GAPS phase II: development and pilot results of the global assessment in pediatric surgery, an evidence-based pediatric surgical capacity assessment tool for low-resource settings.

PURPOSE: Pediatric surgical care in low- and middle-income countries is often hindered by systemic gaps in healthcare resources, infrastructure, training, and organization. This study aims to develop and validate the Global Assessment of Pediatric Surgery (GAPS) to appraise pediatric surgical capacity and discriminate between levels of care across diverse healthcare settings. METHODS: The GAPS Version 1 was constructed through a synthesis of existing assessment tools and expert panel consultation. The resultant GAPS Version 2 underwent international pilot testing. Construct validation categorized institutions into providing basic or advanced surgical care. GAPS was further refined to Version 3 to include only questions with a > 75% response rate and those that significantly discriminated between basic or advanced surgical settings. RESULTS: GAPS Version 1 included 139 items, which, after expert panel feedback, was expanded to 168 items in Version 2. Pilot testing, in 65 institutions, yielded a high response rate. Of the 168 questions in GAPS Version 2, 64 significantly discriminated between basic and advanced surgical care. The refined GAPS Version 3 tool comprises 64 questions on: human resources (9), material resources (39), outcomes (3), accessibility (3), and education (10). CONCLUSION: The GAPS Version 3 tool presents a validated instrument for evaluating pediatric surgical capabilities in low-resource settings.

Cost-effectiveness of a pediatric operating room installation in Sub-Saharan Africa.

The unmet need for pediatric surgery imposes enormous health and economic consequences globally, predominantly shouldered by Sub-Saharan Africa (SSA) where children comprise almost half of the population. Lack of knowledge about the economic impact of improving pediatric surgical infrastructure in SSA inhibits the informed allocation of limited resources towards the most cost-effective interventions to bolster global surgery for children. We assessed the cost-effectiveness of installing and running two dedicated pediatric operating rooms (ORs) in a hospital in Nigeria with a pre-existing pediatric surgical service by constructing a decision tree model of pediatric surgical delivery at this facility over a year, comparing scenarios before and after the installation of the ORs, which were funded philanthropically. Health outcomes measured in disability-adjusted life years (DALYs) averted were informed by the hospital's operative registry and prior literature. We adopted an all healthcare payor's perspective including costs incurred by the local healthcare system, the installation (funded by the charity), and patients' families. Costs were annualized and reported in 2021 United States dollars ($). The incremental cost-effectiveness ratios (ICERs) of the annualized OR installation and operation were presented. One-way and probabilistic sensitivity analyses were performed. We found that installing and operating two dedicated pediatric ORs averted 538 DALYs and cost $177,527 annually. The ICER of the ORs' installation and operation was $330 per DALY averted (95% uncertainty interval [UI] 315-336) from the all healthcare payor's perspective. This ICER was well under the cost-effectiveness threshold of the country's half-GDP per capita in 2020 ($1043) and remained cost-effective in one-way and probabilistic sensitivity analyses. Installation of additional dedicated pediatric operating rooms in Nigeria with pre-existing pediatric surgical capacity is therefore very cost-effective, supporting investment in children's global surgical infrastructure as an economically sound intervention.

Gaps and priorities in innovation for children's surgery.

Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children's surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children's surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children's surgery worldwide.

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.

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa.

BACKGROUND: Out-of-pocket healthcare costs leading to catastrophic healthcare expenditure pose a financial threat for families of children undergoing surgery in Sub-Saharan African countries, where universal healthcare coverage is often insufficient. METHODS: A prospective clinical and socioeconomic data collection tool was used in African hospitals with dedicated pediatric operating rooms installed philanthropically. Clinical data were collected via chart review and socioeconomic data from families. The primary indicator of economic burden was the proportion of families with catastrophic healthcare expenditures. Secondary indicators included the percentage who borrowed money, sold possessions, forfeited wages, and lost a job secondary to their child's surgery. Descriptive statistics and multivariate logistic regression were performed to identify predictors of catastrophic healthcare expenditure. RESULTS: In all, 2,296 families of pediatric surgical patients from 6 countries were included. The median annual income was $1,000 (interquartile range 308-2,563), whereas the median out-of-pocket cost was $60 (interquartile range 26-174). Overall, 39.9% (n = 915) families incurred catastrophic healthcare expenditure, 23.3% (n = 533) borrowed money, 3.8% (n = 88%) sold possessions, 26.4% (n = 604) forfeited wages, and 2.3% (n = 52) lost a job because of the child's surgery. Catastrophic healthcare expenditure was associated with older age, emergency cases, need for transfusion, reoperation, antibiotics, and longer length of stay, whereas the subgroup analysis found insurance to be protective (odds ratio 0.22, P = .002). CONCLUSION: A full 40% of families of children in sub-Saharan Africa who undergo surgery incur catastrophic healthcare expenditure, shouldering economic consequences such as forfeited wages and debt. Intensive resource utilization and reduced insurance coverage in older children may contribute to a higher likelihood of catastrophic healthcare expenditure and can be insurance targets for policymakers.

