An investment in knowledge: Research in global pediatric surgery for the 21st century
Introduction
The year 2015 marked a pivotal transition period for both global health and global surgery. The focus of the global health and development community transitioned from the Millennium Development Goals (MDGs) to a new set of Sustainable Development Goals (SDGs), commitments to Universal Health Coverage (UHC) and recognition of the critical need for resilient health systems. At the same time, multiple advocacy and policy efforts including the Third Edition of Disease Control Priorities (DCP3),1 The Lancet Commission on Global Surgery (LCoGS),2 and the World Health Assembly (WHA) resolution A 68/31 on Strengthening Emergency and Essential Surgical Care,3 demonstrated the need for universal access to surgery and anesthesia in order to achieve these new health and development goals.
Until 2015, however, policymakers and funders had largely ignored the sizeable yet unmet need for surgical care—a treatment required for approximately 30% of the global burden of disease (GBD).2 This lack of attention has left two-thirds of the world’s population without access to surgical services,4 has rendered health systems ill-equipped to fully address the needs of the populations they serve, and threatens to cost countries trillions of dollars in lost economic output if not addressed.5
Although acknowledgment of the need for improved access to surgery is now slowly growing, data and knowledge about both the current state of surgical care, as well as best methods for delivering and improving such care, are largely lacking. This information gap is greatest in low- and middle-income countries (LMICs) and is particularly apparent surrounding the surgical care of children, who comprise nearly half of the population in the least developed regions6 (Figure 1). Research is needed to help fill these knowledge gaps.
Section snippets
Current picture of global surgery research
Application of research findings has the capacity to greatly improve health. For example, development of antiretroviral medications has helped to turn HIV from a fatal diagnosis to one with a fairly normal life expectancy with appropriate antiretroviral treatment.7 Large scale improvements in maternal health over the last 20 years have come in part from adaptation, testing and rapid scale-up of service delivery models.8 Similar research-driven improvements for global surgery, however, are
Suggested research agenda for global pediatric surgery
To help address low research volumes and disparate areas of focus, both DCP3 and LCoGS outlined suggested research agendas for global surgery based on data and knowledge gaps identified during the course of their work.2, 17 Using information gleaned from a review of the literature on research for global pediatric surgery, we adapted these research agendas for a pediatric surgery focus. This eight-point agenda is described below and summarized in panel 2. As with the agendas from DCP3 and LCoGS,
Assessments of the global burden of surgical conditions in children in LMICs
Comprehensive countrywide data for the burden of surgical conditions in people of all age groups is lacking. Civil registration systems (birth and death certifications) are sparse with low-income countries reporting only 1% of deaths by cause.18 Multinational household surveys such as UNICEF’s Multiple Indicator Cluster Surveys (MICS), USAID’s Demographic and Health Surveys (DHS), and the World Bank’s Living Standards Measurement Study (LSMS) have very limited inclusion of questions about
Strategies to address the non-avertable burden of surgical conditions in children in LMICs
DCP3 found that a large proportion of the burden of surgical conditions is currently non-avertable from scaling-up surgical care, meaning that there is a certain level of death and disability that we cannot avert at this time with a surgical intervention, even in the highest-resource settings.17 For example, the death of a child who suffers massive head trauma may not be avertable even with the best of existing surgical care. Similarly, the death of a child who dies immediately at the scene of
Strategies to address the avertable burden of surgical conditions in children in LMICs
One of the most pressing needs surrounding the surgical care of children in LMIC is identifying how surgical and anesthesia care can best be implemented in regions where needs are greatest but health systems are least developed. Implementation efforts can make the most impact when all dimensions of care delivery and all barriers a patient may face in receiving care are considered. Healthcare delivery requires staff, stuff, space, and systems (the 4Ss).4 The presence of all these elements is
Models for scale-up of the pediatric surgical workforce
There is a currently a large deficiency in absolute numbers and a maldistribution of the surgical workforce in many regions of the world. Recent estimates cite a shortage of over 1 million surgical, anesthetic and obstetric (SAO) providers across 136 LMICs.2 In addition to a volume shortage of surgical providers, there is also a gross inequity in their distribution. Only 12% of the specialist surgical workforce works in Africa and Southeast Asia, which is home to 33% of the world’s population.2
Critical evaluation of partnerships
Many aspects of surgical care can be facilitated through effective use of partnerships, including those with non-governmental organizations (NGOs), academic institutions, funding partners, and the private sector. Although such partnerships are common, they are not all effective in addressing a region’s most pressing needs, improving health, or increasing local ability to deliver care. In addition, data on their efforts and outcomes are frequently lacking.
