The Global Initiative for Children’s Surgery: conception, gestation, and delivery

Abstract

More than two thirds of the global population lack access to safe, affordable surgical and anesthesia care. This inequity disproportionately affects children in low- and middle-income countries (LMIC). In 2016, a group of pediatric surgical care providers founded the Global Initiative for Children’s Surgery (GICS). Their goal was to assemble a multidisciplinary team of specialists and advocates to improve surgical care for children, with a particular emphasis on those in low-resource settings. This review details the history of GICS, the process of its inception, the values guiding its work, its past achievements, and its current initiatives. The experience of GICS may serve as an effective model for global collaboration on other areas of public and global health.

The Global Initiative for Children’s Surgery organization (GICS) was founded in 2016 to improve the surgical care of children around the world with a particular emphasis on children in low-resource settings. A review of the reasons for the formation of GICS, the process of its inception, the values driving its work, and its current endeavors and areas of focus are detailed below. The experience of GICS may provide an effective model of global collaboration for other neglected but critical areas of public and global health.

Background: defining the need and historic context

Surgical conditions comprise a large and rising proportion of the global burden of disease [1–3]. Despite this, most people around the world cannot access surgical care [2, 4]. Children are disproportionately affected, as they constitute up to half the population in the least developed regions of the world [5]. Lack of access to surgical care threatens the health and welfare of individuals and their families, as well as the economic development and security of the communities and countries in which they live [2, 6]. Access to surgery is challenging for many underserved populations, not only in low- and middle-income countries (LMICs), but also in high-income countries (HICs) [4, 7]. Access can be further compromised for populations in crisis, such as those experiencing war and other conflicts. Access can also be impeded for people facing displacement, such as refugees, or those encountering natural or man-made disasters.

To frame the current picture in numeric terms, surgical conditions represent over 30% of the global disease burden [1]. Five billion people—over two thirds of the world’s population—lack access to safe, affordable surgical and anesthesia care when needed [4]. This inequity falls most heavily on the poor; 94% of the population in low- and lower-middle-income countries lack adequate access to surgical care [2]. Only three percent of children in low-income countries and eight percent of children in lower-middle-income countries have access to surgery, compared to 85% of children in high-income countries [7]. This means that many common and otherwise easily treatable conditions, such as appendicitis or long bone fractures, could result in death or a lifelong disability. In addition to the physical, psychological, and social impacts of inadequate access to surgery for patients with surgical disease and the families and communities who help care for them, the financial impact of reaching care can be immense. Financial catastrophe is experienced by one quarter of people who successfully access surgical care [2]. This does not include the financial impact to the many people who are unable to reach care. Aside from the health equity and social justice arguments as to why these numbers are unacceptable, there are also powerful economic drivers for prioritizing access to surgery. The opportunity cost to low- and middle-income countries is estimated to be $12.3 trillion by 2030 without accelerated investment in surgical scale-up [6].

These problems and their devastating effects have been known for a long time. In 1980, Dr. Halfdan Mahler, then Director General of the World Health Organization (WHO), stated that “the vast majority of the world’s population has no access whatsoever to skilled surgical care and little is being done to find a solution… I beg of you to give serious consideration to this most serious manifestation of social inequity in health care” [8]. Healthcare supporters, providers, and advocates of global surgery1 have worked tirelessly to change the state of surgical care delivery around the world. However, these calls for largescale improvement had historically been ignored, prompting global surgery to be dubbed the “neglected stepchild of global health” [9]. Around 2015, however, global surgery finally began to gain traction within the global health, development, and academic communities. The 3rd edition of Disease Control Priorities,2 published by the World Bank in 2015, included an entire volume on essential surgery for the first time [10]. Also in 2015, The Lancet prioritized surgery with the publication of the report from The Lancet Commission on Global Surgery, which showed that investing in surgical care is affordable, saves lives and promotes economic growth [2]. At the start of the first meeting of the Commission, then World Bank president Jim King called surgery an “indivisible, indispensable part of health care” [11]. Momentum continued to build as the World Bank started including surgical measures in the World Development Index and the global health and development community transitioned from the Millennium Development Goals to a set of Sustainable Development Goals, many of which are not attainable without access to surgery [12, 13]. Finally, the WHO formally recognized the essential role of surgery and trauma care as a part of Universal Health Coverage, starting with passage of resolution 68.15 at the 68th World Health Assembly [14]. With this growing support for access to surgical care for the global community, 2015 was called the “year of global surgery.”