Defining Surgical Workforce Density Targets to Meet Child and Neonatal Mortality Rate Targets in the Age of the Sustainable Development Goals: A Global Cross-Sectional Study.

OBJECTIVES: To reduce preventable deaths of newborns and children, the United Nations set a target rate per 1000 live births of 12 for neonatal mortality (NMR) and 25 for under-5 mortality (U5MR). The purpose of this paper is to define the minimum surgical workforce needed to meet these targets and evaluate the relative impact of increasing surgeon, anesthesia, and obstetrician (SAO) density on reducing child mortality. METHODS: We conducted a cross-sectional study of 192 countries to define the association between surgical workforce density and U5MR as well as NMR using unadjusted and adjusted B-spline regression, adjusting for common non-surgical causes of childhood mortality. We used these models to estimate the minimum surgical workforce to meet the sustainable development goals (SDGs) for U5MR and NMR and marginal effects plots to determine over which range of SAO densities the largest impact is seen as countries scale-up SAO workforce. RESULTS: We found that increased SAO density is associated with decreased U5MR and NMR (P < 0.05), adjusting for common non-surgical causes of child mortality. A minimum SAO density of 10 providers per 100,000 population (95% CI: 7-13) is associated with an U5MR of < 25 per 1000 live births. A minimum SAO density of 12 (95% CI: 9-20) is associated with an NMR of < 12 per 1000 live births. The maximum decrease in U5MR, on the basis of our adjusted B-spline model, occurs from 0 to 20 SAO per 100,000 population. The maximum decrease in NMR based on our adjusted B-spline model occurs up from 0 to 18 SAO, with additional decrease seen up to 80 SAO. CONCLUSIONS: Scale-up of the surgical workforce to 12 SAO per 100,000 population may help health systems meet the SDG goals for childhood mortality rates. Increases in up to 80 SAO/100,000 continue to offer mortality benefit for neonates and would help to achieve the SDGs for neonatal mortality reduction.

Systematic review of low-income and middle-income country perceptions of visiting surgical teams from high-income countries.

BACKGROUND: The shortage of surgeons, anaesthesiologists and obstetricians in low-income and middle-income countries (LMICs) is occasionally bridged by foreign surgical teams from high-income countries on short-term visits. To advise on ethical guidelines for such activities, the aim of this study was to present LMIC stakeholders' perceptions of visiting surgical teams from high-income countries. METHOD: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in November 2021, using standardised search terms in PubMed/Medline (National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO) and Global Index Medicus, and complementary hand searches in African Journals Online and Google Scholar. Included studies were analysed thematically using a meta-ethnographic approach. RESULTS: Out of 3867 identified studies, 30 articles from 15 countries were included for analysis. Advantages of visiting surgical teams included alleviating clinical care needs, skills improvement, system-level strengthening, academic and career benefits and broader collaboration opportunities. Disadvantages of visiting surgical teams involved poor quality of care and lack of follow-up, insufficient knowledge transfers, dilemmas of ethics and equity, competition, administrative and financial issues and language barriers. CONCLUSION: Surgical short-term visits from high-income countries are insufficiently described from the perspective of stakeholders in LMICs, yet such perspectives are essential for quality of care, ethics and equity, skills and knowledge transfer and sustainable health system strengthening. More in-depth studies, particularly of LMIC perceptions, are required to inform further development of ethical guidelines for global surgery and support ethical and sustainable strengthening of LMIC surgical systems.

Population health outcomes in Nigeria compared with other west African countries, 1998-2019: a systematic analysis for the Global Burden of Disease Study.

