Received: 25 January 2024 - Accepted: 21 April 2024 DOI: 10.1002/wjs.12197 S U R G E R Y I N L O W A N D M I D D L E I N C O M E C O U N T R I E S Responding to the need: An evaluation of the subspecialty units in a pediatric surgical department in a limited resource setting using selected optimal resources for children's surgery strategies T. R. Govender1 | J. Scribante1,2 | T. Govender1 | A. Withers1 | J. A. Loveland1,2,3 1Department of Pediatric Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 2Surgeons for Little Lives, Johannesburg, South Africa 3Department of Transplant Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Correspondence T. R. Govender, Department of Pediatric Surgery, Chris Hani Baragwanath Academic Hospital, 26 Chris Hani Road, Diepkloof, Soweto, Johannesburg 1860, South Africa. Email: tarliar@gmail.com Abstract Background: The Global Initiative for Children's Surgery group published the Optimal Resources for Children's Surgery (OReCS) document outlining the essential criteria and strategies for children's surgical care in low‐ resource settings. Limited data exist on subspecialties in pediatric surgery and their contribution to global surgery efforts. The study aimed to evaluate the development of subspecialty units within Chris Hani Baragwanath Ac- ademic Hospital (CHBAH) Department of Pediatric Surgery (DPS) from January 1, 2018 to December 31, 2021 using selected OReCS strategies for the improvement of pediatric surgery. Methods: A retrospective descriptive research design was followed. The study population consisted of CHBAH PSD records. The following data were collected: number of patients managed in PSD subspecialty unit (the units) clinics and surgeries performed, number of trainees, available structures, processes and outcome data, and research output. Results: Of the 17,249 patients seen in the units' outpatient clinics, 8275 (47.9%) burns, 6443 (37.3%) colorectal, and 2531 (14.6%) urology. The number of surgeries performed were 3205, of which 1306 (40.7%) were burns, 644 (20.1%) colorectal, 483 (15.1%) urology, 341 (10.6%) hep- atobiliary, and 431 (12.8%) oncology. Of the 16 selected strategies evalu- ated across the 5 units, 94% were available, of which 16.4% was partly provided by Surgeons for Little Lives. Outcome data in the form of morbidity and mortality reviews for all the units is available, but there is no data for timeliness of care with waiting lists. There were 77 publications and 41 congress presentations. Conclusion: The subspecialty units respond to the global surgical need by meeting most selected OReCS resources in the clinical service provided. K E Y W O R D S global surgery, low middle income countries, optimal resource for children's surgical care (OReCS), subspecialties This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2024 The Authors. World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC). World J Surg. 2024;48:1301–1308. wileyonlinelibrary.com/journal/wjs - 1301 https://doi.org/10.1002/wjs.12197 https://orcid.org/0000-0001-7937-749X https://orcid.org/0000-0002-2221-5024 https://orcid.org/0000-0002-9613-7938 https://orcid.org/0000-0001-5941-9824 https://orcid.org/0000-0002-3341-0749 mailto:tarliar@gmail.com https://orcid.org/0000-0001-7937-749X https://orcid.org/0000-0002-2221-5024 https://orcid.org/0000-0002-9613-7938 https://orcid.org/0000-0001-5941-9824 https://orcid.org/0000-0002-3341-0749 http://creativecommons.org/licenses/by/4.0/ https://onlinelibrary.wiley.com/journal/14322323 1 | INTRODUCTION The Lancet Commission on Global Surgery reported that five billion people lack safe surgical healthcare.1 It is estimated that 1.7 billion children younger than 19 years cannot access safe surgical care worldwide.2 Of these, 453 million are under the age of 5 years, and most of these children live in low‐middle‐income countries (LMICs).2 It is estimated that 85% of chil- dren in Africa will require surgical care before 15 years3 The surgical burden of disease in children in sub‐ Saharan Africa differs from high‐income countries (HIC) with high rates of congenital anomalies, surgical infections, and trauma.4 In 2015, three publications, namely the World Bank Disease Control Priorities 3: Essential Surgery,5 Lancet Commission on Global Surgery,1 and World Health Assembly Resolution 68.15,6 served as catalysts for the global surgery movement.7 These landmark publica- tions have recognized the health and economic impact of surgical conditions in LMIC.8 The perceived high cost of infrastructure, specialized equipment, and skilled workforce has been outweighed by the greater eco- nomic burden of disability‐adjusted life years associ- ated with untreated surgical conditions.9 Despite highlighting this global predicament, these publications lack detail regarding children's surgical needs.10 This deficit is being addressed by the Global Initiative for Children's Surgery (GICS), an organization formed in 2016 to address health, advocacy, and policy in different regions.11 GICS created the Optimal Re- sources for Children's Surgery (OReCS) guideline in 2019, which provides a guideline to standardize chil- dren's surgery in