This cross-sectional study assessed the pediatric surgical backlog in LMICs using self-reported provider surveys from February to June of 2021. Pediatric surgical providers at 15 different sites in 8 countries in Sub-Saharan Africa and Ecuador completed the survey. To our knowledge, this is one of the first studies to characterize pediatric surgical waitlists by procedure in LMICs, using a multisite self-reported survey.
The overall median wait time was 2 months, with a median waitlist length of 90 patients. Given the breadth of surgical delivery systems included, we found a wide range of waitlist length (8 − 2,500 cumulative patients for all procedures) and wait time (0.25-36 months). Of all the sites, the CHU Pediatric Charles de Gaule facility in Burkina Faso reported the largest number of patients on their waitlist. Meanwhile, Kamuzu Central Hospital Lilongwe in Malawi held the longest wait time with a median overall duration of 36 months, and a waitlist of 90 patients. In Lilongwe, providers stopped scheduling inguinal hernias and orchiopexies since they do not have enough OR space to do them. On rare occasions, they might call a patient with an elective hernia or orchiopexy if there are not enough index cases waiting on the ward. Similar reports have emerged from other sites in the past, especially noting that elective cases are often neglected as emergency cases take priority. Given the infrequency with which these elective cases are performed, 36 months was a conservative estimate based on wait times at other facilities.
Surgical procedures with the longest wait times included hypospadias (mean of 4.5 months) and anoplasty procedures (median 4.5 months). This finding corroborated a previous scoping review on delays in congenital anomaly repairs in Sub-Saharan Africa, which reported substantial backlogs in hypospadias repair (59,180 cases over 6 countries) and anorectal malformations (2,001 cases over 5 countries). They estimated an accumulated disease burden of 75,000 disability adjusted life years (DALYs) from five congenital anomalies left unrepaired due to surgical backlog. Multiple other single-site studies have demonstrated the delay in repairs of congenital anomalies in Kenya, Somaliland, Uganda, and Nigeria, with its associated preventable disease burden., – For surgical volume, hernia repair, hypospadias repair and orchiopexy were surgical procedures with the largest backlogs. This delay is unsurprising, given the relatively non-acute nature of these anatomical anomalies that confer morbidity and much less frequent mortality. This of course should not trivialize the disability risk from incarcerated hernia which has a very real mortality likelihood in young patients. Plus from experience we see desperate families seek care from unqualified surgical providers which can lead to attendant complications.
De los Valles Hospital in Ecuador is a private, for-profit, facility located in an upper middle income country. It had both the shortest waitlist and wait time for all elective procedures. Since the other hospitals in the study were either public or mission hospitals in Sub-Saharan Africa, de los Valles provides a stark point of contrast. We also stratified wait time by lower, lower-middle (Nigeria and Tanzania), and upper-middle income (Ecuador) country status but there was no difference in wait time between low- and lower-middle income countries. In our study, patients in low- and lower- middle income countries who utilized facilities that traditionally serve low income patients struggled with prompt access to surgery during the pandemic while patients at a private hospital in an upper middle income country did not suffer such a significant delay in care.
Even though emergent cases are generally prioritized over elective cases, semi-urgent procedures such as ventriculoperitoneal shunt required a substantial wait time with a median wait of 2 weeks. Tumor resections also had a considerable delay, with wait time ranging from 3 weeks to 3 months. Kasai procedures for biliary atresia were also reported, and the timing of surgery for this condition is directly related to survival. Backlog in these time-sensitive procedures are concerning and suggest that the scarcity of pediatric surgical capacity in LMICs also affects more acute surgical conditions leading to excess preventable morbidity and mortality.
In our survey almost all of the conditions were congenital anomalies. Nevertheless, stakeholders are tasked with taking care of elective congenital anomalies, urgent, and emergent procedures simultaneously. It is challenging to meet the needs of the population with this system, which is in place in most LMICs. A recent prospective cohort study spanning 19 Sub-Saharan African (SSA) countries demonstrated that mortality from pediatric surgical disease is significantly higher in SSA than HIC: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Our findings suggest that delay in surgical treatment is likely a contributing factor and that COVID-19 exacerbated these delays.
