Children's surgery and the emergency, critical, and operative care resolution: Immediate actions to eliminate disparities in surgery, anesthesia, and perioperative care for all children.

Around 1.7 billion children lack access to surgical care worldwide. To reinvigorate the efforts to address these disparities and support work to address global challenges in surgery, anesthesia, emergency, and critical care, the World Health Assembly passed World Health Organization Resolution World Health Assembly 76.2: Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies (ECO) in 2023. This resolution highlights the integral role of surgery, anesthesia, and perioperative care in health systems. However, understanding how best to operationalize this resolution is challenging. We review the ECO resolution and highlight points that the pediatric surgical and anesthesia community can leverage to advocate for its recommendations for operative care.

Picture Cards Versus Physical Examination: A Proof-of-Concept Study to Improve the SOSAS Survey Tool.

INTRODUCTION: The Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool is used to determine the unmet surgical needs in the community and has been validated in several countries. A major weakness is the absence of an objective assessment to verify patient-reported surgically treatable conditions. The goal of this study was to determine whether a picture portfolio, a tool previously shown to improve parental recognition of their child's congenital deformity, could improve the accuracy of the SOSAS tool by how it compares with physical examination. This study focused on children as many surgical conditions in them require prompt treatment but are often not promptly diagnosed. METHODS: We conducted a descriptive cross-sectional community-based study to determine the prevalence of congenital and acquired surgical conditions among children and adults in a mixed rural-urban area of Lagos, Southwest Nigeria. The picture portfolio was administered only to children and the surgical conditions to be assessed were predetermined using an e-Delphi process among pediatric surgeons. The modified The Surgeons OverSeas Assessment of Surgical Needs-Nigeria Survey Tool (SOSAS-NST) was administered to household members to collect other relevant data. Data were analyzed using the REDCap analytic tool. RESULTS: Eight hundred and fifty-six households were surveyed. There were 1984 adults (49.5%) and 2027 children (50.5%). Thirty-six children met the predetermined criteria for the picture portfolio-hydrocephalus (n = 1); lymphatic malformation (n = 1); umbilical hernia (n = 14); Hydrocele (n = 5); inguinal hernia (n = 10) and undescended testes (n = 5). The picture portfolio predicted all correctly except a case of undescended testis that was mistaken for a hernia. The sensitivity of the picture portfolio was therefore 35/36 or 97.2%. CONCLUSIONS: The SOSAS-NST has improved on the original SOSAS tool and within the limits of the small numbers, the picture portfolio has a high accuracy in predicting diagnosis in children in lieu of physical examination.

National Surgical Healthcare Policy Development and Implementation: Where do We Stand in Africa?

BACKGROUND: National surgical policies have been increasingly adopted by African countries over the past decade. This report is intended to provide an overview of the current state of adoption of national surgical healthcare policies in Africa, and to draw a variety of lessons from representative surgical plans in order to support transnational learning. METHODS: Through a desk review of available African national surgical healthcare plans and written contributions from a committee comprising six African surgical policy development experts, a few key lessons from five healthcare plans were outlined and iteratively reviewed. RESULTS: The current state of national surgical healthcare policies across Africa was visually mapped, and lessons from a few compelling examples are highlighted. These include the power of initiative from Senegal; regional leadership from Zambia; contextualization, and renewal of commitment from Ethiopia; multidisciplinary focus and creation of multiple implementation entry points from Nigeria; partnerships and involvement of multiple stakeholders from Rwanda; and the challenge of surgical policy financing from Tanzania. The availability of global expertise, the power of global partnerships, and the critical role of health ministries and Ministers of Health in planning and implementation have also been highlighted. CONCLUSIONS: Strategic planning for surgical healthcare improvement is at various stages across the continent, with potential for countries to learn from one another. Convenings of stakeholders and Ministers of Health from countries at various stages of strategic surgical plan development, execution, and evaluation can enhance African surgical policy development through the exchange of ideas, lessons, and experiences.

Routine Pediatric Surgical Emergencies: Incidence, Morbidity, and Mortality During the 1st 8000 Days of Life-A Narrative Review.