Development of the Global Initiative for Children’s Surgery: priorities, methods, and successes

Despite these advances in the global prioritization of surgery, details specific to specialty care, including the surgical care of children, were not widely included in the burgeoning global surgery discussions. Recognizing that the surgical needs of children differ from those of adults, and that meeting those needs can require different human and material resources, a group of pediatric surgeons, anesthetists, and nurses from around the world came together to found the Global Initiative for Children’s Surgery in 2016 [15]. The goal in creating GICS was to assemble a multidisciplinary team of specialists and advocates from countries of all income levels that would work to improve surgical care for children around the world, with a particular emphasis on children in low-resource settings. Through this inclusive approach, and utilizing a series of international meetings, the organization, GICS, developed and articulated a vision in which every child has access to safe, quality, timely, affordable surgical, anesthesia, and nursing care. This vision was coupled with a mission to define and promote optimal resources for children’s surgery in low-resource regions of the world. GICS instituted a model where needs, priorities, and solutions were identified and driven by stakeholders in LMICs and supported by advocates in countries of all income levels. The key strategies and approaches used by GICS to progress towards its goals, as well as several of its more significant accomplishments, are highlighted in the paragraphs to follow.

The first official meeting of GICS was held at the Royal College of Surgeons in London, United Kingdom in May of 2016. The goal of this meeting was to bring together surgeons from LMICs to evaluate the current state of surgical care for children in low-resource settings and to identify local and global priorities for care improvements. Prior to the meeting, a survey was sent to all invitees to initiate dialog regarding challenges and solutions to delivering surgical care to children. Fifty-two providers from 21 different countries, over half of which were LMICs, attended this inaugural 2-day event. During the gathering, themes from the survey were discussed, and working groups convened around the topics of infrastructure, service delivery, training, and research. It was determined that additional needs assessments were essential, that defining optimal resources and best practices for children’s surgical care were needed, and that the next meeting should center around connecting LMIC providers with professional associations and non-governmental organizations to begin to match global resources with identified needs.

To continue this work after the first meeting, a transnational group of trainees came together to form the Core Operations and Logistics (COL) team. Driven by the enthusiasm, optimism, and passion of these trainees, the COL team would prove to be one of the most dynamic and influential aspects of GICS. The COL team assists with nearly every aspect of GICS, helping to support the administration, coordinate meetings, enhance training, and research programs, drive advocacy and policy initiatives, and provide a social media presence.

Building on the work of the inaugural GICS gathering, a second meeting was held in Washington DC, United States in October of 2016, with a report-out immediately following at the gathering of the World Federation of Associations of Pediatric Surgeons (WOFAPS). The primary goal of this meeting was to develop an implementation plan for realizing GICS’ vision that every child has access to safe, quality, timely, affordable surgical, anesthesia, and nursing care. This second meeting was attended by 94 participants from 38 different countries. Representatives included individual healthcare providers, delegates of non-governmental and governmental organizations, academicians, policy makers, and hospital administrators. Specialty- and country-specific presentations were given to delineate barriers to surgical care delivery for children. Strategies to address these barriers were discussed amongst the multidisciplinary group of participants. Work commenced on developing an Optimal Resources for Children’s Surgery (OReCS) document to define human and material resources necessary to deliver optimal pediatric surgical care in LMICs and to create action plans for how to improve children’s surgery across all levels of the health system. This document built on the work of the American College of Surgeons’ Children’s Surgery Verification Quality Improvement Program but was modeled for more resource-variable environments. Between the second and third meetings, GICS became a non-profit organization with 501(c)(3) status in the United States, allowing it to build further collaborations and accept charitable donations. In addition, a formal Board of Directors, comprised of approximately 20 members from both LMICs and HICs, was created to help guide GICS.

The third official meeting of GICS was held in Vellore, India in January of 2018. Goals of this meeting were implementation-based and included refining and finalizing the OReCS document; defining bellwether procedures for children; incorporating children’s surgery into National Surgical, Obstetric and Anesthesia Plans (NSOAPs)3; and building partnerships and collaborations with organizations. One hundred and ten participants from 33 countries attended the meeting, including delegates from a vast array of organizations such as the WHO; Médecins Sans Frontières; World Federation of Societies of Anesthesiologists; College of Surgeons of East, Central and Southern Africa (COSECSA); LifeBox; Smile Train; InterSurgeon; and Kids Operating Room (KidsOR). Following the meeting in Vellore, the OReCS document4 was completed, and an executive summary was published in the World Journal of Surgery [16]. The OReCS document, developed by GICS’ multidisciplinary collaboration of stakeholders from around the world, describes the resources necessary to care for children with surgical diseases in low-resource settings and provides strategies to incorporate the surgical care of children within national health plans. The document is comprised of two main parts. The first part consists of resource guidelines for different levels of care and types of facilities within a health system. The second delineates the supplies, equipment, and infrastructure necessary to deliver surgical care to children in low-resource environments.

