Pediatric Surgical Capacity Research Articles

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.

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. 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. 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). 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.

Increasing access to pediatric surgical care: Assessing district hospital readiness in rural Rwanda.

Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda. We administered the Children's Surgical Assessment Tool (CSAT), adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains. None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure, and information management for pediatric outpatients and referrals. In SSORT interviews (n=47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score=2.6 out of 5), psychological safety (median score=3.0 out of 5), and resistance to change (mean score=1.5 out of 5 with 5=no resistance). This study highlights challenges in providing safe and high-quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity.

Understanding pediatric surgical needs in North Korea: a modeling analysis

BackgroundSixty-five percent of children worldwide lack access to surgical care, the majority of whom live in low-income and middle-income countries (LMICs). Developing surgical infrastructure requires information on surgical need; however,...

Surgically Amenable Childhood Cancers: An Overview of the Burden and Challenges of Management in Low- and Middle-Income Countries.

The World Health Organization's Global Initiative for Childhood Cancer was launched to decrease the disparities in childhood cancer outcomes and improve treatments for childhood cancer in resource-limited settings. Low-grade glioma, retinoblastoma, and Wilms tumors are among the index cancers included in this global initiative, as these cancers represent a large percentage of childhood tumors and are curable with cost-effective, evidence-based interventions. Herein, we discuss the global childhood tumor burden, the status of pediatric cancer surgery capacity and services around the world, and the strategic considerations for building pediatric surgical oncology capacity.

The status of pediatric surgery in Malawi: a narrative mini-review.

Pediatric surgery is essential to a well-functioning health system. Unmet surgical needs contribute to 6.7% of pediatric deaths in Malawi. Understanding the current state of pediatric surgical care in Malawi is necessary to recognize gaps and opportunities in service delivery and to develop evidence-based national planning and solutions. This narrative mini review synthesized the literature on the state of pediatric surgery in Malawi through the pillars of the World Health Organization's Health System Building Blocks. A search of PubMed, Embase, and Scopus databases was executed to identify relevant studies and a thematic analysis was performed. Further, to ensure contextual accuracy, pediatric surgeons from Malawi were consulted and involved in this review. Twenty-six papers were identified. In Malawi's central hospitals, there are six specialist pediatric surgeons for a pediatric population of more than 8 million. There is limited pediatric surgical capacity at the district hospitals. There is little to no written evidence of the national governing and finance structures in place for pediatric surgical services. In countries like Malawi, where a significant portion of the population comprises children, it is crucial to recognize that pediatric services are currently inadequate and fall short of the required standards. It is crucial to prioritize the enhancement of services specifically designed for this age group. This review aims to shed light on the existing gaps within pediatric surgical services in Malawi, providing valuable insights that can inform the development of comprehensive national surgical planning strategies.

PASS-A course in Pediatric Acute Surgical Support to build pediatric surgical emergencies capacity in developing countries

ObjectivesThe burden of pediatric trauma and emergency, including pediatric surgical emergencies in low middle income countries (LMIC) is high. The goal of Pediatric Acute Surgical Support (PASS) course is to prepare caregivers in LMIC for the acute management of life-threatening pediatric surgical emergencies. We aim to show the feasibility of its initial deployment. MethodsPASS was developed in 2016 with LMIC faculty from a teaching children hospital CH. The course contents consisted of a mix of didactic materials for serious general neonatal and pediatric surgery modified PALS/ATLS, in-person multidisciplinary team-based skill stations, interactive clinical scenarios and simulated trauma cases. The course was subsequently revised and delivered to 92 learners in four classes of 2.5-days sessions at two CHs between 2017 and 2019. Learners’ demographics, written exams, team-based case performance, and post-course survey data were prospectively collected and retrospectively analyzed. ResultsPhysician (60%) and nurse learners (40%) from pediatric critical care (36%), surgery (23%), emergency medicine (20%) and anesthesiology (9%) had 3.6 +/- 3.6 years of clinical practice; pre- and post-course written exam score of 55.4+/-15.5% vs 71.6+/-12.8%, team-based trauma scenario management 22.6 ± 7.8% vs 54.7 ± 16.6% and team-based dynamic scores 17+/- 10% vs 53.3+/- 15.5%, respectively (p<0.0001). Self-reported satisfaction scores were ≥ 95% for course method, level of difficulty, clinical applicability, and quality of instructors. ConclusionPASS is well-received by LMIC learners, with short-term improvement in knowledge-, team-based management of acute pediatric surgery emergencies; and has the potential to be a model of horizontal capacity building for pediatric surgery in LMIC. Level of evidenceII

Age at Primary Cleft Lip Repair: A Potential Bellwether Indicator for Pediatric Surgery.