BACKGROUND: Many potentially treatable non-congenital and non-traumatic surgical conditions can occur during the first 8000 days of life and an estimated 85% of children in low- and middle-income countries (LMICs) will develop one before 15 years old. This review summarizes the common routine surgical emergencies in children from LMICs and their effects on morbidity and mortality. METHODS: A narrative review was undertaken to assess the epidemiology, treatment, and outcomes of common surgical emergencies that present within the first 8000 days (or 21.9 years) of life in LMICs. Available data on pediatric surgical emergency care in LMICs were aggregated. RESULTS: Outside of trauma, acute appendicitis, ileal perforation secondary to typhoid fever, and intestinal obstruction from intussusception and hernias continue to be the most common abdominal emergencies among children in LMICs. Musculoskeletal infections also contribute significantly to the surgical burden in children. These "neglected" conditions disproportionally affect children in LMICs and are due to delays in seeking care leading to late presentation and preventable complications. Pediatric surgical emergencies also necessitate heavy resource utilization in LMICs, where healthcare systems are already under strain. CONCLUSIONS: Delays in care and resource limitations in LMIC healthcare systems are key contributors to the complicated and emergent presentation of pediatric surgical disease. Timely access to surgery can not only prevent long-term impairments but also preserve the impact of public health interventions and decrease costs in the overall healthcare system.

Surgically Correctable Congenital Anomalies: Reducing Morbidity and Mortality in the First 8000 Days of Life.

BACKGROUND: Congenital anomalies are a leading cause of morbidity and mortality worldwide. We aimed to review the common surgically correctable congenital anomalies with recent updates on the global disease burden and identify the factors affecting morbidity and mortality. METHOD: A literature review was done to assess the burden of surgical congenital anomalies with emphasis on those that present within the first 8000 days of life. The various patterns of diseases were analyzed in both low- and middle-income countries (LMIC) and high-income countries (HIC). RESULTS: Surgical problems such as digestive congenital anomalies, congenital heart disease and neural tube defects are now seen more frequently. The burden of disease weighs more heavily on LMIC. Cleft lip and palate has gained attention and appropriate treatment within many countries, and its care has been strengthened by global surgical partnerships. Antenatal scans and timely diagnosis are important factors affecting morbidity and mortality. The frequency of pregnancy termination following prenatal diagnosis of a congenital anomaly is lower in many LMIC than in HIC. CONCLUSION: Congenital heart disease and neural tube defects are the most common congenital surgical diseases; however, easily treatable gastrointestinal anomalies are underdiagnosed due to the invisible nature of the condition. Current healthcare systems in most LMICs are still unprepared to tackle the burden of disease caused by congenital anomalies. Increased investment in surgical services is needed.

Estimates of Treatable Deaths Within the First 20 Years of Life from Scaling Up Surgical Care at First-Level Hospitals in Low- and Middle-Income Countries.

BACKGROUND: Surgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life. METHODS: Epidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries. RESULTS: An estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year. CONCLUSIONS: Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

Impact of corona virus disease 2019 pandemic on paediatric surgery in a sub-saharan tertiary hospital: An observational study.

Background: The impact of the corona virus disease 2019 (COVID-19) pandemic on global health, has reached far beyond that caused by the disease itself. With ongoing mutations and the emergence of new strains of the virus alongside repeated waves of the pandemic, the full impact of the pandemic is still evolving and remains difficult to predict or evaluate. In paediatric surgery, it has led to significant disruptions in patient care, the extent and consequence of which are not fully documented in Nigeria. Aim: This study aims to evaluate the impact of COVID-19 on services, training and research in a busy paediatric surgery unit during the initial 3-month period of the COVID-19 pandemic lockdown. Methods: This study was an ambispective evaluation of the preceding 3 months before lockdown and the initial 3 months of lockdown. Clinic cancellations, elective and emergency surgeries, delays in access, extra cost of care to patients, impact on training and research, and the psychologic impact of the pandemic on staff and guardians were evaluated. Results: During the 3-month lockdown period, an estimated 78 new cases and 637 follow-up cases could not access care. Ninety-seven elective surgeries in 91 patients were postponed. Two (2.2%) patients' symptoms progressed. All emergency patients received care. Out-of-pocket expenditure increased averagely by $124. The pandemic contributed to delays in seeking (13%), reaching (20%) and receiving care (6%). Trainee participation in surgeries was reduced and academic programmes were suspended. Five staff were exposed to the virus and 3 infected. Conclusion: Paediatric surgery has been negatively impacted by COVID-19. Efforts must focus on planning and implementing interventions to mitigate the long-term impact.

Evaluation of the effect of nutritive versus non-nutritive pacifiers as adjuncts to local anaesthesia in male neonatal circumcision using the plastibell technique - A prospective randomised controlled study.