The fourth, and most recent in-person meeting of GICS was held in Johannesburg, South Africa in January of 2020. This was GICS’ largest meeting to date, convening 225 attendees from 44 different countries. The goal of this meeting was to delve further into implementation plans, with specific focus on strategies to best apply OReCS work. Additional discussions took place regarding the inclusion of children’s surgery within NSOAPs and incorporation of the surgical care of children within broader pediatric and global health initiatives. Further dialog centered around promoting the idea that the health and well-being of individuals, communities, populations, and economies cannot be realized without universal access to surgery, and without special consideration for the surgical needs of children beyond those of adults.

As these four meetings progressed, working groups were created across numerous clinical specialties to further examine each area of focus. These working groups include anesthesia, cardiac surgery, congenital anomalies, critical care, dental and oral surgery, family support, adult general surgery, pediatric general surgery, neurosurgery, nursing, oncology, ophthalmology, orthopedic surgery, otolaryngology, plastic surgery, radiology, trauma surgery, and urology. Over time, additional committees were created in the realms of administration and finances; financing, advocacy, and policy; infrastructure, standards, and verification; partnerships and memorandum of understandings (MOUs); publications; research webinar; research, data, and quality improvement; training, human resources, and education; and website, networking, and communications. These working groups and committees provide periodic updates on their endeavors to the larger GICS community during the international gatherings, as well as via quarterly online membership meetings and newsletters. The working groups then use feedback generated from these events to guide their work and collaborations.

To prioritize involvement of participants from LMICs, GICS worked with numerous donors and sponsors to provide scholarships for flights and housing for delegates from low-resource settings to attend these four in-person meetings. Professional organizations, non-governmental organizations and academic institutions served as the primary donors [17]. For the later meetings, participants had the option of submitting research posters to highlight investigative projects in surgical care delivery around the world. As not all knowledge is captured by research endeavors, all meetings had a series of presentations from participants to highlight successes and difficulties in care provision. Meeting content and focus was driven by participants and GICS members. Ideas were shared broadly to amplify discussion and magnify impact. Collaboration across countries, sectors and areas of expertise were promoted to foster ideas and promote sweeping change.

As 2020 progressed and SARS-CoV-2 impacted the global community, GICS expanded its focus to combat this new threat. It rapidly developed a compendium of resources to support the global surgical community in fighting this disease.5 It held webinars on challenges and mitigation strategies and supported research aimed at improving surgical care delivery during the pandemic. Due to the dangers of travel and social gatherings, GICS held a 2-day webinar in February of 2022 in lieu of an in-person meeting. The hope is that GICS will be able to gather safely in person again in 2024 in the Philippines for its fifth official meeting.

GICS today

Today, despite the pandemic, GICS is flourishing. It is one of the largest multidisciplinary groups of advocates for the surgical care of children in low-resource settings in the world. It holds monthly board meetings and quarterly membership discussions. Its expansive number of working groups and committees have developed robust partnerships in the realms of clinical care delivery, research, training and education, and advocacy and policy work. Its COL group of trainees continues to function as an indispensable action arm and influential force for the organization. Although the full extent of the work of GICS and its members is beyond the scope of this review, several partnerships and areas of focus are discussed below to highlight its efforts.

Multiple GICS members have been integral in working within existing policy structures to incorporate the surgical care of children within NSOAPs for their countries. For example, Dr. Lubna Samad, Senior Consultant and Pediatric Surgeon with Indus Hospital and Health Network in Pakistan, has been instrumental in working with Pakistan to become Asia’s first country to develop a national surgical plan. Dr. Samad and her team started with garnering ministerial support, performing situational and baseline assessments, and generating stakeholder engagement. Eventually, they were able to develop the National Vision for Surgical Care to align with the National Health Vision for Pakistan and develop a Universal Health Coverage Benefit Package pilot that specifically incorporates surgical care for children.6 Similarly, Professor Emmanuel Ameh, Commissioner for The Lancet Commission on Global Surgery, Professor and Consultant Pediatric Surgeon for the National Hospital, Abuja, Nigeria, and current GICS Chair, played a fundamental role in working with his country to develop a surgical plan that includes children. Through a series of strategic conversations and deliberations, using a method of inclusion and diversity, Nigeria developed a National Surgical, Obstetrics, Anaesthesia and Nursing Plan (NSOANP).7 This plan includes components for the surgical care of children, who comprise 62% of the total population in the country.

