S. Ullrich1, N. Kakembo2, P. Kisa3, A. Muzira4, M. Nabukenya8, J. Tumukunde3, T. Fitzgerald5, M. Langer6, M. Situma7, J. Sekabira2, O. Doruk1 1Yale University School Of Medicine,Pediatric Surgery,New Haven, CT, USA 2Mulago Hospital,Surgery,Kampala, Uganda 3Makerere University,College Of Health Sciences,Kampala, Uganda 4University of British Columbia,Surgery,Vancouver, BC, Canada 5Duke University,Department Of Surgery,Durham, NC, USA 6Ann & Robert H Lurie Children’s Hospital of Chicago,Pediatric Surgery,Chicago, IL, USA 7Mbarara Regional Referral Hospital,Surgery,Mbarara, Uganda 8Mulago Hospital,Anesthesia,Kampala, Uganda
Introduction: Ninety-four percent of congenital anomalies occur in low and middle-income countries (LMICs). In Uganda, only four pediatric surgeons and three pediatric anesthesiologists serve over 20 million children. This study estimates burden, outcomes, and coverage of neonatal surgical conditions in Uganda and compares them with our prior estimates. We also estimate economic benefit of neonatal surgery.
Methods: A prospectively collected database was reviewed for neonatal (age < 30 days) general surgical admissions from January 1 2012, to May 31, 2017 at the only two sites with specialist pediatric surgical coverage, one that started providing services in mid-2014. Outcomes were compared with high-income countries, and met and unmet need were estimated using disability-adjusted life years (DALYs). We estimated economic benefit using a value of a statistical life-year approach.
Results: A total of 1,177 neonatal admissions were identified, representing 25% of all pediatric surgery admissions. Mean age of presentation was 7 days and overall mortality was 36%. Mean distance travelled was 92 km. The most common conditions were anorectal malformations (18%), gastroschisis (17%), omphalocele (15%), and intestinal atresia (10%). Almost half of presenting neonates (49%) underwent surgical intervention. Post-operative mortality was 24%. Mortality for neonates was significantly associated with surgical intervention (p<0.001) and age (p<0.001). Highest mortality conditions were gastroschisis (85%) and biliary atresia (80%). Gastroschisis (42%) and anorectal malformations (42%) had the greatest reduction in mortality with surgical intervention. Met need was 3,531 DALYs/ year and 140,220 DALYS were potentially avertable (unmet need). The current met need corresponds to a $2.9 million net economic benefit to Uganda, with a potential additional benefit of $116 million if unmet need were fully addressed. Approximately 2.3% of the total need was met by the healthcare system.
Conclusions: Neonatal surgery improves survival for most conditions despite resource limitations such as lack of neonatal intensive care. Despite slight increases in workforce and infrastructure, a negligible proportion of the need for neonatal surgery is currently being met in Uganda, similar to estimates five years ago (3%). This is likely multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial. More advocacy is needed to increase capacity for pediatric surgical care in Uganda and similarly resourced LMICs.