Background: Male circumcision is the most common surgical procedure worldwide and is often carried out for religious, cultural, medical and public health reasons. It is commonly performed during the neonatal period. Many studies have now shown that pain is a common intra- and post-operative complication. To ensure proper analgesia during the procedure, many surgeons opt for the use of pacifiers as an adjunct to anaesthesia during neonatal circumcision. The aim of this study is to compare nutritive pacifiers (NPs) versus non-NPs (NNPs) as adjuncts to local anaesthesia in male neonatal circumcision using the Plastibell technique. Methods: A prospective randomised controlled study was carried out between October 2019 and March 2020. A total of 100 neonates were circumcised using the Plastibell technique and randomised into NP (Group A, n = 33), NNP (Group B, n = 33) and controls (Group C, n = 34), respectively. The differences in pain scores using the Neonatal Infant Pain Scale, total crying time and heart rate during circumcision were recorded and assessed. Results: The age of participants ranged from 5 to 28 days and the weight ranged from 2.5 to 5.0 kg. The overall mean age, birth weight and current weight of the participants were 15.5 ± 6.1 days, 3.4 ± 0.4 kg and 3.5 ± 0.6 kg, respectively. The control group had the highest average pain score of 5.5 (4.5-5.8) compared to the intervention groups with median pain score (NP: 3.3 [1.3-4.3] and (NNP: 4.3 [3.1-5.1], respectively). NPs had significantly lower pain scores (P = 0.023) and reduced total crying time (P = 0.019) at all stages of the circumcision compared to those given NNPs and controls. Conclusion: This study showed that NPs were superior to NNPs in providing additional pain control during male neonatal circumcision.

National surgical, obstetric, anaesthesia and nursing plan, Nigeria.

Recent evidence suggests that strengthening surgical care within existing health systems will strengthen the overall health-care system. However, Nigeria's national strategic health development plan 2018-2022 placed little emphasis on surgical care. To address the gap, we worked with professional societies and other partners to develop the national surgical, obstetric, anaesthesia and nursing plan 2019-2023. The aim was to foster actions to prioritize surgical care for the achievement of universal health coverage. In addition to creating a costed strategy to strengthen surgical care, the plan included children's surgery and nursing: two key aspects that have been neglected in other national surgical plans. Pilot implementation of the plan began in 2020, supported by a nongovernmental organization with experience in surgical care in the region. We have created specific entry points to facilitate the pilot implementation. In the pilot, an electronic surgery registry has been created; personnel are being trained in life support; nurses are being trained in safe perioperative care; biomedical technicians and sterile supplies nurses are being trained in surgical instrument repair and maintenance; and research capacity is being strengthened. In addition, the mainstream media are being mobilized to improve awareness about the plan among policy-makers and the general population. Another development partner is interested in providing support for paediatric surgery, and a children's hospital is being planned. As funding is a key challenge to full implementation, we need innovative domestic funding strategies to support and sustain implementation.

De récentes preuves suggèrent que le renforcement des soins chirurgicaux au sein des systèmes de santé existants entraînera un renforcement du système tout entier. Pourtant, le plan 2018­2022 de développement stratégique de la santé au Nigeria n'accorde que peu d'importance à ces soins. Pour remédier au problème, nous avons travaillé avec des associations professionnelles ainsi que d'autres partenaires afin de mettre au point le plan national de chirurgie, d'obstétrique, d'anesthésie et de soins infirmiers 2019­2023. Objectif: favoriser les mesures privilégiant les soins chirurgicaux, en vue d'offrir une couverture maladie universelle. Outre l'élaboration d'une stratégie chiffrée servant à consolider le secteur, le plan a intégré les unités de soins infirmiers et de chirurgie pédiatrique, deux aspects clés qui ont été négligés dans d'autres plans nationaux relatifs à la chirurgie. La mise en œuvre de la version pilote du plan a démarré en 2020, avec l'aide d'une organisation non gouvernementale possédant de l'expérience en matière d'interventions chirurgicales dans la région. Nous avons établi des points de départ spécifiques pour faciliter cette mise en œuvre. Dans le cadre de la version pilote, un registre de chirurgie électronique a été créé; le personnel a été formé à l'assistance vitale; les infirmiers ont découvert comment administrer des soins périopératoires sûrs; les techniciens biomédicaux et les infirmiers en stérilisation du matériel ont appris à réparer les instruments chirurgicaux; et enfin, les capacités de recherche et de maintenance ont été revues à la hausse. Par ailleurs, les médias traditionnels ont été sollicités afin d'informer les législateurs et la population en général au sujet du plan. Un partenaire de développement supplémentaire a proposé son aide en matière de chirurgie pédiatrique, et un hôpital pour enfants est prévu. Les fonds constituant l'un des principaux défis d'une mise en œuvre complète, nous avons besoin de stratégies de financement innovantes à l'échelle nationale pour la soutenir et la maintenir.