low‐resource settings.12 The docu- ment classifies healthcare facilities, details the resources needed at different levels of facilities, and suggests quality improvement strategies.12 Global surgery initiatives should no longer be centered on surgeons from HIC seeking an opportunity for short‐term volunteerism with little long‐lasting benefit to the host country. Focus has now turned to locally championed interventions.13 Inequities of global surgery were examined by Qin et al.14 They identified Western epistemology (established from colonialism), unequal participation, and geographic inequity as some of the barriers to inclusive global surgery.14 The World Bank classifies South Africa as an upper‐middle‐ income country.15 However, the country has one of the highest inequality rates described globally due to a large percentage of the population living below the upper‐middle‐income country poverty line.16 Access to healthcare in South Africa is influenced and impacted by the historical spatial and geographical segregation of racial groups.17 Significant disparities in access to healthcare exist amongst different ethnic groups in postapartheid South Africa.18 It is estimated that 84% of the population relies on public healthcare.19 As in many parts of Africa, general surgeons provide the majority of surgical care to children outside of central hospitals.4,10 For national policies to be implemented, contextu- alizing the burden of pediatric surgical needs in the public healthcare sector and assessing the physical and systems resources is essential.8 Global pediatric surgery provision was previously considered too expensive to implement in LMICs. However, using cost‐ effective ratios, Smith et al18 concluded that there are viable, cost‐effective strategies for childhood surgery. If these strategies are implemented, they will not only affect the micro‐economies of households and com- munities, but also reduce the disability‐adjusted life years of children, and promote macro‐level economic growth.20 In the Department of Pediatric Surgery (DPS) at Chris Hani Baragwanath Academic Hospital (CHBAH), the surgical burden is addressed by locally championed global surgery efforts. CHBAH is a central public hospital that provides tertiary services. A central hospital receives patients from more than one province, provides training to healthcare workers, and must be attached to a medical school for undergraduate training.21 It is the largest hospital in Africa22 situated in Soweto, the largest township in South Africa.23 In 2019, there was 48.1% growth in the population of Soweto from the decade prior.23 The CHBAH DPS is the largest of the three tertiary hospitals in Gauteng province which has an estimated population of 11.4 million.22 The department provides surgical care that spans from OReCS basic surgical care to complex and advanced surgical care.12 Each of the subspecialty units developed from a need for advanced surgical care, surgeons with special areas of interest, and with the multidisciplinary team members employed at CHBAH. Subspecialist care and centrali- zation of care are concepts considered at odds with global surgery dogma24; therefore, we chose to assess the resources offered by the DPS subspecialty units using a global surgery tool. In general pediatric surgery, the evolution to sub- specialty care is expected, and the development of subspecialty units has multiple benefits.25 High surgery volumes performed by a dedicated surgical team with tailored multidisciplinary adjuncts result in optimal resource utilization, better patient outcomes, and sur- gical training.22,23 In South Africa, general surgeons often perform children's surgery outside tertiary and urban centers.10 The CHBAH is a central hospital providing what OReCS defines as basic, intermediate, and advanced childhood surgical care.12 Due to the lack of resources at other levels of care,8 the DPS was required to serve those patients. These services are still provided by the DPS even after the establishment of the subspecialty units, but numerous OReCS strategies, for advance care, are met since their formation. These include physical resources, including dedicated theater lists and the outpatient and admissions building. 1302 - GOVENDER ET AL. 14322323, 2024, 6, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/w js.12197 by U niversity O f W itw atersrand, W iley O nline L ibrary on [07/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense Additional human resources who form the multidisci- plinary team have defined and formal roles with the subspecialty units. Referring to appendix 2 in OReCS,12 the DPS covers care offered at all levels of care. Examples of each include (1) incision and drainage of superficial abscesses offered by a health centers, (2) trauma and emergency laparotomies including colostomies offered by a first‐level hospitals, (3) trauma thoracotomy offered by second‐level hospitals, (4) congenital anomalies including gastroschisis and oncology cases offered by third‐level hospitals, and finally (5) what is offered by National Children's hospital which includes the work of the subspecialty units, advanced