BACKGROUND: Population-level health and mortality data are crucial for evidence-informed policy but scarce in Nigeria. To fill this gap, we undertook a comprehensive assessment of the burden of disease in Nigeria and compared outcomes to other west African countries. METHODS: In this systematic analysis, using data and results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, we analysed patterns of mortality, years of life lost (YLLs), years lived with disability (YLDs), life expectancy, healthy life expectancy (HALE), and health system coverage for Nigeria and 15 other west African countries by gender in 1998 and 2019. Estimates of all-age and age-standardised disability-adjusted life-years for 369 diseases and injuries and 87 risk factors are presented for Nigeria. Health expenditure per person and gross domestic product were extracted from the World Bank repository. FINDINGS: Between 1998 and 2019, life expectancy and HALE increased in Nigeria by 18% to 64·3 years (95% uncertainty interval [UI] 62·2-66·6), mortality reduced for all age groups for both male and female individuals, and health expenditure per person increased from the 11th to third highest in west Africa by 2018 (US$18·6 in 2001 to $83·75 in 2018). Nonetheless, relative outcomes remained poor; Nigeria ranked sixth in west Africa for age-standardised mortality, seventh for HALE, tenth for YLLs, 12th for health system coverage, and 14th for YLDs in 2019. Malaria (5176·3 YLLs per 100 000 people, 95% UI 2464·0-9591·1) and neonatal disorders (4818·8 YLLs per 100 000, 3865·9-6064·2) were the leading causes of YLLs in Nigeria in 2019. Nigeria had the fourth-highest under-five mortality rate for male individuals (2491·8 deaths per 100 000, 95% UI 1986·1-3140·1) and female individuals (2117·7 deaths per 100 000, 1756·7-2569·1), but among the lowest mortality for men older than 55 years. There was evidence of a growing non-communicable disease burden facing older Nigerians. INTERPRETATION: Health outcomes remain poor in Nigeria despite higher expenditure since 2001. Better outcomes in countries with equivalent or lower health expenditure suggest health system strengthening and targeted intervention to address unsafe water sources, poor sanitation, malnutrition, and exposure to air pollution could substantially improve population health. FUNDING: The Bill & Melinda Gates Foundation.

Financing Pediatric Surgery: A Provider's Perspective from the Global Initiative for Children's Surgery.

BACKGROUND: Half the world's population is at risk of catastrophic health expenditure (CHE, out-of-pocket spending of more than 10% of annual expenditure) should they require surgery. Protection against CHE is a key indicator of successful health care delivery and has been identified as a priority area by the Global Initiative for Children's Surgery (GICS). Data specific to pediatric surgical patients is limited. This study examines the financial risks for pediatric surgical patients and their families from a provider's perspective. METHODS: We surveyed GICS members about the existing financial protection mechanisms and estimated expenditures for their patients. Questions were structured based on the National Surgical, Obstetric and Anesthesia Planning Surgical Indicators and finalized based on multi-institutional consensus between high-income country and low-and middle-income country (LMIC) providers. Chi-squared test, Fisher's exact test and student's t-test were used as appropriate. RESULTS: Among 107 respondents, 72.4% were from low income or lower-middle income (LIC/LMIC) countries, and 55.1% were attending or consultant physicians. Families were most likely to decline surgery in LIC/LMIC due to inability to afford treatment (mean Likert = 3.77 ± 1.06). The odds of incurring CHE after children's surgery are up to 17 times greater in LIC/LMIC (P = 0.001, unadjusted OR 17.28, 95%CI 2.13-140.02). Over 50% of families of children undergoing major surgery in these settings face CHE. An estimated 5.1% of providers in LIC/LMIC and 56.2% (P < 0.001) of providers in UMIC/HIC reported that families are able to pay for their direct medical costs with the assistance available to them and were more likely to sell assets (74.4% vs. 33.3%, P = 0.005). CONCLUSION: Patients in LMICs are at greater risk for CHE and have less financial risk protection than their HIC counterparts. Given this disparity, intervention is needed to make safe surgery affordable for children worldwide.

Academic Global Surgery Curricula: Current Status and a Call for a More Equitable Approach.

INTRODUCTION: We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery. METHODS: We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies. RESULTS: Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on "Health Equity and Social Justice" and only one mentioned "Social and Environmental Determinants of Health." Only 22% (n = 4) were available as open-access. CONCLUSION: Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world.

