, according to the three-delay framework. We evaluated predictors of the three delays through a multivariate logistic regression model, including the child’s age, gender, village type, household income level, region, and household size. Of the 196 children identified with a surgical condition, 50 (27.3%) children had a delay in seeking care (D1), 28 (20.6%) children had a delay in reaching care (D2), and 84 (71.2%) children had a delay in receiving care (D3), including 10 children who also experienced D1 and D2. The main reasons cited for D1 included seeking a traditional healthcare provider, while lack of money and availability of care were main reasons cited for D2. Significant predictors for delays included household size for D1 and D3 and condition type and region for D2. Children in Somaliland experience several barriers to surgical care along the entire continuum of care, allowing for policy guidance tailored to specific local challenges and resources. Since delays in surgical care for children can substantially impact the effectiveness of surgical interventions, viewing delays in surgical care under the lens of the three-delay framework can inform strategic interventions along the pediatric surgical care continuum, thereby reducing delays and improving the quality of surgical care for children.

BackgroundThe global burden of disease in children is large and disproportionally affects low-income and middle-income countries (LMICs). Geospatial analysis offers powerful tools to quantify and visualise disparities in surgical care in LMICs. Our study aims to analyse the geographical distribution of paediatric surgical conditions and to evaluate the geographical access to surgical care in Somaliland.MethodsUsing the Surgeons OverSeas Assessment of Surgical Need survey and a combined survey from the WHO’s (WHO) Surgical Assessment Tool—Hospital Walkthrough and the Global Initiative for Children’s Surgery Global Assessment in Paediatric Surgery, we collected data on surgical burden and access from 1503 children and 15 hospitals across Somaliland. We used several geospatial tools, including hotspot analysis, service area analysis, Voronoi diagrams, and Inverse Distance Weighted interpolation to estimate the geographical distribution of paediatric surgical conditions and access to care across Somaliland.ResultsOur analysis suggests less than 10% of children have timely access to care across Somaliland. Patients could travel up to 12 hours by public transportation and more than 2 days by foot to reach surgical care. There are wide geographical disparities in the prevalence of paediatric surgical conditions and access to surgical care across regions. Disparities are greater among children travelling by foot and living in rural areas, where the delay to receive surgery often exceeds 3 years. Overall, Sahil and Sool were the regions that combined the highest need and the poorest surgical care coverage.ConclusionOur study demonstrated wide disparities in the distribution of surgical disease and access to surgical care for children across Somaliland. Geospatial analysis offers powerful tools to identify critical areas and strategically allocate resources and interventions to efficiently scale-up surgical care for children in Somaliland.

ObjectivesThe optimal size of the health workforce for children’s surgical care around the world remains poorly defined. The goal of this study was to characterise the surgical workforce for children across Brazil, and to identify associations between the surgical workforce and measures of childhood health.DesignThis study is an ecological, cross-sectional analysis using data from the Brazil public health system (Sistema Único de Saúde).Settings and participantsWe collected data on the surgical workforce (paediatric surgeons, general surgeons, anaesthesiologists and nursing staff), perioperative mortality rate (POMR) and under-5 mortality rate (U5MR) across Brazil for 2015.Primary and secondary outcome measuresWe performed descriptive analyses, and identified associations between the workforce and U5MR using geospatial analysis (Getis-Ord-Gi analysis, spatial cluster analysis and linear regression models).FindingsThere were 39 926 general surgeons, 856 paediatric surgeons, 13 243 anaesthesiologists and 103 793 nurses across Brazil in 2015. The U5MR ranged from 11 to 26 deaths/1000 live births and the POMR ranged from 0.11–0.17 deaths/100 000 children across the country. The surgical workforce is inequitably distributed across the country, with the wealthier South and Southeast regions having a higher workforce density as well as lower U5MR than the poorer North and Northeast regions. Using linear regression, we found an inverse relationship between the surgical workforce density and U5MR. An U5MR of 15 deaths/1000 births across Brazil is associated with a workforce level of 5 paediatric surgeons, 200 surgeons, 100 anaesthesiologists or 700 nurses/100 000 children.ConclusionsWe found wide disparities in the surgical workforce and childhood mortality across Brazil, with both directly related to socioeconomic status. Areas of increased surgical workforce are associated with lower U5MR. Strategic investment in the surgical workforce may be required to attain optimal health outcomes for children in Brazil, particularly in rural regions.

Investing in surgery has been highlighted as integral to strengthening overall health systems and increasing economic prosperity in low-income and middle-income countries (LMICs). The provision of surgical care in LMICs not only affects economies on a macro-level, but also impacts individual families within communities at a microeconomic level. Given that children represent 50% of the population in LMICs and the burden of unmet surgical needs in these areas is high, investing pediatric-specific components of surgical and anesthesia care is needed. Implementation efforts for pediatric surgical care include incorporating surgery-specific priorities into the global child health initiatives, improving global health financing for scale-up activities for children, increasing financial risk protection mechanisms for families of children with surgical needs, and including comprehensive pediatric surgical models of care into country-level plans.