perioper- ative care of complex conditions by a multidisciplinary team. This demonstrates how the DPS at CHBAH is able to provide subspecialty care without compromising the basic surgical care offered. In addition to their sur- gical subspecialties, the specialists working in the DPS operate on emergency pediatric surgery cases, neonatal surgeries, trauma, and elective surgeries falling outside the subspecialties. Furthermore, there are dedicated trainee‐run theater lists that serve to address the backlog of day pediatric surgery cases, including inguinal and umbilical hernias, orchidopexies, circumcisions, and excisions of soft tissue masses. The subspecialty units at CHBAH were developed by the DPS without formal centralization of pediatric surgical care. The impact of responding to the need and developing subspecialty units within the DPS was un- known. This study evaluated the development of sub- specialty units within the DPS from January 1, 2018 to December 31, 2021 using selected OReCS strategies for improving pediatric surgery.12 2 | MATERIALS AND METHODS CHBAH is a 2680‐bed central public hospital where, on average, the DPS have 11,932 patient encounters and 2316 surgeries are performed annually.26 The hospital functions as an OReCS third‐level hospital and also fulfills some of the functions of a national children's hospital.12 Affiliated to the DPS is Surgeons for Little Lives (SFLL), a registered nonprofit organization, committed to saving sick children's lives.27 The definition of a subspecialty in the DPS differs from the traditional definition. Pediatric surgeons with a special interest lead the subspecialty units as the Col- lege of Pediatric Surgeons of South Africa offers no formal subspecialty training. The current subspecialty units in the DPS are burns, colorectal, hepatobiliary (which includes upper gastrointestinal surgeries), oncology, and urology. The weekly activities of the subspecialty units are independent. Each has regular theater lists, scheduled weekly multidisciplinary meet- ings, and clinic days. A supernumerary trainee is a non‐funded, interna- tional, or from another South African province post- graduate doctor training to become a specialist pediatric surgeon with the College of Medicine of South Africa (CMSA). To specialize as a pediatric surgeon in South Africa, you are required to complete 5 years of training, to pass the CMSA examination, and achieve a master's degree in the field.28 A fellow is a specialist pediatric surgeon with a special interest in continued professional development and spends dedicated time in a subspecialty unit under an experienced surgeon in the field, and these fellowships are not formally accredited. A supernumerary fellow is a non‐funded, specialist pediatric surgeon with a special interest in continued medical education and spends dedicated time in a subspecialty unit under an experienced sur- geon in the field. The study population consisted of departmental re- cords. The departmental records used to obtain and cross‐reference the data included the departmental outpatient clinic register, ward admission books, theater logbook, departmental training record, subspecialty unit records, weekly morbidity and mortality (M and M) documents, and departmental research reports. The undergraduate pediatric surgery training records were excluded from the study. This was a retrospective descriptive study; therefore, a sample size calculation was not required. A REDCap data collection sheet was developed for the study. A summary of the data collected is shown in Table 1. One author (TRG) collected the data to ensure credible data. Quality improvement in this study included selected OReCS improvement strategies, namely physical, financial, and human resources, available processes, consultant supervision, patient outcomes, and research.12 T A B L E 1 Summary of collected data. Section 1 � The number of patients managed in the outpatient department � The number of surgeries performed by each subspecialty Section 2 � The number of doctors undergoing training a. Trainees b. Supernumerary trainees c. Supernumerary fellows Section 3 � Available structures (physical, financial, and human resources excluding doctors) � Available processes (standard operating procedures (SOP), guidelines, and consultant supervision) � Outcome data (M and M document review and waiting lists) Section 4 � Research resources � Research output (degree and nondegree) � Publications � Conference presentations WORLD JOURNAL OF SURGERY - 1303 14322323, 2024, 6, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/w js.12197 by U niversity O f W itw atersrand, W iley O nline L ibrary on [07/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense The DPS provides the resources needed for general pediatric surgery; therefore, the strategies selected exclude those specific to other specialties in OReCS, such as orthopedic surgery, neurosurgery, pediatric anesthesia, and intensive care. Data analysis was performed using Microsoft® Excel® 16.78.3. Categorical variables were reported as numbers and percentages. 