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.

Access to paediatric surgery: the geography of inequality in Nigeria.

BACKGROUND: About 96.3 million children and adolescents aged 0-19 years reside in Nigeria, comprising 54% of the population. Without adequate access to surgery for commonly treatable diseases, many face disability and increased risk of mortality. Due to this population's unique perioperative needs, increasing access to paediatric surgical care requires a situational evaluation of the distribution of paediatric surgeons and anaesthesiologists. This study's aim is to identify the percentage of Nigerian youth who reside within 2 hours of paediatric surgical care at the state and national level. METHODS: The Association of Paediatric Surgeons of Nigeria and the Nigeria Society of Anaesthetists provided surgical and anaesthesia workforce data by state. Health facilities with paediatric surgeons were converted to point locations and integrated with ancillary geospatial layers and population estimates from 2016 and 2017. Catchment areas of 2 hours of travel time around a facility were deployed as the benchmark indicator to establish timely access. RESULTS: Across Nigeria's 36 states and Federal Capital Territory, the percentage of Nigeria's 0-19 population residing within 2 hours of a health facility with a paediatric surgical and anaesthesia workforce ranges from less than 2% to 22.7%-30.5%. In 3 states, only 2.1%-4.8% of the population can access a facility within 2 hours, 12 have 4.9%-13.8%, and 8 have 13.9%-22.6%. CONCLUSION: There is significant variation across Nigerian states regarding access to surgical care, with 69.5%-98% of Nigeria's 0-19 population lacking access. Developing paediatric surgical services in underserved Nigerian states and investing in the training of paediatric surgical and anaesthesia workforce for those states are key components in improving the health of Nigeria's 0-19 population and reducing Nigeria's burden of surgical disease, in line with Nigeria's National Surgical, Obstetrics, Anaesthesia and Nursing Plan.

Global and regional overview of the inclusion of paediatric surgery in the national health plans of 124 countries: an ecological study.

OBJECTIVE: This study evaluates the priority given to surgical care for children within national health policies, strategies and plans (NHPSPs). PARTICIPANTS AND SETTING: We reviewed the NHPSPs available in the WHO's Country Planning Cycle Database. Countries with NHPSPs in languages different from English, Spanish, French or Chinese were excluded. A total of 124 countries met the inclusion criteria. PRIMARY AND SECONDARY OUTCOME MEASURES: We searched for child-specific and surgery-specific terms in the NHPSPs' missions, goals and strategies using three analytic approaches: (1) count of the total number of mentions, (2) count of the number of policies with no mentions and (3) count of the number of policies with five or more mentions. Outcomes were compared across WHO regional and World Bank income-level classifications. RESULTS: We found that the most frequently mentioned terms were 'child*', 'infant*' and 'immuniz*'. The most frequently mentioned surgery term was 'surg*'. Overall, 45% of NHPSPs discussed surgery and 7% discussed children's surgery. The majority (93%) of countries did not mention selected essential and cost-effective children's procedures. When stratified by WHO region and World Bank income level, the West Pacific region led the inclusion of 'pediatric surgery' in national health plans, with 17% of its countries mentioning this term. Likewise, low-income countries led the inclusion of surg* and 'pediatric surgery', with 63% and 11% of countries mentioning these terms, respectively. In both stratifications, paediatric surgery only equated to less than 1% of the total terms. CONCLUSION: The low prevalence of children's surgical search terms in NHPSPs indicates that the influence of surgical care for this population remains low in the majority of countries. Increased awareness of children's surgical needs in national health plans might constitute a critical step to scale up surgical system in these countries.

Catastrophic Healthcare Expenditure from Typhoid Perforation in Children in Nigeria.