Background:The bellwether procedures described by the Lancet Commission on Global Surgery represent the ability to deliver adult surgical services after there is a clear and easily made diagnosis. There is a need for pediatric surgery bellwether indicators. A pediatric bellwether indicator would ideally be a routinely performed procedure, for a relatively common condition that, in itself, is rarely lethal at birth, but that should ideally be treated with surgery by a standard age. Additionally, the condition should be easy to diagnose, to minimize the confounding effects of delays or failures in diagnosis. In this study, we propose the age at primary cleft lip (CL) repair as a bellwether indicator for pediatric surgery.Method:We reviewed the surgical records of 71,346 primary cleft surgery patients and ultimately studied age at CL repair in 40,179 patients from 73 countries, treated by Smile Train partners for 2019. Data from Smile Train’s database were correlated with World Bank and WHO indicators.Results:Countries with a higher average age at CL repair (delayed access to surgery) had higher maternal, infant, and child mortality rates as well as a greater risk of catastrophic health expenditure for surgery. There was also a negative correlation between delayed CL repair and specialist surgical workforce numbers, life expectancy, percentage of deliveries by C-section, total health expenditure per capita, and Lancet Commission on Global Surgery procedure rates.Conclusion:These findings suggest that age at CL repair has potential to serve as a bellwether indicator for pediatric surgical capacity in Lower- and Middle-income Countries.

Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals

BackgroundSignificant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children’s surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity. MethodsTwo years of a prospective clinical database of children’s surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered. ResultsFrom 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society. ConclusionThis investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.

Geospatial Mapping of Pediatric Surgical Capacity in North Kivu, Democratic Republic of Congo.

Despite recent attention to the provision of healthcare in low- and middle-income countries, improvements in access to surgical services have been disproportionately lagging. This study analyzes the geographic variability in access to pediatric surgical services in the province of North Kivu, Democratic Republic of Congo (DRC). On-site data collection was conducted using the Global Assessment of Pediatric Surgery tool. Spatial distribution of providers was mapped using the Geographical Information System and open-sourced spatial data to determine distances traveled to access surgical care. Forty facilities were evaluated across 32 health zones; 68.9% of the provincial population was within 15km of these facilities. Eleven facilities met a minimum World Health Organization safety score of 8; 48.1% of the population was within 15km of corresponding facilities. The majority of children were treated by someone with specific pediatric surgery training in only 4 facilities; one facility had a trained pediatric anesthesia provider. Fifty-seven percent of the population was within 15km of a facility with critical care and emergency medicine (EM) capabilities. There was one pediatric critical care provider and no pediatric EM providers identified within the province. Location-allocation assessment is needed to combine geographic area with potential for greatest impact and facility assessment. Limitations in access to surgical care in the DRC are multifactorial with poor resources, few formally trained surgical providers, and near-absent access to pediatric anesthesiologists. The study highlights the deficits in the capacity for surgical care while demonstrating a reproducible model for assessment and identification of ways to improve access to care.

A Nationwide Enumeration of Operations Performed for Pediatric Patients in Ghana.

Currently, there are no existing benchmarks for evaluating a nation's pediatric surgical capacity in terms of met and unmet needs. Data on pediatric operations performed from 2014 to 2015 were obtained from a representative sample of hospitals in Ghana, then scaled up for national estimates. Operations were categorized as "essential" (most cost-effective, highest population impact) as designated by the World Bank's Disease Control Priorities versus "other." Estimates were then compared with pediatric operation rates in New Zealand to determine unmet pediatric surgery need in Ghana. A total of 29,884 operations were performed for children <15 years, representing an annual operation rate of 284/100,000 (95% uncertainty interval: 205-364). Essential procedures constituted 66% of all pediatric operations; 12,397 (63%) were performed at district hospitals. General surgery (8,808; 29%) and trauma (6,302; 21%) operations were most common. Operations for congenital conditions were few (826; 2.8%). Tertiary hospitals performed majority (55%) of operations outside of the essential category. Compared with the New Zealand benchmark (3,806 operations/100,000 children <15 years), Ghana is meeting only 7% of its pediatric surgical needs. Ghana has a large unmet need for pediatric surgical care. Pediatric-specific benchmarking is needed to guide surgical capacity efforts in low- and middle-income country healthcare systems.

