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Funding Paediatric Surgery Procedures in sub-Saharan Africa

Sebastian O Ekenze, Chukwunonso A Jac-Okereke, Elochukwu P Nwankwo

Sub-Department of Paediatric Surgery


                                                                  Abstract

Background

In sub-Saharan Africa, the growing awareness of the burden of paediatric surgical diseases has highlighted the large discrepancy between the capacity to treat and the ability to afford treatment, and the effect of this on access to care. This review focuses on the sources and challenges of funding paediatric surgical procedures in sub-Saharan Africa.

Methods

We undertook a search for studies published between January 2007 and November 2016 that reported funding of paediatric surgical procedures and were conducted in sub-Saharan Africa. Abstract screening, full-text review, and data abstraction were completed and analyzed with the Statistical Package for Social Sciences (SPSS).

Results

Thirty-five studies meeting the inclusion criteria were reviewed. The countries predominantly emphasized in the publications were Nigeria, South Africa, Kenya, Ghana, and Uganda.  The paediatric surgical procedures covered general paediatric surgery/urology, cardiac, neurosurgery, oncology, plastic, ophthalmology, orthopaedics, and otorhinolaryngology. The mean cost of these procedures ranges from USD 60 to USD 21,140. The source of funding for the procedures was mostly out-of-pocket payment (OOP) by patients’ families in 32 (91.4%), and medical mission/Non-governmental organizations (NGOs) in 21 (60%) studies. This pattern did not differ appreciably between the articles published in the initial and latter 5-years of the study period, but there is trend towards reduction in out-of pocket funding.  Improvements of healthcare funding by individual countries supported by the international organizations/charity, were the main suggested solutions to the funding challenges.

Conclusion

Barring the limitation of diversity of design, the reviewed publications indicate that funding of paediatric surgical procedures in sub-Saharan Africa is mostly by out of pocket payment by families of the patients. This may result in limited access to some procedures. Coordinated effort and collaboration of individual countries and international agencies may reduce out of pocket funding and improve access to the procedures.

Key Words: Healthcare financing; Paediatric surgery; Challenges; sub-Saharan Africa


 Introduction

The past decade has witnessed increased awareness of the burden of paediatric surgery in developing countries1, 2. Compounding this burden are late presentation for care, concomitant malnutrition, large cache of unoperated conditions with a huge burden of chronic surgical disability, advanced disease on presentation requiring more complex procedures, and an increased likelihood of postoperative complications1 – 5.  As a result, the scale of the burden of disease estimated to be due to paediatric surgical conditions in sub-Saharan Africa (SSA) may be enormous. Although there has been significant advances in the management of these disorders with excellent outcome for most of the cases in more developed climes6, 7, studies have shown that there is substantial lack of access to surgical care for these disorders in SSA4, 5, 8. The lack of access may be in the form of dearth of facilities and trained professional, or large discrepancy between the capacity to treat and the ability to afford treatment. The latter is reported to be a major challenge to tackling the huge paediatric surgical burden in SSA8, 9. This is worsened by lack of focused intervention by individual countries and their institutions10 and has prompted the initiation of programmes by a number of non-governmental agencies and international and local charitable organizations to improve funding and access to treatment for these children11. Despite these efforts, the solution is limited and sustainability to a large extent is lacking8, 12.

Evaluation of the sources of funding paediatric surgery procedures in SSA may provide veritable insight into the ways to achieve a more universal and sustainable improvement in funding and possibly improve access to care. In this systematic review, publications providing data on healthcare funding of paediatric surgery in sub-Saharan Africa over 10 years are evaluated with a focus on the sources and possible solutions to challenges of funding paediatric surgical procedures.

 

Materials and Methods

We followed the guidelines described by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement13 and conducted a systematic review of literature for Healthcare funding for paediatric surgery in sub-Saharan Africa. To identify all possible literature on Healthcare funding for paediatric surgery in sub-Saharan Africa we undertook searches of databases of PubMed, African Index Medicus, and African Journal Online (AJOL) using the following search details: (“Economics” OR “Funding”) AND (“Pediatric ” AND “Surgery” OR “Pediatric surgery”) AND (“Africa”). Only articles published from January 2007 to November 2016 from sub-Saharan Africa were considered.  Article titles and abstracts were screened for relevance.