For example, there are over 300
Tools for incorporating and measuring surgical care as a basic component of health systems
Over the past two decades, global health has focused primarily on individual diseases. As a result, the majority of global health efforts, such as those surrounding the MDGs, have also focused more narrowly on addressing and tracking single diseases or health measures for select populations. This has facilitated remarkable reductions in death and disability from certain conditions, but such gains have not been mirrored by similar improvements to health systems, integration of services,
Methods for assessing the human, financial and economic impact of surgical conditions and surgical care
Disability adjusted life years (DALYs) are currently the standard measure for assessing the global burden of disease. DALYs include both mortality and morbidity components by combining years of life lost (YLL) due to premature mortality with years lost due to disability for individuals living with a disease.56
However, the DALY-based approach to estimating the GBD has been criticized for having many limitations including subjectivity, comparability, oversimplification, practicality and
Aligning pediatric surgical care with other global health and development endeavors
Access to surgical and anesthesia care can help alleviate death and disability from numerous conditions and is a necessity for good population health. Surgical services are needed across all GBD subcategories,13 throughout the course of life (from birth to death) and within all levels of care (prevention to palliation).62 Surgery’s integral and cross-cutting nature means that incorporating it into the priorities, delivery plans and monitoring mechanisms of other areas of global health focus can
Considerations for evaluators and partners of potential global pediatric surgery research projects
Research has great potential to generate findings that can ultimately lead to improved patient health and welfare. However, if not conducted judiciously, there is also potential for harm. The Lancet Commission on Global Surgery presented a series of questions for implementers, funders, editors and ethics committees to consider (in addition to the academic merit of the proposal) when evaluating potential global surgery projects. These considerations were developed from discussions with academic
Research availability, use, and dissemination
Lack of pediatric surgical research in LMICs is compounded by poor accessibility of research that does exist, and limited dissemination of research findings. Both accessing as well as publishing research articles often requires money, English fluency, and electronic access. This complicates the ability of many professionals in LMICs to access relevant articles, as well as publish their own research. Examples of options and attempts to address these access issues include open access journals,
Conclusion
At the heart of global pediatric surgery research is a desire that no child should suffer the consequences of surgical conditions for which effective treatments can be provided. Improved understanding of the epidemiology of pediatric surgical disease; its impact on individuals, families, communities, and countries; the availability and accessibility of safe surgical and anesthesia care; the comparative effectiveness of models for scaling-up surgical care; the economic consequences of inaction;
Action points and opportunities for national and international partners to improve global pediatric surgical research
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An increase in research capacity, training, funding and output in LMICs should be a priority on both local and global levels. Partners with advanced research abilities and experience can support the development of research capacity in LMICs through locally driven, locally vested partnerships. Both HIC-LMIC and LMIC–LMIC relationships can effectively build capacity, especially if an accompaniment approach is used.
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Those involved with the publication of research—including journals, journal
References (71)
- et al.
Global access to surgical care: a modelling study
Lancet Global Health
(2015) - et al.
Global economic consequences of selected surgical diseases: a modelling study
Lancet Global Health
(2015) - et al.
Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013
Lancet
(2014) - et al.
Challenges of pediatric surgical practice in Africa. Preface
Semin Pediatr Surg
(2012) - et al.
Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda
Surgery
(2013) - et al.
Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey
Lancet
(2012) - et al.
Outcomes and unmet need for neonatal surgery in a resource-limited environment: estimates of global health disparities from Kampala, Uganda
J Pediatr Surg
(2014) - et al.
The burden of waiting: DALYs accrued from delayed access to pediatric surgery in Kenya and Canada
J Pediatr Surg
(2015) - et al.
Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis
Lancet
(2015) - et al.
Neonatal surgery in Africa: a systematic review and meta-analysis of challenges of management and outcome
Lancet
(2015)
Challenges of training and delivery of pediatric surgical services in Africa
J Pediatr Surg
Training and practice of pediatric surgery in Africa: past, present, and future
Semin Pediatr Surg
Pediatric emergency and essential surgical care in Zambian hospitals: a nationwide study
J Pediatr Surg
Mortality of pediatric surgical conditions in low and middle income countries in Africa
J Pediatr Surg
Optimal resources for children’s surgical care: a global perspective
J Am Coll Surg
Interest in international surgical volunteerism: results of a survey of members of the American Pediatric Surgical Association
J Pediatr Surg
Catastrophic expenditure to pay for surgery worldwide: a modelling study
Lancet Global Health
Global burden of surgical disease: an estimation from the provider perspective
Lancet Global Health
Surgery and global health: a Lancet Commission
Lancet
Health gains and financial risk protection afforded by public financing of selected interventions in Ethiopia: an extended cost-effectiveness analysis
Lancet Global Health
Burden need, or backlog: a call for improved metrics for the global burden of surgical disease
Int J Surg
Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development
Lancet
Impact on life expectancy of HIV-1 positive individuals of CD4+ cell count and viral load response to antiretroviral therapy
AIDS
Funding flows to global surgery; an analysis of contributions from the U.S
Lancet
The role of surgery in global health: analysis of United States inpatient procedure frequency by condition using the Global Burden of Disease 2010 framework
PloS One
The global paediatric surgery network: a model of subspecialty collaboration within global surgery
World J Surg
Surgical interventions for congenital anomalies
Global burden of surgical conditions
Disease Control Priorities, 3rd Edition. (Volume 1)
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2022, Journal of Pediatric UrologyCitation Excerpt :Genitourinary conditions represent the third most common types of non-chromosomal congenital anomalies, after heart and limb defects in Europe, and it may be assumed that the same holds true in LMICs [6,7]. This burden can be considered as “avertable” or “non-avertable” [8–10]. In pediatric urology, many neural tube defects could be considered avertable depending on the availability of dietary folic acid supplements; hypospadias may be partially avertable depending on maternal environmental exposures, and bladder exstrophy might be considered non-avertable.
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2021, Journal of Pediatric UrologyCitation Excerpt :Five billion people worldwide are estimated to lack access to safe surgery and anesthesia, of whom 1.7 billion are children. The World Health Organization estimates that over 90% of congenital malformations occur in Low- and Middle-Income Countries (LMICs) [1–4,33]. Surgical collaborations and short-term missions have attempted to address unmet surgical needs in some LMICs [1,2,6,8–11,20].
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2020, World NeurosurgeryCitation Excerpt :One such example of successful LMIC–LMIC partnership includes the endoscopic third ventriculostomy with choroid plexus coagulation procedure collaboration between the Nelson Mandela Children’s Hospital and CURE Uganda. Further research into LMIC-LMIC neurosurgical partnerships is warranted given its vital role in LMIC neurosurgical education and health systems strengthening.44 It is also important to highlight the benefits that HIC actors receive from HIC–LMIC partnership models.
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2019, Journal of Pediatric SurgeryCitation Excerpt :However, none of these guidelines provide a quantitative method of evaluating or comparing centers. Current literature has focused on the descriptive assessment of surgical capacity in different LMICs [7]. However, literature aimed at developing methods to improve this capacity is lacking, even though investing in surgical care for children is highly cost-effective in several cases and provides societal benefits [30].