Burden of emergency pediatric surgical procedures on surgical capacity in Uganda: a new metric for health system performance

BackgroundThe significant burden of emergency operations in low- and middle-income countries can overwhelm surgical capacity leading to a backlog of elective surgical cases. The purpose of this investigation was to determine the burden of emergency procedures on pediatric surgical capacity in Uganda and to determine health metrics that capture surgical backlog and effective coverage of children’s surgical disease in low- and middle-income countries. MethodsWe reviewed 2 independent and prospectively collected databases on pediatric surgical admissions at Mulago National Referral Hospital and Mbarara Regional Referral Hospital in Uganda. Pediatric surgical patients admitted at either hospital between October 2015 to June 2017 were included. Our primary outcome was the distribution of surgical acuity and associated mortality. ResultsA combined total of 1,930 patients were treated at the two hospitals, and 1,110 surgical procedures were performed. There were 571 emergency cases (51.6%), 108 urgent cases (9.7%), and 429 elective cases (38.6%). Overall mortality correlated with surgical acuity. Emergency intestinal diversions for colorectal congenital malformations (anorectal malformations and Hirschsprung’s disease) to elective definitive repair was 3:1. Additionally, 30% of inguinal hernias were incarcerated or strangulated at time of repair. ConclusionEmergency and urgent operations utilize the majority of operative resources for pediatric surgery groups in low- and middle-income countries, leading to a backlog of complex congenital procedures. We propose the ratio of emergency diversion to elective repair of colorectal congenital malformations and the ratio of emergency to elective repair of inguinal hernias as effective health metrics to track this backlog. Surgical capacity for pediatric conditions should be increased in Uganda to prevent a backlog of elective cases.

Availability of post-hospital services supporting community reintegration for children with identified surgical need in Uganda

BackgroundCommunity services and supports are essential for children transitioning home to recover from the hospital after surgery. This study assessed the availability and geographic capacity of rehabilitation, assistive devices, familial support, and school reintegration programs for school-aged children in Uganda with identified surgical need.MethodsThis study assessed the geographic epidemiology and spatial analysis of resource availability in communities in Uganda. Participants were children with identified surgical need using the Surgeons OverSeas Assessment of Surgical need (SOSAS). Community-based resources available to children and adolescents after surgery in Uganda were identified using publicly available data sources and searching for resources through consultation with in-country collaborators We sought resources available in all geographic regions for a variety of services.ResultsOf 1082 individuals surveyed aged 5 to 14 yearsr, 6.2% had identified surgical needs. Pediatric surgical conditions were most prevalent in the Northern and Central regions of Uganda. Of the 151 community-based services identified, availability was greatest in the Central region and least in the Northern region, regardless of type. Assuming 30% of children with surgical needs will need services, a maximum of 50.1% of these children would have access to the needed services in the extensive capacity estimates, while only 10.0% would have access in the minimal capacity estimates. The capacity varied dramatically by region with the Northern region having much lower capacity in all scenarios as compared to the Central, Eastern, or Western regions.ConclusionsOur study found that beyond the city of Kampala in the Central region, community-based services were severely lacking for school-aged children in Uganda. Increased pediatric surgical capacity to additional hospitals in Uganda will need to be met with increased availability and access to community-based services to support recovery and community re-integration.

A Cost-Effectiveness Analysis of a Pediatric Operating Room in Uganda

This study examines the cost-effectiveness of constructing a dedicated pediatric operating room (OR) in Uganda, a country where access to surgical care is limited to 4 pediatric surgeons serving a population of over 20 million children under 15 years of age. MethodsA simulation model using a decision tree template was developed to project the cost and disability-adjusted life-years saved by a pediatric OR in a low-income setting. Parameters are informed by patient outcomes of the surgical procedures performed. Costs of the OR equipment and a literature review were used to calculate the incremental cost-effectiveness ratio of a pediatric OR. One-way and probabilistic sensitivity analysis were performed to assess parameter uncertainty. Economic monetary benefit was calculated using the value of a statistical life approach. ResultsA pediatric OR averted a total of 6,447 disability-adjusted life-years /year (95% uncertainty interval 6,288–6,606) and cost $41,182/year (UI 40,539–41,825) in terms of OR installation. The pediatric operating room had an incremental cost-effectiveness ratio of $6.39 per disability-adjusted life-year averted (95% uncertainty interval of 6.19-6.59), or $397.95 (95% uncertainty interval of 385.41-410.67) per life saved based on the country's average life expectancy in 2015. These values were well within the WHO guidelines of cost-effectiveness threshold. The net economic benefit amounted to $5,336,920 for a year of operation, or $16,371 per patient. The model remained robust with one-way and probabilistic sensitivity analyses. ConclusionThe construction of a pediatric operating room in Uganda is a cost-effective and worthwhile investment, endorsing future decisions to enhance pediatric surgical capacity in the resource-limited settings of Sub-Saharan Africa.

