Specialized pediatric healthcare with limited resources: Surgery, anesthesia and oncology for children in low- and middle-income countries

Abstract: Aim: This thesis serves two purposes. First, it informs specialists in global public health to consider a broader spectrum of pediatric disease. Second, it informs specialists in pediatric hospital care of how the feasibility of their clinical practice depends on a functioning health care system. Methods: The papers contextualize pediatric disease entities that so far have received relatively sparse global health attention, including examples from oncology, surgery, and anesthesia in low- and middle-income countries. Specialized healthcare is broadly defined as referral level hospital care, which often involves interdisciplinary collaboration of specialized personnel, sophisticated diagnostic methods and advanced therapeutic modalities. The study populations come from low- and middle-income countries from different parts of the world. The analyses benefit from a range of statistical methods and study designs. The thesis explores how children and families experience barriers to adequate hospital care, both before (I–Surgery case-series, Haiti) and after arriving at the hospital (II–Oncology cohort-study, Vietnam). The thesis also researches how limited resources influences doctors, both in terms of clinical decision-making (III–Anesthesia cohort, Bangladesh) and as a cause of migration and workforce shortage (IV–Survey, US). Finally, an integrated health system perspective is applied, determining to what extent certain evidence-based treatment strategies from high-income countries are applicable to a low-and middle-income setting (V–Markov model decision analysis). Results: Children seem to experience greater geographical barriers to surgical care than adults (I). Interventions that increase adherence to cancer treatment may have greater impact on childhood cancer survival than medical care improvement (II). Major neonatal surgery is often performed without general anesthesia, and health care systems must respond to the pandemic of anesthetic mortality (III). Surgeon migration can be addressed by providing adequate domestic surgical infrastructure, training, and career pathways (IV). State-of-the-art management algorithms from high-income countries can be suboptimal when applied to the health care systems of low- and middle-income countries (V). Conclusion: Specialized pediatric healthcare benefits from a health system perspective and attention to the social context of patients, and should be part of a continuum of integrated care for children also in low- and middle-income countries.