Las evidencias recientes sugieren que el fortalecimiento de la atención quirúrgica dentro de los sistemas sanitarios existentes reforzará el sistema general de la atención sanitaria. Sin embargo, el plan nacional estratégico para el desarrollo de la salud 2018-2022 de Nigeria dio poca importancia a la atención quirúrgica. Para abordar esta carencia, trabajamos con sociedades profesionales y otros asociados con el fin de elaborar el plan nacional de intervención quirúrgica, obstetricia, anestesia y enfermería 2019-2023. El objetivo era impulsar acciones para priorizar la atención quirúrgica en pro del logro de la cobertura sanitaria universal. Además de crear una estrategia con costes para reforzar la atención quirúrgica, el plan incluía intervenciones quirúrgicas y cuidados de enfermería para niños, que son dos aspectos clave que se han ignorado en otros planes nacionales de intervención quirúrgica. La implementación piloto del plan comenzó en 2020, con el apoyo de una organización no gubernamental que tiene experiencia en la atención quirúrgica en la región. Se han creado puntos iniciales específicos para facilitar la implementación piloto. En el plan piloto, se ha creado un registro electrónico de intervenciones quirúrgicas; se está capacitando al personal en apoyo vital; se está capacitando al personal de enfermería en cuidados perioperatorios seguros; se está capacitando a los técnicos biomédicos y al personal de enfermería de suministros estériles en la restauración de instrumentos quirúrgicos; y se está fortaleciendo la capacidad de mantenimiento e investigación. Además, se está recurriendo a los principales medios de comunicación para dar a conocer el plan a los responsables de formular las políticas y a la población en general. Otro asociado para el desarrollo está interesado en prestar apoyo a la intervención quirúrgica pediátrica, y se está planificando un hospital infantil. Como el financiamiento es un desafío clave para implementar el plan en su totalidad, se requieren estrategias innovadoras de financiamiento nacional para apoyar y sostener la implementación.

Inclusion of Children's Surgery in National Surgical Plans and Child Health Programmes: the need and roadmap from Global Initiative for Children's Surgery.

About 1.7 billion children and adolescents, mostly in low- and middle-income countries (LMICs) lack access to surgical care. While some of these countries have developed surgical plans and others are in the process of developing theirs, children's surgery has not received the much-needed specific emphasis and focus in these plans. With the significant burden of children's surgical conditions especially in low- and middle-income countries, universal health coverage and the United Nations' (UN) Sustainable Development Goals (SDG) will not be achieved without deliberate efforts to scale up access to children's surgical care. Inclusion of children's surgery in National Surgical Obstetric and Anaesthesia Plans (NSOAPs) can be done using the Global Initiative for Children's Surgery (GICS)-modified Children's Surgical Assessment Tool (CSAT) tool for baseline assessment and the Optimal Resources for Children Surgical Care (OReCS) as a foundational tool for implementation.

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.

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.

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.

Screening methods for congenital anomalies in low and lower-middle income countries: A systematic review.

INTRODUCTION: Surgically correctable congenital anomalies are responsible for a significant burden of morbidity and mortality in children from low-and lower-middle-income countries (LMICs). Early identification through fetal and neonatal screening is critical to reducing death and disability. This study aims to identify feasible screening methods for surgically correctable congenital anomalies in LMICs. METHODS: A systematic search looking at screening for congenital anomalies in LMIC was conducted in seven databases from 2000 until May 25, 2020, with no language restriction. All articles discussing screening methods for surgically correctable congenital anomalies in LMICs were included. Articles were screened by two independent contributors using Rayyan software, with a third contributor resolving conflicts. Feasibility of the screening method and its risk of bias were assessed using the MINORS scale. RESULTS: Of 3473 articles, 24 were included in the full-text review. Nine screening methods (three prenatal and six postnatal) were identified - the most frequently utilized being physician clinical examination (45.8%), pulse oximetry (33.3%) and fetal ultrasound (20.8%). The use of a birth defect picture toolkit was the most feasible screening method. The risk of bias scale yielded an average of 11.9 points, which corresponds to a moderate level of bias. CONCLUSION: Despite clear benefits, prenatal and neonatal screening methods are infrequently used in LMICs to identify surgically correctable congenital anomalies in neonates, likely due to financial, material, and human resource constraints. Further research into the development of low-cost feasible methods is needed within these settings. PROSPERO REGISTRATION NUMBER: CRD42020192051. TYPE OF STUDY: Systematic review. LEVEL OF EVIDENCE: IV.