A Nationwide Assessment of Pediatric Surgical Capacity in Mongolia.

Mongolia is a country characterized by its vast distances and extreme climate. An underdeveloped medical transport infrastructure makes patient transfer from outlying regions dangerous. Providing pediatric surgical care locally is crucial to improve the lives of children in the countryside. This is the first structured assessment of nationwide pediatric surgical capacity. Operation rates were calculated using data from the Mongolian Center for Health Development and population data from the Mongolian Statistical Information Service. The Pediatric Personnel, Infrastructure, Procedures, Equipment, and Supplies (PediPIPES) survey tool was used to collect data at all survey sites. Descriptive data analyses were completed using Excel. Studies of association were completed using Stata. All reported percentages are of the hospitals outside of the capital (n = 21). All provincial hospitals have general surgeons; seven (33.3%) of them have pediatric surgeon(s). One facility has no anesthesiologist. All facilities perform basic procedures and provide anesthesia. Four (19%) can treat common congenital anomalies. All facilities have basic operating room equipment. Nine hospitals do not have pulse oximetry available. Twelve hospitals do not have pediatric surgical instruments always available. Pediatric supplies are lacking. Provincial hospitals in Mongolia can perform basic procedures. However, essential pediatric supplies are lacking. Consequently, certain life-saving procedures are not available to children outside of the capital. Only a few improvements would be amendable to low-cost process improvement adjustment, and the majority of needs require resource additions. Procedure, equipment, and supply availability should be further explored to develop a comprehensive nationwide pediatric surgical program.

Characterizing pediatric surgical capacity in the Eastern Democratic Republic of Congo: results of a pilot study.

Characterize pediatric surgical capacity in the eastern Democratic Republic of Congo (DRC) to identify areas of potential improvement. The Pediatric Personnel, Infrastructure, Procedures, Equipment, and Supplies (PediPIPES) survey was used in two representative eastern DRC provinces to assess existing surgical infrastructure and capacity. We compared our results to previously published reports from other sub-Saharan African countries. Fourteen hospitals in the eastern DRC and 37 in 19 sub-Saharan African (SSA) countries were compared. The average PediPIPES index for the DRC was 7.7 compared to 13.5 for SSAs. The greatest disparities existed in the areas of personnel and infrastructure. Running water was reportedly available to 57.1% of the hospitals in the DRC, and the majority of hospitals (78.6%) were dependent on generators and solar panels for electricity. Only two hospitals in the DRC (14.3%) reported a pediatric surgeon equivalent on staff, compared to 86.5% of facilities sampled in SSA reporting ≥ 1 pediatric surgeon. Significant barriers in personnel, infrastructure, procedures, equipment, and supplies impede the provision of adequate surgical care to children. Further work is needed to assess allocation and utilization of existing resources, and to enhance training of personnel with specific attention to pediatric surgery.

Pediatric surgical capacity building – a pathway to improving access to pediatric surgical care in Haiti