Each of the articles was then evaluated in full to identify all papers reporting healthcare funding for paediatric surgery in sub-Saharan Africa. Criteria for inclusion were:  publications based on studies on sub-Saharan Africa that reported funding of specific paediatric surgical procedures including the sources for the funding and the solutions to challenges of funding. The surgeries were not limited to procedures performed by paediatric general surgeons, but included all surgical procedures undertaken in children. Excluded were publications that did not contain data on specific funding sources for the procedures, and studies that dealt with cost analysis without emphasizing access in relation to cost, and funding of the procedures.  No articles were excluded for being published in a language other than English. Articles published in other languages were translated to English using online translation resources. The evidence obtained was reviewed and evaluated by the authors. Following this, duplicates were also excluded. We used data extraction sheet to collect information, including type, span, year, Key aspects and country emphasized in the study; surgical procedures, funding sources, trend in funding, challenges of funding, and suggestions to address funding challenges.

Data analysis

We used the Statistical Package for Social Sciences (SPSS 15.0 version, SPSS Inc, Chicago, Ill) for data entry and analysis. Results were expressed as percentages, or mean. Descriptive percentages were used as the percentage of the parameters for which that data point was available, since complete data were not available for all the parameters.  Data were analyzed by Chi-square test. In all, the significance level was set to p<0.05.

Results

Search results

The initial database search for healthcare funding for paediatric surgery in sub-Saharan Africa yielded 401 publications. After screening these publications, 35 articles were evaluated in full. The algorithm for the selection of the publications is shown in Figure-1.  Of the 35 studies, 22 (62.9%) were published in the last 5-years of the study period (January 2012 – November 2016), and 13 (37.1%) published in the first 5-years (January 2007 – December 2011). The articles (Table 1) were of retrospective type4, 19 -23, 34 – 38, 41, 43, 44 in 14 (40%), prospective14, 25, 27, 29, 30, 33, 39 in 7 (20%), review1, 5, 9, 16, 18, 31, 32, 40, 42 in 9 (25.7%), survey15, 28 in 2 (5.7%), letter to the editor17, 24 in  2 (5.7%), and one (2.9%) case report26. The sub-Saharan African countries emphasized in the studies were Nigeria (14), South Africa (9), Kenya (8), Ghana (6), Malawi (5), Uganda (4), Zambia (4), Cameroon (3), Liberia (3), Sierra Leone (3), Mozambique (3), and Zimbabwe (3).  Others were Botswana (1), CoteD’voire (1), Ethiopia (1), and Tanzania (1).

The paediatric surgical procedures

The surgical procedures covered in the publications were general paediatric surgery/paediatric urology (n=13), Oncology (n=10), Cardiac/thoracic surgery (n=9), Neurosurgery (n=8), Plastic surgery (n=6), Orthopaedics (n= 5), Ophthalmology (n=5), and Otorhinolaryngology (n=4). The distribution of the specialties indicated in the various countries is shown in Table 2.

 Funding of the procedures

All the 35 studies specified the sources of funding for the procedures. However, only 9 (25.7%) indicated exact cost of the surgical procedures4, 14, 19, 23, 27 – 29, 33, 39. The mean costs of the procedures as indicated range from USD 60 for paediatric hernia or cataract to USD 21,140 for cardiac surgery. The reported source of funding for the procedures was predominantly by out of pocket payment by parents/guardian in 32 (91.4%) of the publications; medical mission and Non-governmental organizations (NGOs) in 21 (60%); health insurance in 5 (14.3%); and direct government funding in 3 (8.6%). Comparison of the major sources of funding for the procedures between the articles published in the last 5-years of the study period and those published in the first 5-years shows a trend towards reduction in out-of pocket funding (table 3). All the publications indicated limitation in access to the procedures due to funding challenges.

Suggested solutions to funding challenges

The publications had one or more suggestions to improve funding. The main suggestions were improvement of funding effort by government of individual countries and international bodies in 30 (85.7%) publications; establishment or improvement of health insurance scheme (n=21; 60%); and sustaining charity/medical mission (n=15; 42.9%).