Advocating for children's surgery within country health plans: lessons from Nigeria and the global stage.

Background: Despite the growing emphasis on provision of quality safe and affordable surgical care in low- and middle-income countries, and the World Health Assembly resolution 68. 15 on strengthening emergency and essential surgical care and anesthesia as components of universal health coverage, a review of published surgical plans of various countries, revealed a lack of emphasis on children's surgery. Due to the peculiarities of the human resource, infrastructure and equipment required for children's surgery, a lack of deliberate actions and policies targeted at strengthening surgical care for children implies that achieving universal health coverage for children may not be a reality in this setting. Methods: A baseline assessment of children's surgical capacity was conducted in Nigeria as a part of the National Surgical Obstetrics Anesthesia and Nursing Plan (NSOANP) process. The assessment was done using the World Health Organization (WHO) hospital assessment tool modified for children's surgery (Children Surgical Assessment Tool). Results: Significant infrastructural gaps were found, with an abysmally low density of pediatric surgeons and anaesthesiologists, poor emergency preparedness, lack of reliable surgical data and non-inclusion of children's surgery in the national strategic health plan. Using the Global Initiative for Children's Surgery's (GICS) Optimal Resources for Children's Surgical Care (OReCS) document and focusing on the strategic goals and priorities, children's surgery was incorporated into the NSOANP. Implementation of the plan is currently ongoing. Conclusion: From Nigeria's experience, appropriate advocacy and inclusion of children surgery providers in policy making will promote prioritization of children's surgery in country health and surgical plans.

From research to a political commitment to strengthen access to surgical, obstetric, and anesthesia care in Africa by 2030.

Objective: This study aimed to engage African leaders and key stakeholders to commit themselves toward the strengthening of surgical, obstetric, and anesthesia care systems by 2030 in Africa. Methods: From research to a political commitment, a baseline assessment was performed to foster the identification of the gaps in surgical care as a first step of an inclusive process. The preliminary findings were discussed during the International Symposium on Surgical, Obstetric, and Anesthesia Systems Strengthening by 2030 in Africa. The conclusions served to draft the Dakar Declaration and its Regional Action Plan 2022-2030 to improve access to surgical care by 2030 in Africa, endorsed by Heads of State. Results: The International Symposium was composed of two meetings that gathered (i) 85 scientific experts and (ii) 28 ministers of health or representatives from 28 sub-Saharan African countries. The 28 African countries represent (i) 51% of the continent's total population, (ii) 68% of the 47 African countries of the WHO Africa Region, (iii) 58% of all African Union countries, and (vi) 79% (3,371) of the WHO Africa Region's total (4,271) health districts. The International Symposium and the Heads of State Summit successfully produced the Dakar Declaration on access to equitable, affordable, and quality Surgical, Obstetric, and Anesthesia Care by 2030 in Africa and its Regional Actions Plan 2022-2030 which prioritizes 12 urgent actions needed to be implemented, six strategic priorities, 16 key indicators, and an annual dashboard to monitor progress. Conclusion: The Dakar Declaration and its Regional Action Plan 2022-2030 are a commitment to establish quality and sustainable surgical, obstetric, and anesthesia care in each African country within the ambitious framework of "The Africa we want" Agenda 2063.

Biliary Atresia Splenic Malformation: A Case Report from A Tertiary Centre in West Africa and the Lessons Learnt.

Biliary atresia (BA) is a rare disease characterised by biliary obstruction of unknown origin that presents in the neonatal period. It is classified into syndromic with various congenital anomalies and non-syndromic (isolated anomaly). We present a case of syndromic BA associated with polysplenia and intestinal malrotation, discovered incidentally during the Kasai procedure. The small intestine was found to be non-rotated with the duodenojejunal junction to the right of the vertebral column. The presence of accessory spleens was noted. Kasai portoenterostomy and Ladd's procedure were performed. The patient had an uneventful postoperative course with the passage of cholic stool from the third postoperative day. At the seventh-month follow-up, the stool remained cholic. A multidisciplinary approach in the care of babies with BA and long-term follow-up is crucial for a successful outcome.