PurposeLack of human resources is a major barrier to accessing pediatric surgical care globally. Our aim was to establish a model for pediatric surgical training of general surgery residents in a resource constrained region. Materials/methodsA pediatric surgical program with a pediatric surgical rotation for general surgery residents in a tertiary hospital in Haiti in 2015 was established. We conducted twice daily patient rounds, ran an outpatient clinic, and provided emergent and elective pediatric surgical care, with tasks progressively given to residents until they could run clinic and perform the most common elective and emergent procedures. We conducted baseline and post-intervention knowledge exams and dedicated 1 day a week to teaching and research activities. We measured the following outcomes: number of residents that completed the rotation, mean pre and post intervention test scores, patient volume in clinic and operating room, postoperative outcomes, resident ability to perform most common elective and emergent procedures, and resident participation in research. ResultsNine out of 9 residents completed the rotation; 987 patients were seen in outpatient clinic, and 564 procedures were performed in children <15years old. There was a 50% increase in volume of pediatric cases and a 100% increase in procedures performed in children <4years old. Postoperative outcomes were: 0% mortality for elective cases and 18% mortality for emergent cases, 3% complication rate for elective cases and 6% complication rate for emergent cases. Outcomes did not change with increased responsibility given to residents. All senior residents (n=4) could perform the most common elective and emergent procedures without changes in mortality and complication rates. Increases in mean pre and post intervention test scores were 12% (PGY1), 24% (PGY2), and 10% (PGY3). 75% of senior residents participated in research activities as first or second authors. ConclusionsEstablishing a program in pediatric surgery with capacity building of general surgery residents for pediatric surgical care provision is feasible in a resource constrained setting without negative effects on patient outcomes. This model can be applied in other resource constrained settings to increase human resources for global pediatric surgical care provision. Level of evidenceIII

Evaluating Pediatric Surgical Capacity in the Eastern Democratic Republic of Congo: Results of a Pilot Study

Cairo, Sarah B. MD, MPH; Kalisya, Luc Malemo MD; Bigabwa Bahirwe, Richard R.B.; Rothstein, David H. MD, FACS, FAAP, FACS Author Information

Pediatric surgical capacity in Africa: Current status and future needs

BackgroundAfrican pediatric surgery (PS) faces multiple challenges. Information regarding existing resources is limited. We surveyed African pediatric surgeons to determine available resources and clinical, educational, and collaborative needs. MethodsMembers of the Pan-African Pediatric Surgical Association (PAPSA) and the Global Pediatric Surgery Network (GPSN) completed a structured email survey covering PS providers, facilities, resources, workload, education/training, disease patterns, and collaboration priorities. ResultsOf 288 deployed surveys, 96 were completed (33%) from 26 countries (45% of African countries). Median PS providers/million included 1 general surgeon and 0.26 pediatric surgeons. Median pediatric facilities/million included 0.03 hospitals, 0.06 ICUs, and 0.17 surgical wards. Neonatal ventilation was available in 90% of countries, fluoroscopy in 70%, TPN in 50%, and frozen section pathology in 35%. Median surgical procedures/institution/year was 852. Median waiting time was 40days for elective procedures and 7 days? for emergencies. Weighted average percent mortality for key surgical conditions varied between 1% (Sierra Leone) and 54% (Burkina Faso). Providers ranked collaborative professional development highest and direct clinical care lowest priority in projects with high-income partners. ConclusionsThe broad deficits identified in PS human and material resources in Africa suggest the need for a global collaborative effort to address the PS gaps. Level of evidenceLevel 5, expert opinion without explicit critical appraisal.

Can Economic Performance Predict Pediatric Surgical Capacity in Sub-Saharan Africa?

The relationship between economic status and pediatric surgical capacity in low- and middle-income countries (LMICs) is poorly understood. In sub-Saharan Africa (SSA), Nigeria accounts for 20% of the population and has the highest Gross Domestic Product (GDP), but whether this economic advantage translates to increased pediatric surgical capacity is unknown. This study compares the pediatric surgical capacity between Nigeria and other countries within the region. The Pediatric Personnel, Infrastructure, Procedures, Equipment and Supplies (PediPIPES) survey, a recent tool that is useful in assessing and comparing the capacity of health facilities to deliver essential and emergency surgical care (EESC) to children in LMICs, was used for this evaluation. Data from hospitals in Nigeria (n=24) and hospitals in 17 other sub-Saharan African countries (n=25) were compared. The GDP of Nigeria was approximately twenty-five times the average GDP of the 17 other countries represented in our survey. Running water was unavailable in 58% of the hospitals in Nigeria compared to 20% of the hospitals in the other countries. Most hospitals in Nigeria and in the other countries did not have a CT scan (67 and 60%, respectively). Endoscopes were unavailable in 58% of the hospitals in Nigeria and 44% of the hospitals in the other countries. Despite better economic indicators in Nigeria, there were no distinct advantages over the other countries in the ability to deliver EESC to children. Our findings highlighted the urgent need for specific allocation of more resources to pediatric surgical capacity building efforts across the entire region.