Paediatric surgery in Uganda : burden of disease and barriers to quality of care

Abstract

Background: In recent years there has been an increased awareness of surgical conditions within global health. A special emphasis is needed for children which constitute a large proportion of the populations in many countries. Many surgical conditions affect children, and an estimated 85% of all children in LMIC aged 15 will require surgery. Also, life-threatening conditions such as incarcerated hernias can be successfully corrected by surgical intervention. There is compelling evidence that the quality of basic surgical care for children is compromised in hospitals especially in low-resourced countries in Sub-Saharan Africa. This widespread quality gap suggests a potential for improved health systems to cater for children with surgical need at all levels of care. Uganda with a population of 20 million children has enormous unmet need for paediatric surgical care. There are numerous obstacles to increasing children’s surgical capacity in Uganda. How far surgical services for children in Uganda are affected has not been investigated.

Aim: The overall aim of the work reported in this thesis was to address knowledge gaps in paediatric surgery in Uganda. This included the prevalence of paediatric surgical conditions, the burden of paediatric surgical disease, identifying barriers and solutions to surgical care, and, finally, assessing the impact of covid-19 on the access to surgical care for children.

Methods: Four studies were undertaken: Study I was a cross-sectional, cluster-based study of the prevalence of paediatric surgical conditions in eastern Uganda. It was conducted at a Health Demographic Surveillance Site (HDSS). Study II was a nationwide facility-based study with retrospective data collection. It sought to determine the volumes and type of surgical procedures done for children in Uganda. Study III was a qualitative, interview-based exploration of the barriers and potential solutions for improved surgical care for children with hernia in eastern Uganda. Study IV was a mixed-method study combining quantitative registry-hospital data and qualitative interview-based data to investigate the impact of Covid- 19 on access to paediatric surgery in the Teso sub-region in Eastern Uganda.

Results: I) the overall prevalence of paediatric surgical conditions was high at 16%, unmet need was 6.3%, and 10.1% had some degree of disability verified by physical examination. II) The average annual rate of 22.0 of major surgical procedures per 100,000 paediatric population in Uganda was assessed in 2013-2014. The rate varied between the four regions from 12 per 100 000 children in Northern Uganda to 27.7 per 100 000 children in Central Uganda. The most common conditions were congenital (n=3111, 39%), infections (n=2264, 28.7%) and trauma (n =1210,15.3%). Specialist surgeons performed 60% (n=4758) of the procedures, and anaesthesia was administered by specialist physician anaesthetists in 11.6%, n =917. III) Traditional beliefs and gender inequalities were considered major issues; others included lack of funds, transport, long distance and mistrust in the health system care. Possible solutions included partnering with the local community leaders to increase knowledge and acceptability in the community in general and by the parents. Another solution was capacity building for the health workers. IV) Total procedures for children increased by 24% between 2019 (n= 1407) and 2021 (n=1751). Procedures performed for pregnancy-related conditions increased most (58.3%). Some 12 parents and 25 health workers participated in the interviews. Using reflexive thematic analysis, two themes emerged, i) conflicts between reality and perception of the situation during the pandemic, and ii) lessons learned and a way forward.

Conclusion: The prevalence of paediatric surgical conditions in Uganda is high with a huge unmet need for paediatric surgery. Procedures are performed in the country in a fairly decentralized manner, but with variation in the four regions, especially the northern region being underserved. Health-policy makers should promote programmes that are geared to the training and retention of a surgical workforce evenly distributed throughout the country. It is key to improve infrastructure and ensure regular supply of equipment and medicines. In partnership with non-governmental organizations the Government need to introduce programmes geared to empowering the country’s youth with skills for survival.