Discussion

This study has shown an increase in the number of publications on funding paediatric surgery in sub-Saharan Africa (SSA) in the recent years. This may be an offshoot of increased medical and paediatric surgical literature in recent years, or it may reflect an increasing interest in global surgery and access to paediatric surgery care in developing countries. Remarkably, literature on funding for paediatric surgery from High income countries (HICs) is scant in the past decade as most studies focused on people with low income and incomplete insurance45 – 48. This may be related to improved access and coordinated funding protocol for paediatric surgery in these countries. Despite the increase in publications on this theme in our setting, a substantial proportion of those reviewed for this study were descriptive or retrospective4, 19 -23, 34 – 38, 41, 43, 44 in nature and devoid of analysis, and this limited the information obtainable therefrom.  Nonetheless, the selected publication offered some insight into the paediatric surgery procedures and funding sources, challenges of funding, and suggestions to address the challenges.

The reviewed literature indicated that a wide array of procedures in various specialties was undertaken in SSA. A substantial proportion of the surgical procedures undertaken in children and reported in global literature were covered. However the more modern approach to some of these procedures like laparoscopy and robotic surgery, and transplantation surgeries were not emphasized by the cited literature probably because these procedures were not routinely undertaken in this setting and hence not reported. As the studies1, 5, 9, 16, 19, 20, 22, 25, 26, 30, 34, 44 have shown, a considerable proportion of funding for these procedures was from out-of-pocket (OOP) payment by parents/guardian of the affected children.  Previous studies45, 46, 49, 50 have shown that OOP payments has potential to undermine core objectives of health care systems, including those of equitable financing, equal access, and improved health among the population. Barring limitations of the cited literature, these deficits in healthcare were also shown in the present report. The consequences of decreased access in our setting may range from delayed treatment with its attendant complication1, 5, 20, to accumulation of large cache of unoperated conditions with a huge burden of chronic surgical disability1 – 5, 51. Although similar circumstances have been reported from some other developing countries2, 3, 10, 46, 49, 52, 53, there is evidence that OOP payment also take place in HICs47, 48 but this is in a significantly reduced proportion and largely for people with low income and incomplete insurance. The reason for the predominance of OOP payment for procedures in our setting could not be conclusively deduced from the included studies, however some of the studies1, 5, 9, 16, 19, 20, 22, 25, 26, 30, 34 indicated lack of effective health insurance scheme and inadequate government healthcare funding in the affected countries as the key contributing factors. The latter may be traced to the very low total expenditure on health as a percentage of gross domestic products in SSA (2.5%) compared to over 10% in HICs54. Effort geared towards increasing percentage of the gross domestic product spent on health in this setting may address this deficiency. In another vein, this study has revealed that charity funding/medical mission plays an important supportive role in funding paediatric surgery procedures in SSA. While this has been known to have beneficial short-term role, the long-term benefits and sustainability has been called to question11, 55. It is also pertinent to note that despite the benefit of such humanitarian efforts, there may be the possibility that these may lull the affected countries into false sense of improved healthcare delivery thereby reducing their commitment towards improving healthcare spending.

In order to possibly reduce these inequities, expand financial protection, and promote adequate paediatric surgical access, certain measures may be needed. Although the substantial diversity of the study designs in the present review might make it arduous to offer strong recommendations, the cited studies espoused some measures to improve funding for pediatric surgery procedures. The suggested measures emphasize considerable effort by individual countries to reduce the proportion of total health expenditure by OOP

payment1, 4, 5, 9, 20, 22, 25, 31, 41, 44. This may be achievable by increasing government expenditure on health and establishment of effective health insurance scheme with broader coverage of benefits. Another option for the affected countries is the example from Sierra Leone17 where the government introduced free healthcare for pregnant women, new mothers, and children younger than 5 years. The effect of this on paediatric surgery access, care and averted death and severe disability is reported to be substantial. However, there is need for a note of caution as there might be challenges with sustainability; and reproducibility in more populated LMICs may be difficult. A similar challenge of limited coverage and sustainability may also attend the reliance on charities/medical missions and has prompted some previous reports to recommend this method of funding as adjunct to individual countries effort1, 11, 12. Finally, the World Health Assembly resolution56 on “Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage” in 2015, and the other key events in global surgery viz- The Lancet Commission on Global Surgery57, and The Amsterdam Declaration on Essential Surgical Care58 seek to achieve health equity for all people who require surgical care, with a special emphasis on underserved populations and populations in crisis. It is anticipated that these international effort may provide suitable framework for long-term solution to funding challenges of paediatric surgery in sub-Saharan Africa and other LMICs59.