In addition to policy, GICS is also very engaged in research efforts. GICS has developed a formal partnership with Pediatric Surgery International, generating a platform for publishing both policy documents and research articles within the global children’s surgical community. Pediatric Surgery International is part of the Health InterNetwork Access to Research Initiative (HINARI) program.8 HINARI is a collaboration that was established between the WHO and numerous publishers that allows countries with limited resources to gain free or low-cost access to a large collection of health literature. It includes over 8,500 journals and 7,000 electronic books.

Through its various partnerships, GICS has published numerous papers on improving global surgical care for children.9 It has supported its members in research efforts by organizing research methodology workshops, providing study design assistance, creating research support and mentorship networks, and holding research webinars. GICS has partnered with Miss Naomi Wright in her leadership role of the Global PaedSurg Research Collaboration.10 She is a longstanding member of the COL team, Pediatric Surgery Registrar, and Wellcome Trust Clinical PhD Fellow at King's Centre for Global Health and Health Partnerships, King's College London. The Global PaedSurg Research Collaboration is the world’s largest prospective cohort study of gastrointestinal congenital anomalies. It aims to address the paucity of research on congenital anomalies in LMICs, identify factors affecting outcomes for children with congenital anomalies, and enhance research capacity amongst collaborators. The group recently published a landmark, multicenter, international prospective cohort study of children with gastrointestinal congenital anomalies, highlighting stark differences in mortality for children in low-income, middle-income, and high-income countries [18]. This work underscores the need for improved access to high quality neonatal surgical care in LMICs and will serve as a foundation for future efforts.

GICS and its members are also very active in the realms of capacity building, training, and education. One example of this is through the work of its members with KidsOR, the world’s leading provider of access to safe surgery for children in LMICs. This pioneering organization installs operating theaters for children in low-resource settings and provides specialized training and education to strengthen local surgical capacity and health care systems. One such example of an educational endeavor is the Pan-African Paediatric Surgery E-Learning Program (PAPSEP). PAPSEP is Africa’s first comprehensive pediatric surgery e-learning educational repository. It aims to bolster knowledge of trainees in pediatric surgery in Africa using content created by African surgeons. It is a collaboration between KidsOR, the Institute of Global Surgery at the Royal College of Surgeons in Ireland (RCSI), COSECSA, and the West African College of Surgeons (WACS). The platform was launched in May of 2021 as part of the World Health Assembly. Additional recent educational efforts of GICS include dissemination of pertinent onco-surgical webinars through the oncology working group, creation of an online GICS grand rounds which launched in June of 2022 and collaboration with the WHO in updating the Surgical Care at the District Hospital Manual to include the surgical care of children.

One final example of the work of GICS is the mentorship and subsequent capacity building it provides via the COL group. Trainee engagement with GICS’ diverse offerings and extensive network of peers and mentors provides unparalleled career development in the avenues of clinical care delivery, education, research, and advocacy. The global shortage of pediatric surgical care providers is large and disproportionately affects LMICs, where the median pediatric surgical workforce density is approximate 1% of that in HICs [19]. While interest in pursuing careers in pediatric surgical care exists, trainees—particularly in low-resource settings—often lack the mentorship, networks, opportunities, and financial support necessary to realize these career goals. By engaging and partnering with trainees in all aspects of its work, GICS has created a pipeline to help support development of well-rounded pediatric surgical care providers who are equipped to fulfill the roles of academician, clinician, and advocate. Through its model of sustainable advocacy and capacity building for pediatric surgical care, GICS provides trainees a platform for ongoing leadership development and collaboration.

GICS, through the dedication and focus of its members, will continue to work until every child has access to safe, quality, timely and affordable surgical, anesthetic, and nursing care. It will do this through its general principles of transparency, inclusion, equity and the inherent worth of all people. Through scoping partnerships and collective action, it will continue to promote the basic human right to health for all children and families through facilitating universal access to surgical care.

Author contributions

All authors contributed to the study conception and design. Material preparation and data acquisition were performed by Dr. SG. The first draft of the manuscript was written by Dr. SG. Dr. HC, Dr. GH, Dr. LG, Dr. NK, and Dr. KO provided critical revisions of the manuscript. All authors read and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

All data used for this review are available in the public domain.

Declarations

Conflict of interest

The authors have no financial conflict of interest to disclose. Sarah Greenberg and Laura Goodman are on the Board of Directors for GICS, and Keith Oldham is part of the Advisory Group for GICS. All authors have interacted with GICS via working groups and meetings. Keith Oldham was previously on the Editorial Board for Pediatric Surgery International.