Global children's surgery: Economic and policy priorities.

An estimated two-thirds of the world's children and adolescents, most of whom live in low- and middle- income countries lack access to safe, quality, and timely surgical care. While much efforts have been made in the last decade to advocate for children' surgery, several economic and policy gaps remain, hampering progress and investments. These gaps range from lack of adequate data on costs and cost-effectiveness, high rate of out-of-pocket payments and limited health insurance coverage, to non-inclusion of children's surgical care in public child health policies and surgical plans. Given the magnitude of the limitations, actions and initiatives need to be prioritised to facilitate coordinated investments. Urgent investments are required to generate reliable and convincing data on costs of children's surgical care, as well as costs of equipment and supplies. To support actions and initiatives, children's surgery should be included in any existing and planned child public health initiatives and surgical plans. Integration of injury prevention and early identification of surgical conditions into school health initiatives would also strengthen care. The overall return on investment in children's surgical care are enormous with implications for child survival, family, and society stability as well as country workforce and economy. Investments should be well coordinated at country, regional and global levels to avoid waste of resources and duplication of efforts, while encouraging convergence of efforts.

Burden of Complicated Intra-Abdominal Infections in Children in Nigeria: Recent Experience and Systematic Review.

Background: Intra-abdominal infections encompass a wide range of conditions from uncomplicated appendicitis to fecal peritonitis. Little is known about the burden of complicated intra-abdominal infection (cIAIs) in children in low- and middle-income countries (LMICs). Method: This a report of recent experience and a systematic review of the burden in Nigeria. Results: Of 85 children with cIAIs, the most common primary cause was typhoid intestinal perforation (54; 63.5%) and complicated appendicitis (20; 23.5%). The complication rate after surgery was high, including surgical site infection (SSI) in 49 (57.6%), post-operative intra-abdominal abscess in 14 (16.5%), and complete abdominal wound dehiscence in 13 (15.3%). The rate of re-operation was 19 (22.4%) and 12 (14.1%) patients required re-admission for adhesion intestinal obstruction and unresolved SSI. Eight (9.4%) died from overwhelming infection. Systematic review revealed only a few publications, but these were mostly on specific causes of cIAIs and publications providing comprehensive data are lacking. Conclusion: Investment in research into cIAIs in children in LMICs is needed. Efforts need to be focused on the role of source control in reducing the high complication rate and mortality.

Choice of Future Location of Surgical Practice: A Survey of Surgical Trainees in Nigeria and Implications for Timely Access to Surgical Care.

BACKGROUND: There is inequity and maldistribution of the surgical workforce in Nigeria. Most specialists practice in second- and third-level hospitals often located in urban or semi-urban areas. A knowledge of the proposed choice of practice location of surgical trainees and the factors that influence the choice could provide insight into future surgical coverage and help in planning and policy-making. METHODS: This is a cross-sectional survey of surgical trainees attending the mandatory integrated revision and update course of the West African College of Surgeons. Anonymous structured questionnaires were self-administered to 200 trainees, of which 143 completed the questionnaires. RESULTS: The response rate was 71.5%. One hundred and six (74.1%) trainees preferred to work in a tertiary hospital on completion of training, 13 (9.1%) were in a Private Hospital, and 16 (11.2%) were undecided. Nearly all tertiary hospitals are in urban or semi-urban towns. The commonest factors influencing choice of practice location were proximity to family 19 (13.3%), proximity to hometown 11 (7.6%), availability of working facilities 10 (6.9%), income 7 (4.9%) and underserved areas 7 (4.9%). Of 122 (85.3%) trainees who agreed to work for some period each year (ranging from 1 week to 6 months) in a rural setting, 42 (29.3%) would do it without additional financial incentive. CONCLUSION: The choice of most surgical trainees not to work in a rural setting as specialists would exacerbate the ongoing surgical workforce maldistribution and inequity in Nigeria. However, the willingness of 85.3% to provide periodic rural surgical coverage could be leveraged in planning of initiatives to address the maldistribution.

Developing Metrics to Define Progress in Children's Surgery.

There is a need for relevant, valid, and practical metrics to better quantify both need and progress in global pediatric surgery and for monitoring systems performance. There are several existing surgical metrics in use, including disability-adjusted life years (DALYs), surgical backlog, effective coverage, cost-effectiveness, and the Lancet Commission on Global Surgery indicators. Most of these have, however, not been yet applied to children's surgery, leaving therefore significant data gaps in the burden of disease, infrastructure, human resources, and quality of care assessments in the specialty. This chapter reviews existing global surgical metrics, identifies settings where these have been already applied to children's surgery, and highlights opportunities for further inquiry in filling the knowledge gaps. Directing focused, intentional knowledge translation efforts in the identified areas of deficiency will foster the maturation of global pediatric surgery into a solid academic discipline able to contribute directly to the cause of improving the lives of children around the world.