Limitations of Study

This study was limited by the retrospective nature, and diversity of design of most of the studies included in the review. This resulted in some missing data on types of funding and funding challenges, and precluded a more detailed analysis.  Another limitation of the study is the literature search only including papers that include ‘developing countries OR Africa. Thus studies, which may not have used these terms, would have been excluded.

Conclusion

The published literature on funding of paediatric surgery in sub-Saharan Africa indicate that a wide variety of paediatric surgery procedures in various specialties are undertaken in the region. Though limited by diversity of design and missing data, the reviewed literature denotes that a substantial proportion of these procedures are funded by out of pocket payment by parents/guardian, and this may limit access to care in some procedures. The challenges of funding may be addressed by improved spending on healthcare by individual countries, enhanced health insurance programme, and augmentation from charities and medical mission. International effort via global surgery programmes may provide suitable framework for long-term solution.

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Introduction

The past decade has witnessed increased awareness of the burden of paediatric surgery in developing countries1, 2. Compounding this burden are late presentation for care, concomitant malnutrition, large cache of unoperated conditions with a huge burden of chronic surgical disability, advanced disease on presentation requiring more complex procedures, and an increased likelihood of postoperative complications1 – 5.  As a result, the scale of the burden of disease estimated to be due to paediatric surgical conditions in sub-Saharan Africa (SSA) may be enormous. Although there has been significant advances in the management of these disorders with excellent outcome for most of the cases in more developed climes6, 7, studies have shown that there is substantial lack of access to surgical care for these disorders in SSA4, 5, 8. The lack of access may be in the form of dearth of facilities and trained professional, or large discrepancy between the capacity to treat and the ability to afford treatment. The latter is reported to be a major challenge to tackling the huge paediatric surgical burden in SSA8, 9. This is worsened by lack of focused intervention by individual countries and their institutions10 and has prompted the initiation of programmes by a number of non-governmental agencies and international and local charitable organizations to improve funding and access to treatment for these children11. Despite these efforts, the solution is limited and sustainability to a large extent is lacking8, 12.

Evaluation of the sources of funding paediatric surgery procedures in SSA may provide veritable insight into the ways to achieve a more universal and sustainable improvement in funding and possibly improve access to care.

In this systematic review, publications providing data on healthcare funding of paediatric surgery in sub-Saharan Africa over 10 years are evaluated with a focus on the sources and possible solutions to challenges of funding paediatric surgical procedures.

 

Materials and Methods

We followed the guidelines described by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement13 and conducted a systematic review of literature for Healthcare funding for paediatric surgery in sub-Saharan Africa. To identify all possible literature on Healthcare funding for paediatric surgery in sub-Saharan Africa we undertook searches of databases of PubMed, African Index Medicus, and African Journal Online (AJOL) using the following search details: (“Economics” OR “Funding”) AND (“Pediatric ” AND “Surgery” OR “Pediatric surgery”) AND (“Africa”). Only articles published from January 2007 to November 2016 from sub-Saharan Africa were considered.  Article titles and abstracts were screened for relevance.

Each of the articles was then evaluated in full to identify all papers reporting healthcare funding for paediatric surgery in sub-Saharan Africa. Criteria for inclusion were:  publications based on studies on sub-Saharan Africa that reported funding of specific paediatric surgical procedures including the sources for the funding and the solutions to challenges of funding. The surgeries were not limited to procedures performed by paediatric general surgeons, but included all surgical procedures undertaken in children. Excluded were publications that did not contain data on specific funding sources for the procedures, and studies that dealt with cost analysis without emphasizing access in relation to cost, and funding of the procedures.  No articles were excluded for being published in a language other than English. Articles published in other languages were translated to English using online translation resources.

The evidence obtained was reviewed and evaluated by the authors. Following this, duplicates were also excluded. We used data extraction sheet to collect information, including type, span, year, Key aspects and country emphasized in the study; surgical procedures, funding sources, trend in funding, challenges of funding, and suggestions to address funding challenges.