In light of the recent COVID-19 pandemic, worldwide national lockdowns greatly diminished surgical volume in both HICs and LMICs. LMICs have a reduced capacity to consolidate resources to rebound from the setback, compounding already extensive waitlists. A survey of 74 Nigerian pediatric surgeons on the impact of COVID-19 pandemic reported that 92% of centers suspended elective surgeries while emergency surgeries were offered but cases were reduced by 31%. In a recent interrupted time series analysis (ITSA) there was a decrease in surgical volume without evidence of sustained recovery across multiple LMIC hospitals. The ITSA demonstrated the persistent effects of the pandemic and provided evidence that the collateral damage of the pandemic on health services extended to children’s surgery.  Unfortunately, this damage also affected other areas of child health and development. COVID-19 created the largest disruption of education systems in history, affecting nearly 1.6 billion students in more than 190 countries. In addition, according to the WHO Pulse survey on continuity of essential health services during the COVID-19 pandemic, published in August 2020, 90% of countries reported disruptions to essential health services for children due to the pandemic., 
Routine surgical services in LMICs have largely been neglected and the pandemic made health service delivery even more difficult. The surgical backlog demonstrated in this study fits into the Three Delays Model, which Thaddeus and Maine initially proposed in 1990. This model characterizes delays in preventable maternal mortality associated with: 1) deciding to seek care, 2) accessing a quality healthcare facility, and 3) obtaining appropriate care. The model has been subsequently applied to neonatal mortality and delays in pediatric surgery in resource limited settings.,  COVID-19 and limited financial resources likely reduced the number of patients who chose to seek care and inadequate pediatric surgical capacity led to long wait times and waitlists for those patients who did present to a pediatric surgeon. Although all three types of delays likely affect children with surgical conditions our study focuses on the third delay: obtaining appropriate care.
Patients who were documented in waitlists at these sites only account for those who successfully made contact with the healthcare facility. Not captured were patients who never accessed a pediatric surgeon, which could have been for a variety of reasons: lack of awareness of the necessity for these services, prohibitive cost, transportation barriers, lack of universal healthcare coverage, and COVID-19 restrictions. Previous work in Uganda has shown that families of children with a surgically correctable disease waited for a median of 56 days before visiting the outpatient pediatric surgical clinic at the country’s only national referral hospital. In this study, a majority of patients sought care at other healthcare facilities beforehand and 17% presented to the outpatient clinic three or more times for the same condition due to delays in definitive surgery.  A recent study in Tanzania showed that even though most families in the coastal region can access surgery within 2 hours, 66% of families presenting for pediatric surgery face catastrophic health expenditure, especially families presenting for emergency surgery. Combined, these studies imply an incomplete characterization of the full surgical backlog given the multilevel barriers preventing a child from receiving much needed care.
A major strength of the study is the inclusion of multiple sites over a broad array of countries straddling two continents, enhancing the generalizability of our findings. The disease-specific detail of the backlogs also allows for the examination of backlog at a more granular level, enabling some distinction between purely elective and semi-elective procedures. Study limitations include the cross-sectional design, such that only a single time-point was captured without analysis of trends over time. This is especially relevant during the COVID-19 pandemic with its associated escalating surgical delays. A future direction would be to repeat the survey in the post-COVID period and compare backlog volumes. We also did not estimate how long it would take to catch up given current output per week. For most centers the likelihood is that there would be no catching up. The recent COVID surg study estimated 45 weeks to clear backlog if there was a 20% increase in activity, something most LMIC centers do not have the resources for.  Furthermore, this was a self-reported survey from surgical providers who provided estimates for wait times and the potential for recall bias exists.
Despite this study’s limitations it not only highlights the importance of tracking surgical backlogs but also demonstrates the investment needed in the healthcare workforce and infrastructure. Some sites only have one pediatric surgeon and the OR cannot reach 100% utilization without investment in other cadres of the health workforce. The longest wait time (Lilongwe) reported difficulty performing elective cases due to lack of OR space. This is even despite recent investment in upscaling pediatric theater space from KidsOR. Measuring and tracking priority surgical conditions should be a part of standard surgical metrics for health system performance, but are not currently formally documented. Future work may correlate the validity of provider reported backlogs with documented waitlists in selected centers in order to help corroborate how accurate provider recall is. From anecdotal experience late presentation generally leads to excess resource utilization, morbidity, and mortality but we have not measured how delays may render some conditions inoperable, or much more challenging and expensive to treat.
Strides have been made to improve surgical data collection in LMICs. KidsOR has built 50 pediatric operating rooms in 20 countries across Sub Saharan Africa, Latin American, and the Caribbean. They collaborate with sites to collect perioperative data. Yet currently, there is no record of who is waiting for surgery. Stakeholders cannot document data based reduction of backlog without waitlists and evidence of shortened waitlists will remain anecdotal. The moral insult that providers suffer when they lack the resources to provide care to children they know need help also injures those tasked with the enormous responsibility of caring for patients in under-resourced environments. In order to improve humanitarian outreach and more importantly buoy the efforts of local champions then stakeholders must track cases and backlogs. Data should direct global interventions for these vulnerable and neglected patients and surgical waitlists are critical to prevent ongoing suffering and disability.