Pediatric cardiac surgery: a status report on availability, access, and funding across 193 countries

Congenital heart defect is the most common birth defect and approximately 1.4 million children are born with it every year [1]. Pediatric cardiac surgery is one of the most resource-intensive sub-specialties. According to one report, six of the ten birth defects accounting for highest healthcare expenditure are congenital heart defects (CHD) [2]. Another report demonstrates that CHD accounts for only 4% of the hospital admissions, but results in a disproportionate 23% of the healthcare expenditure [3]. The incidence of CHD is approximately 8 to 12 per 1000 live births across all regions of the world. However, the burden of CHD is significantly higher in populations with a high birth rate. These are invariably also the countries with lowest per capita income and thereby the disparity is further accentuated. Furthermore, these countries have an ever-increasing number of children, adolescents, and adults with untreated CHDs. The aim of healthcare policy of any government should be threefold, namely, keeping its citizens healthy by measures for prevention and early detection of disease, providing treatment for the sick, and protecting its citizens from financial ruin by out-of-pocket expense. Only one-fifth of 193 countries can claim successful implementation of this threefold health policy for their citizens. The priority for the developing and underdeveloped countries is still prevention and treatment of communicable diseases. The diagnosis and treatment for CHD is often overlooked by policymakers in these countries. Consequently, a quarter of 1.4 million children born with CHD die in their first year of life [4].

This letter attempts to ascertain the availability, access, and funding for pediatric cardiac surgery across 193 countries and provides a country-specific alpha-numeric code for ready understanding. A focused literature search was performed by combining name of the country and the phrase “Congenital Heart Surgery.” A total of 512 reports were reviewed. The status of availability and accessibility of pediatric cardiac surgery was qualified by a three-letter code as follows:

• AAA: Excellent Paediatric Cardiac Surgery available and accessible to all children with CHD

• AA0: Paediatric Cardiac Surgery available, but not accessible to a significant proportion of children with CHD

• A00: Pediatric Cardiac Surgery barely or intermittently available

• NA0: Paediatric Cardiac Surgery not available

Three financing systems for funding for pediatric cardiac surgery were identified and a three-letter code was assigned.

• G00: Pediatric Cardiac Surgery Predominantly Funded by Government or Employer Insurance

• H00: Paediatric Cardiac Surgery Funded by Humanitarian missions

• GPH: Paediatric Cardiac Surgery funded by Government/Insurance + Out of Pocket + Humanitarian missions

All 193 countries were classified into four groups based on the availability of pediatric cardiac surgical services and the modes of financing the same. Each group was designated with a six lettered alphanumeric code.

• Group 1: (AAAG00)

This group has 47 countries and includes developed economies from North America, Europe, Australasia, and a few middle eastern Asian countries. The average per capita gross domestic product(GDP) of these countries is US$46,951 and the average per capita spent is US$ 16 per child with CHD. Only 8% of children with CHD are born in these countries. These children have access to excellent pediatric cardiac services, which are either funded by the government or insurance companies. If there is an out-of-pocket expense, it is very little.

• Group 2: (AA0G00 + AA0GPH)

There are thriving and growing pediatric cardiac programs, but they are still inadequate to take care of all children with CHD. This group includes 40 countries. Most of these countries are from Asia and South America. The per capita GDP of these countries is UD$ 11,370 and the per capita GDP expenditure is US$ 0.69 per child with CHD. Forty-one percent of all children with CHD are born in these countries. This group includes the two most populous countries of China and India. Excellent pediatric cardiac services are available in these countries, but are inadequate due to either affordability or skewed geographical distribution. There is regional variation with concentration of pediatric cardiac programs in metropolitan areas keeping large populations devoid of any pediatric cardiac services. All three financing systems are available in 27 countries (AA0GPH) with a considerable reliance on out-of-pocket expenditure. In the remaining 13 (AA0G00) countries, the government bears the majority of healthcare expenditure.

• Group 3: (A00H00 + A00GPH)

Pediatric cardiac surgery is available, but it is grossly inadequate or it is available intermittently during visiting humanitarian missions. This group comprises of 53 countries, 21 (A00G00) of which have pediatric cardiac surgery by humanitarian missions only. The remaining 32 belong to A00GPH category, where all three models of funding are operational. Most of African countries and many Asian and small island nations are in this group. The average per capita GDP of this group is US$3456 and the potential per capita GDP expenditure on CHD is US$ 0.36 per child. Forty-one percent of all children with CHD are born in this group. These countries are still struggling with communicable diseases, and the focus on CHDs by the policymakers is either negligible or non-existent. These countries depend entirely on humanitarian missions for providing limited intermittent pediatric cardiac service. The funds are raised by the non-governmental organizations (NGO) to finance pediatric cardiac surgeries.

• Group 4: (NA0000)

Pediatric cardiac surgery is not available in 53 countries in this group. These are some of the poorest, smallest, most remote countries where even the humanitarian missions have not reached. The exceptions in this group are some of the richest but smallest countries like Principality of Andorra, Liechtenstein, St. Kitts, and Barbados. The population of these countries is so small that it not feasible to run a viable pediatric cardiac service. The very few children who are born with CHD in these countries are treated in neighboring countries. These rich countries have been excluded while calculating the per capita GDP and the potential per capita GDP expenditure on CHD per child. The average per capita income of these countries is US$3451. Fortunately, only 9% of children with CHD are born in these countries.

The availability and accessibility of pediatric cardiac care is variable across the world. Approximately 90% of the children with CHD are born in countries where pediatric cardiac surgery is either unavailable or barely available. The majority of pediatric cardiac programs are located in the developed countries which account for only 10% of the global burden of the disease. This has resulted in decreasing volume of surgeries per center in the developed countries and an ever-increasing number of untreated children in the rest of the world. The solution lies in collaboration and an intent on the part of the developed countries and their congenital heart programs to help develop new programs in areas of need. The collaboration will be mutually beneficial providing the necessary case load to a low-volume program and thereby preventing de-skilling of its surgeons and also mitigating the threat of closure posed by regionalization. The real beneficiaries of this collaboration will be the children with CHD living in poorer parts of the world, who will get a new lease of life. While doing so, the cost-effective models operational in countries like India should be studied and implemented, which will be crucial for sustainability and growth.

Funding

None.

Compliance with ethical standards

Conflict of interest

The author declares that there is no conflict of interest.

Ethics committee approval

Waived.

Informed consent

Not applicable.

Human and animal rights violation

Not applicable.