Data analysis

We used the Statistical Package for Social Sciences (SPSS 15.0 version, SPSS Inc, Chicago, Ill) for data entry and analysis. Results were expressed as percentages, or mean. Descriptive percentages were used as the percentage of the parameters for which that data point was available, since complete data were not available for all the parameters.  Data were analyzed by Chi-square test. In all, the significance level was set to p<0.05.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Results

 

Search results

The initial database search for healthcare funding for paediatric surgery in sub-Saharan Africa

yielded 401 publications. After screening these publications, 35 articles were evaluated in full. The algorithm for the selection of the publications is shown in Figure-1.  Of the 35 studies, 22 (62.9%) were published in the last 5-years of the study period (January 2012 – November 2016), and 13 (37.1%) published in the first 5-years (January 2007 – December 2011). The articles (Table 1) were of retrospective type4, 19 -23, 34 – 38, 41, 43, 44 in 14 (40%), prospective14, 25, 27, 29, 30, 33, 39 in 7 (20%), review1, 5, 9, 16, 18, 31, 32, 40, 42 in 9 (25.7%), survey15, 28 in 2 (5.7%), letter to the

editor17, 24 in  2 (5.7%), and one (2.9%) case report26. The sub-Saharan African countries emphasized in the studies were Nigeria (14), South Africa (9), Kenya (8), Ghana (6), Malawi (5), Uganda (4), Zambia (4), Cameroon (3), Liberia (3), Sierra Leone (3), Mozambique (3), and Zimbabwe (3).  Others were Botswana (1), CoteD’voire (1), Ethiopia (1), and Tanzania (1).

 

The paediatric surgical procedures

The surgical procedures covered in the publications were general paediatric surgery/paediatric urology (n=13), Oncology (n=10), Cardiac/thoracic surgery (n=9), Neurosurgery (n=8), Plastic surgery (n=6), Orthopaedics (n= 5), Ophthalmology (n=5), and Otorhinolaryngology (n=4). The distribution of the specialties indicated in the various countries is shown in Table 2.

 

Funding of the procedures

All the 35 studies specified the sources of funding for the procedures. However, only 9 (25.7%) indicated exact cost of the surgical procedures4, 14, 19, 23, 27 – 29, 33, 39. The mean costs of the procedures as indicated range from USD 60 for paediatric hernia or cataract to USD 21,140 for cardiac surgery. The reported source of funding for the procedures was predominantly by out of pocket payment by parents/guardian in 32 (91.4%) of the publications; medical mission and Non-governmental organizations (NGOs) in 21 (60%); health insurance in 5 (14.3%); and direct government funding in 3 (8.6%). Comparison of the major sources of funding for the procedures between the articles published in the last 5-years of the study period and those published in the first 5-years shows a trend towards reduction in out-of pocket funding (table 3). All the publications indicated limitation in access to the procedures due to funding challenges.

 

Suggested solutions to funding challenges

The publications had one or more suggestions to improve funding. The main suggestions were improvement of funding effort by government of individual countries and international bodies in 30 (85.7%) publications; establishment or improvement of health insurance scheme (n=21; 60%); and sustaining charity/medical mission (n=15; 42.9%).

 

 

 

 

 

 

 

 

 

 

Discussion

This study has shown an increase in the number of publications on funding paediatric surgery in sub-Saharan Africa (SSA) in the recent years. This may be an offshoot of increased medical and paediatric surgical literature in recent years, or it may reflect an increasing interest in global surgery and access to paediatric surgery care in developing countries. Remarkably, literature on funding for paediatric surgery from High income countries (HICs) is scant in the past decade as most studies focused on people with low income and incomplete insurance45 – 48. This may be related to improved access and coordinated funding protocol for paediatric surgery in these countries. Despite the increase in publications on this theme in our setting, a substantial proportion of those reviewed for this study were descriptive or retrospective4, 19 -23, 34 – 38, 41, 43, 44 in nature and devoid of analysis, and this limited the information obtainable therefrom.  Nonetheless, the selected publication offered some insight into the paediatric surgery procedures and funding sources, challenges of funding, and suggestions to address the challenges.