Metrics to measure the burden of surgical conditions, such as disability weights (DWs), are poorly defined, particularly for pediatric conditions. To summarize the literature on DWs of children’s surgical conditions, we performed a systematic review of disability weights of pediatric surgical conditions in low- and middle-income countries (LMICs). For this systematic review, we searched MEDLINE for pediatric surgery cost-effectiveness studies in LMICs, published between January 1, 1996, and April 1, 2017. We also included DWs found in the Global Burden of Disease studies, bibliographies of studies identified in PubMed, or through expert opinion of authors (ES and HR). Out of 1427 publications, 199 were selected for full-text analysis, and 30 met all eligibility criteria. We identified 194 discrete DWs published for 66 different pediatric surgical conditions. The DWs were primarily derived from the Global Burden of Disease studies (72%). Of the 194 conditions with reported DWs, only 12 reflected pre-surgical severity, and 12 included postsurgical severity. The methodological quality of included studies and DWs for specific conditions varied greatly. It is essential to accurately measure the burden, cost-effectiveness, and impact of pediatric surgical disease in order to make informed policy decisions. Our results indicate that the existing DWs are inadequate to accurately quantify the burden of pediatric surgical conditions. A wider set of DWs for pediatric surgical conditions needs to be developed, taking into account factors specific to the range and severity of surgical conditions.

BackgroundExisting data suggest a large burden of surgical conditions in low- and middle-income countries (LMICs). However, surgical care for children in LMICs remains poorly understood. Our goal was to define the hospital infrastructure, workforce, and delivery of surgical care for children across Somaliland and provide policy guidance to improve care.MethodsWe used two established hospital assessment tools to assess infrastructure, workforce, and capacity at all hospitals providing surgical care for children across Somaliland. We collected data on all surgical procedures performed in children in Somaliland between August 2016 and July 2017 using operative logbooks.ResultsData were collected from 15 hospitals, including eight government, five for-profit, and two not-for-profit hospitals. Children represented 15.9% of all admitted patients, and pediatric surgical interventions comprised 8.8% of total operations. There were 0.6 surgical providers and 1.2 anesthesia providers per 100,000 population. A total of 1255 surgical procedures were performed in children in all hospitals in Somaliland over 1 year, at a rate of 62.4 surgical procedures annually per 100,000 children. Care was concentrated at private hospitals within urban areas, with a limited number of procedures for many high-burden pediatric surgical conditions.ConclusionsWe found a profound lack of surgical capacity for children in Somaliland. Hospital-level surgical infrastructure, workforce, and care delivery reflects a severely resource-constrained health system. Targeted policy to improved essential surgical care at local, regional, and national levels is essential to improve the health of children in Somaliland.

Key Points Question What is the prevalence of pediatric surgical conditions in Somaliland? Findings In this cross-sectional study that included 1503 children in Somaliland, the prevalence of pediatric surgical conditions was 12.2%. Only 23.7% of surgical conditions had been corrected at the time of this study. Meaning A scale-up of pediatric surgical infrastructure and resources to provide the needed surgical care for children in low- and middle-income countries is warranted., This cross-sectional study measures the prevalence of pediatric surgical conditions across Somaliland using a nationwide community-based household survey., Importance Although surgical conditions are increasingly recognized as causing a significant health care burden among adults in low- and middle-income countries (LMICs), the burden of surgical conditions among children in LMICs remains poorly defined. Objective To estimate the prevalence of pediatric surgical conditions across Somaliland using a nationwide community-based household survey. Design, Setting, and Participants This cross-sectional study was conducted through a national community-based sampling survey from August through December 2017 in Somaliland. Participants were 1503 children surveyed using the Surgeons OverSeas Assessment of Surgical Need (SOSAS). Main Outcomes and Measures The SOSAS survey contains 2 components, including a section on household demographics, deaths, and financial information and sections querying children’s history of surgical conditions. Results In this cross-sectional study that included 1503 children (55.6% male; mean [SE] age, 6.4 [0.1] years), 221 surgical conditions were identified among 196 children, yielding a mean (SE) prevalence of pediatric surgical conditions of 12.2% (1.5%). Only 53 of these 221 surgical conditions (23.7%) had been surgically corrected at the time of the survey. The most common conditions encountered were congenital anomalies (33.8%) and wound-related injuries (24.6%). Nationally, an estimated 256 745 children have surgical conditions, with an estimated 88 345 to 199 639 children having unmet surgical needs. Conclusions and Relevance Using national sampling, this study found that children have a high burden of surgical conditions in Somaliland. These data highlight the need for a scale-up of pediatric surgical infrastructure and resources to provide the needed surgical care for children in LMICs.