Background: Out-of-pocket payments and catastrophic healthcare expenditures (CHE) are important barriers to achieving equity and access to emergency and essential surgical care in low- and middle-income countries (LMICs), with important implications for universal health coverage (UHC). However, data on CHE for surgical care in these settings are limited, especially with regard to infections. Methods: We performed a retrospective review of 32 children receiving laparotomy for typhoid intestinal perforation in a four-year period. Data on medical costs were reviewed. Because of the lack of reliable data on household incomes and average national incomes for Nigeria, gross domestic product per capita was used to calculate CHE. The GDP per capita for the country during the study period was $2,028.182. Expenditure >10% GDP per capita (or > $202.82) was considered CHE. Results: There were 15 boys and 17 girls aged 2-15 years (mean 7.72 years). Seventeen patients (53%) were referred from district/general hospitals or mission hospitals. After surgical treatment, 16 patients (50%) developed complications (intra-abdominal abscesses and incision complications), and nine (28.1%) required re-operation. Seven patients (21.9%) required intensive care (ICU) treatment and three (9.4%) died from overwhelming infection. The hospital stay was 3-93 days (mean 23 days). The average total medical cost was $452 (range $236-$1,700). The total medical costs exceeded 10% of GDP ($202.82) for all patients. Total expenditure for four patients requiring intensive care exceeded $202.82 for the ICU care alone. Conclusion: Surgical treatment of typhoid intestinal perforation in children is associated with a high rate of CHE if care is provided at tertiary hospitals. Investments in prevention and control of this and other surgical infections as well as scale up of capacity at district hospitals to provide such care are important in preventing CHE.

Globalization of national surgical, obstetric and anesthesia plans: the critical link between health policy and action in global surgery.

Efforts from the developed world to improve surgical, anesthesia and obstetric care in low- and middle-income countries have evolved from a primarily volunteer mission trip model to a sustainable health system strengthening approach as private and public stakeholders recognize the enormous health toll and financial burden of surgical disease. The National Surgical, Obstetric and Anesthesia Plan (NSOAP) has been developed as a policy strategy for countries to address, in part, the health burden of diseases amenable to surgical care, but these plans have not developed in isolation. The NSOAP has become a phenomenon of globalization as a broad range of partners - individuals and institutions - help in both NSOAP formulation, implementation and financing. As the nexus between policy and action in the field of global surgery, the NSOAP reflects a special commitment by state actors to make progress on global goals such as Universal Health Coverage and the United Nations Sustainable Development Goals. This requires a continued global commitment involving genuine partnerships that embrace the collective strengths of both national and global actors to deliver sustained, safe and affordable high-quality surgical care for all poor, rural and marginalized people.

Perspectives on perioperative management of children's surgical conditions during the COVID-19 pandemic in low-income and middle-income countries: a global survey.

Background: Many organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019 (COVID-19) pandemic. We surveyed providers of children's surgical care working in low-income and middle-income countries (LMICs) to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices. Methods: A survey of children's surgery providers in LMICs was performed. Respondents reported how their perioperative practice had changed in response to COVID-19. They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform. Changes in surgical practice reported by respondents were analyzed thematically. Results: A total of 132 responses were obtained from 120 unique institutions across 30 LMICs. 117/120 institutions (97.5%) had issued formal guidance on delaying or limiting elective children's surgical procedures. Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities (82% in LICs vs 99% in lower middle-income countries and 100% in upper middle-income countries, p=0.036). Although 122 (97%) providers believed cases should be limited during a global pandemic, there was no procedure where more than 61% of providers agreed cases should be delayed or canceled. Conclusions: There is little consensus on which procedures should be limited or delayed among LMIC providers. Expansion of testing capacity and local, context-specific guidelines may be a better strategy than international consensus, given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.

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.

Infrastructure Expansion for Children's Surgery: Models That are Working.

Children's surgical care is cost-effective and can avert mortality and long-term disability in children, with ramifications throughout life not only for the patient, but for the extended family and community as well. Considering the current gaps and limited capacity for children's surgery in low- and middle-income countries (LMICs), it is clear that without expanding and scaling up the infrastructure, World Health Assembly (WHA) resolution 68/15 targets and child-related targets of Sustainable Development Goals and Universal Health Care are unlikely to be met by 2030. The most promising models to expand infrastructure are those that include ongoing partnerships and capacity building by educating and training local surgeons and healthcare professionals who will not only provide care for children, but who will train future generations of surgical providers as well. Efforts to improve infrastructure necessarily include raising the standard of children's surgical care at all levels of the healthcare system, which will hopefully be guided by National Surgical, Obstetrics, and Anesthesia Plans and by the Optimal Resources for Children's Surgery document. The private sector can be effectively engaged to fill infrastructure and service gaps that cannot be met by government budgets. Ultimately, success of any infrastructure expansion initiative depends on strong advocacy to allocate ample funding for children's surgical care.