In Pursuit Of Health Equity For Children With Surgical Needs (Viewpoint)
Dr. Jamshed Akhtar
Health equity is described as highest attainable health for all people. However, the definition is not uniformly agreed upon.(1) The concept of equity is linked to various factors including political stability, will of the policy makers and prevalence of social justice in general. The United Nations Millennium Development Goals (MDGs) proposed in pursuit of achieving equitable living world for all in year 2000. These were eight in number. The target was to achieve them by 2015. However, same is yet to be attained. It is however good to know that success is reported in accomplishing some of the goals especially those related to communicable diseases, especially the 4-A, that was meant to reduce the mortality in children.(2)
Time moved on and in 2015 another vision was adopted by the United Nations Member States. This was “Transforming Our World: The 2030 Agenda for Sustainable Development.” There are 17 Sustainable Development Goals (SDGs). These are interrelated and indivisible as each one is intertwined with other. The vision relates to the prevailing social, economic and environmental challenges. United Nations secretary general Mr. Antonio Guterres in his address has mentioned, “Development is not sustainable if it is not fair and inclusive”. It is therefore important to understand the concept of equity specially in the context of healthcare services across the globe irrespective of the gender and age group.(3)
The children in the low and middle income countries (LMIC) suffer the most. Political instability along-with regional armed conflicts for economic gains as well as natural environmental disasters and man-made climate related challenges lead to absolute poverty that deprived people of basic needs including safe drinking water, food, sanitation and many others. Interestingly high birth-rate, a reflection of social needs without considering the responsibility at individual level with limited resources, adds to the perennial challenges in the LMICs. Though healthcare is given a priority in all the policies but same is not visible on ground. The main reasons are the poor governance, corruption and dysfunctional judiciary to name a few.
Surgical conditions of children are not on the priority list of policy makers. With high birth rate, the incidence of congenital anomalies also increases. In addition, trauma, cancers, infectious diseases add to the existing burden. Pediatric patients with surgical diseases do not get a comprehensive care in Pakistan and other developing countries. General pediatric surgeons are over-burdened with huge patient load. In Pakistan, with a population of about 240 million, about 300 pediatric surgeons are registered with the Pakistan Medical-andDental Council, the federal licensing body. The number is insufficient even to manage index gastrointestinal malformations like anorectal conditions. Pediatric surgeons are also not trained to deal with specific surgical conditions like those related head-and-neck (ENT), ophthalmology, plastic-reconstructive surgery, oncology and others. Adult surgeons are not experienced to deal with pediatric and adolescents surgical conditions. There are no fellowship programs in the specialties for comprehensive training for surgical conditions of the children.
The provision of equity gets strengthened when one finds lack of availability of pediatric anesthetists, nurses and rehabilitation services dedicated for the children. Research in the context of needs of the children from LMICs is also lacking. Hardly any funding is available to find out the actual burden of diseases and to set up a registry for congenital anomalies. The recent issue of Seminars in Pediatric Surgery is dedicated to the global surgery (2023Dec).(4) However, the journal charges US dollars 3440 for open access processing for an article. This whooping amount is far from the reach of any clinician and researcher working in the LMICs. In Pakistan, an average pediatric surgeon employed in a governmental hospital gets around US dollars 700 per month as salary. Thus, research is almost non-existent.
National Institute of Child Health in Karachi is the largest tertiary care center in Pakistan for the provinces of Sindh and Baluchistan. It also caters to patients referred from neighboring countries such as the Afghanistan and Iran. More than 40,000 pediatric surgical patients visit outpatient department each year. This number is far from what the institute can handle. There is a long waiting list for elective surgical procedures.
Considering the ground realities and pledges made at different conferences at national and international level, there is growing feeling that voices of those who are at the receiving end are not heard. Most of the agenda remained unattainable as with many of the goals set by WHO and United Nations. Solution to any problem should come from within. The communities themselves should actively take measures to understand their own needs and work on as to how to address them. A true representation from the population is to be identified and workable strategies planned that are applicable to a particular context. At times funding is also available but it is difficult to channelize it in right direction. Social networking and artificial intelligence can help in making strategies with goal oriented time bound tasks.
References
[1] Liburd LC, Hall JE, Mpofu JJ, Williams SM, Bouye K, Penman-Aguilar A. Addressing Health Equity in Public Health Practice: Frameworks, Promising Strategies, and Measurement Considerations. Annu Rev Public Health. 2020 Apr 2; 41: 417-432
[2] Millennium Development Goals (MDGs) 2018. [Internet] Available from the URL https://www.who.int/newsroom/fact-sheets/detail/millennium-developmentgoals-(mdgs) {Accessed on 10 Dec 2023
[3] International Institute for sustainable development. What the world learned setting development goals. [Internet] Available from URL https://www.iisd.org/ articles/deep-dive/what-world-learned-settingdevelopment-goals {Accessed on 10 Dec 2023}
[4] Seminars in Pediatric Surgery 2023 Dec; 32(6): Full issue