Available online 25 November 2023, 151346

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Challenges:

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1.7 billion children are deprived of surgical care due to economic, political and social factors that lead to inequitable healthcare.

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90% of children live in LMICs where surgical ecosystems are often deficient with regards to children-specific infrastructure and health providers

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Nearly half the population in LMICs lives in rural areas, however most surgical facilities are concentrated in urban centers with limited access due to poor infrastructure and costly or difficult transportation.

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The cycle of poverty is difficult to break; it affects a family's ability to attain education and resources which can hinder the identification, understanding and treatment of surgical problems.

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There is a lack of political will, both on regional and global fronts, to mobilize resources to improve surgical access in general, but particularly for children.

A Call to Action:•

Children's surgery must be recognised as an essential component of both childhood and surgical care policies and initiatives.

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To improve outcomes, the general health of a child must be made a priority. This entails promotion of a safe and healthy environment, good reproductive and antenatal health, along with regular checkups.

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Local surgical systems must be strengthened by raising awareness, increasing training opportunities and improving infrastructure.

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Health facilities should be categorized according to resource availability and there should be locally relevant expectations of care at each resource level. Referral systems must be developed to avoid late presentations and mismanagement.

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Global health funders and political stakeholders must be engaged to raise funds for children's surgery, with a focus on equitable distribution of resources.

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Population control may be a sustainable long-term solution to correct the disbalance between need and resources, particularly in rapidly growing countries with a poor economic forecast.

Section snippetsInequity

There are major obstacles at global and national levels that contribute to inequity in children's health. While health care is recognized as a human right it has become a veritable commodity. A child belonging to a low-income country is destined to have a drastically different health journey than one who belongs to a high-income country. According to UNICEF's estimates, children born in low-income countries are 14 times more likely to die before reaching 5 years of age than children born in

Barriers and Challenges

Cultural barriers

Children do not play an active role in decisions regarding their health; instead, their health depends on household circumstances and family members. Many of children's problems arise from generational unattainability of nutrition and healthcare and this cycle of poverty is difficult to break. For instance, poor maternal nutrition can lead to prematurity and low birth weight which may predispose a child to a variety of surgical or medical health conditions that may even affect

Economic barriers

Surgical expenses, both medical and non-medical costs, pose a major barrier to surgical access (29). Aside from the direct hospital expenses of surgery, anesthesia, investigations and outpatient and inpatient care, there are miscellaneous expenses on travel and accommodation. Globally, almost a quarter of people who undergo a surgical procedure incur financial catastrophe. This burden falls more heavily on low and lower-middle income countries, particularly on those in the lower socioeconomic

Customizing health services to children's needs

Adequate and appropriate materials must be made available for good surgical results. It is unjust to assume that one size fits all, when children are not recognized as a distinct entity with separate needs from adults. A surgical ecosystem —consisting of multidisciplinary teams, appropriate infrastructure and processes involved in providing all surgical subdisciplines, anesthesia, and intensive care—must be created specifically for the child. These multidisciplinary teams may include

Access

Distance to surgical centers and care availability are determined to be the main spatial predictors of unmet surgical need (41). In the US, more than 90% of children live within a 2-hour radius from a facility that offers pediatric surgery (42). Among the different states of Nigeria, the percentage of Nigerian children with 2-hour access to paediatric surgical services varies from less than 2% to 31% (43). This means that most children do not have access to timely surgical care and can be

Political will

Low-income countries rely on external funds for about 29% of their health expenditure but less than 1% of health aid from high-income countries to LMICs is devoted to surgical care (45,46). Multilateral organizations like the WHO and UNICEF, along with NGOs have played a monumental role in promoting children's health. Thus, in 2015 when the World Health Assembly's Resolution 68.15 prioritized emergency and essential surgery and anesthesia services as part of its agenda, the explicit inclusion

What must happen?

Surgery as an essential component in childhood care policies and indicators:

The solution primarily lies in recognizing that children's surgical burden represents a significant portion of the surgical workload. The first step in the advocacy process would be to create region specific databases of the met and unmet surgical needs of children. Local governments and NGOs should then be recruited for the compilation and consequent utilization of this data. Registries with quality data should be made

Awareness and early diagnosis

Early diagnosis is of the essence and can save children from the morbidity and complications associated with delayed care. Campaigns to bring awareness to healthcare givers and to the population about pediatric surgical diseases can help minimize the cultural barriers.

Short- and long-term training investment in all levels of human resources for children's care should be planned. Local models of education and training of health professionals should be introduced in areas with low physician

Access to effective health systems

Health facilities should be categorized according to resource availability and there should be nationally developed, locally relevant expectations of care at each resource level. Guidelines or recommendations should be established using a resource stratification framework for effective management strategies and optimal utilization of the available resources. Resource stratification may be used at either the regional or facility level, although intraregional resource variation can be expected.

Training of dedicated surgical workforce for children

It is important to invest in the training of surgeons and multidisciplinary teams to deal with pediatric surgical conditions. Brain drain should be avoided with political models that facilitate the trained surgeon to stay where needed. Hybrid training models including HIC and regional hubs, added by political will, with actions to retain surgeons where they are needed and provide adequate resources locally can minimize the brain drain.

Holistic approach to the health of children

Attention should be paid to primary and secondary prevention. The general health of a child is a major determinant of outcomes, especially surgical outcomes. It is the right of each child to grow up in a safe living environment and have access to clean water and food; however, for this, strong financial backing must be leveraged. Focus should be directed towards reproductive health and antenatal care. Antenatal screening and neonatal physician evaluation play a key role in the detection and

Funding for children's' surgery

Surgery is a highly effective modality of treatment and contributes to equity in all populations. At first, it can seem expensive, but having an adequate surgical structure benefits many other parts of the hospitals. A strong investment case for children's surgery needs to be developed to attract global health funders. Explicit inclusion of pediatric surgery in health budget allocation and government policies should be made a priority. The Lancet Commission on Global Surgery (LCoGS) introduced

Population control

Population control may be a sustainable long-term solution to the disbalance between need and resources, especially for countries with a poor economic forecast that are experiencing rapid population growth. However, we must act with urgency to mobilize resources in a more equitable way to address the crisis at hand.

Conclusion

A significant surgical burden exists among children in LMICs, yet there is limited access to surgical care in these regions as a result of internal and external factors. A lack of political commitment to expand surgical services, particularly children's services, is a key factor. As a first step, there needs to be a broad recognition that surgical services are an indispensable part of children's health. Surgical care for children can be optimized through advocacy, strategic investments in

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