The reviewed literature indicated that a wide array of procedures in various specialties was undertaken in SSA. A substantial proportion of the surgical procedures undertaken in children and reported in global literature were covered. However the more modern approach to some of these procedures like laparoscopy and robotic surgery, and transplantation surgeries were not emphasized by the cited literature probably because these procedures were not routinely undertaken in this setting and hence not reported. As the studies1, 5, 9, 16, 19, 20, 22, 25, 26, 30, 34, 44 have shown, a considerable proportion of funding for these procedures was from out-of-pocket (OOP) payment by parents/guardian of the affected children.  Previous studies45, 46, 49, 50 have shown that OOP payments has potential to undermine core objectives of health care systems, including those of equitable financing, equal access, and improved health among the population. Barring limitations of the cited literature, these deficits in healthcare were also shown in the present report. The consequences of decreased access in our setting may range from delayed treatment with its attendant complication1, 5, 20, to accumulation of large cache of unoperated conditions with a huge burden of chronic surgical disability1 – 5, 51. Although similar circumstances have been reported from some other developing countries2, 3, 10, 46, 49, 52, 53, there is evidence that OOP payment also take place in HICs47, 48 but this is in a significantly reduced proportion and largely for people with low income and incomplete insurance. The reason for the predominance of OOP payment for procedures in our setting could not be conclusively deduced from the included studies, however some of the studies1, 5, 9, 16, 19, 20, 22, 25, 26, 30, 34 indicated lack of effective health insurance scheme and inadequate government healthcare funding in the affected countries as the key contributing factors. The latter may be traced to the very low total expenditure on health as a percentage of gross domestic products in SSA (2.5%) compared to over 10% in HICs54. Effort geared towards increasing percentage of the gross domestic product spent on health in this setting may address this deficiency. In another vein, this study has revealed that charity funding/medical mission plays an important supportive role in funding paediatric surgery procedures in SSA. While this has been known to have beneficial short-term role, the long-term benefits and sustainability has been called to question11, 55. It is also pertinent to note that despite the benefit of such humanitarian efforts, there may be the possibility that these may lull the affected countries into false sense of improved healthcare delivery thereby reducing their commitment towards improving healthcare spending.

In order to possibly reduce these inequities, expand financial protection, and promote adequate paediatric surgical access, certain measures may be needed. Although the substantial diversity of the study designs in the present review might make it arduous to offer strong recommendations, the cited studies espoused some measures to improve funding for pediatric surgery procedures. The suggested measures emphasize considerable effort by individual countries to reduce the proportion of total health expenditure by OOP

payment1, 4, 5, 9, 20, 22, 25, 31, 41, 44. This may be achievable by increasing government expenditure on health and establishment of effective health insurance scheme with broader coverage of benefits. Another option for the affected countries is the example from Sierra Leone17 where the government introduced free healthcare for pregnant women, new mothers, and children younger than 5 years. The effect of this on paediatric surgery access, care and averted death and severe disability is reported to be substantial. However, there is need for a note of caution as there might be challenges with sustainability; and reproducibility in more populated LMICs may be difficult. A similar challenge of limited coverage and sustainability may also attend the reliance on charities/medical missions and has prompted some previous reports to recommend this method of funding as adjunct to individual countries effort1, 11, 12. Finally, the World Health Assembly resolution56 on “Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage” in 2015, and the other key events in global surgery viz- The Lancet Commission on Global Surgery57, and The Amsterdam Declaration on Essential Surgical Care58 seek to achieve health equity for all people who require surgical care, with a special emphasis on underserved populations and populations in crisis. It is anticipated that these international effort may provide suitable framework for long-term solution to funding challenges of paediatric surgery in sub-Saharan Africa and other LMICs59.

 

Limitations of Study

This study was limited by the retrospective nature, and diversity of design of most of the studies included in the review. This resulted in some missing data on types of funding and funding challenges, and precluded a more detailed analysis.  Another limitation of the study is the literature search only including papers that include ‘developing countries OR Africa. Thus studies, which may not have used these terms, would have been excluded.

 

Conclusion

The published literature on funding of paediatric surgery in sub-Saharan Africa indicate that a wide variety of paediatric surgery procedures in various specialties are undertaken in the region. Though limited by diversity of design and missing data, the reviewed literature denotes that a substantial proportion of these procedures are funded by out of pocket payment by parents/guardian, and this may limit access to care in some procedures. The challenges of funding may be addressed by improved spending on healthcare by individual countries, enhanced health insurance programme, and augmentation from charities and medical mission. International effort via global surgery programmes may provide suitable framework for long-term solution.

 

 

 

 

 

 

 

 

 

 

 

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