3 | RESULTS During the study period, the DPS managed 51,268 outpatients and 17,303 patients in three subspecialty units: burns, colorectal, and urology. The numbers for the oncology and hepatobiliary subspecialty outpatients were unavailable as these patients are seen in the general pediatric oncology clinic and the general pedi- atric gastrointestinal clinic and do not differentiate in their record keeping between their medical and surgical patients. The five subspecialties performed 3205 sur- geries. The number of outpatients managed in the three subspecialty units and the number of surgeries per- formed during the study period are shown in Table 2. The surgeries reflected do not include emergencies or surgeries outside the listed subspecialties. The number of trainees, supernumerary trainees, and supernumerary fellows who were trained during the study period is shown in Table 3. There were no fellows during the study period. The selected OReCS strategies for quality improvement in each subspecialty unit are shown in Table 4. Previously, general pediatric surgery admis- sions and outpatient visits were conducted in a small, prefabricated building. SFLL funded and maintains a permanent building for pediatric surgery admissions and outpatients. This building provided the facilities for the formation of subspecialty unit clinics. A full‐time researcher is employed to assist with subspecialty research and a mobile app for data collection and management by administrators. SFLL sponsors all of these research resources. The annual publications and conference presentations for both degree and nondegree purposes are shown in Table 5. There was a 66% increase in published research be- tween 2018 and 2021. Due to COVID‐19, in 2020, there was a peak in publications but the slowest number of conference presentations. This reflects that the addi- tional hours gained from lack of elective surgeries were spent on research and publications. Conference pre- sentations were limited due to restrictions on traveling and gatherings that year. There is a monthly general M and M review. The outcomes for all the subspecialty units are captured. In the study period included, more than 5000 surgeries were reviewed. This number includes those cases which are not subspecialty specific. The subspecialty surgeries accounted for 3205 of those cases. As stip- ulated in OReCS, predetermined filters for complica- tions are used to classify morbidities. Although no specific classification model is used, during discussion, actionable aspects are identified and emphasized in order to improve future outcomes. Examples of how M and M reviews have influenced clinical work include laparoscopic procedures being done under consultant supervision in response to high relook rates from appendicitis and burns backlog addressed by both burn theater and other theater lists being utilized for burns cases. And finally, for the registrar rotations in sub- specialty units to be no less than 3 months in order to benefit from training under consultants in the unit. 4 | DISCUSSION The benefits of subspecialty units have been demon- strated in adult25 and pediatric surgery29 operative volume, institution designation, and fellowship training, improving patient outcomes with shorter hospital stays, and fewer morbidities and mortalities.27,28 The number of elective surgeries performed by each subspecialty has increased over the study period except in 2020 during the COVID‐19 pandemic when elective surgery was limited. However, the burns and T A B L E 2 The number of outpatients managed and the surgeries performed in the selected subspecialty units. Subspecialty unit 2018 2019 2020 2021 Total Outpatients managed Burns 1371 2487 2652 1765 8275 Colorectal 1618 2264 932 1629 6443 Urology 571 726 405 883 2531 Total 12,460 15,089 10,661 13,058 17,249 Surgeries performed Burns 482 326 219 279 1306 Colorectal 238 187 63 156 644 Urology 161 120 60 142 483 Hepatobiliary 156 86 35 64 341 Oncology 124 116 80 111 431 Total 1161 835 457 752 3205 T A B L E 3 The number of trainees, supernumerary trainees, and supernumerary fellows. 2018 2019 2020 2021 Trainees 7 8 8 8 Supernumerary trainees 5 4 5 3 Supernumerary fellows 1 1 1 1 1304 - GOVENDER ET AL. 14322323, 2024, 6, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/w js.12197 by U niversity O f W itw atersrand, W iley O nline L ibrary on [07/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense oncology units showed an increase in the number of surgeries during 2020 due to the predominant emer- gency nature of the surgery. Although there has been an increase in the number of elective surgeries per- formed by each subspecialty unit, the impact made on the surgical need could not be determined as the sub- specialty waiting lists do not include the waiting time. Therefore, timeliness of care as an OReCS strategy is not measured by the DPS. In the DPS, there is a monthly general M and M review. The outcomes for all the subspecialty units are captured. OReCS emphasizes the M and M review as an essential part of quality improvement affecting pa- tient care by facilitating loop closure.12 Elective and emergency surgeries performed by the subspecialty units and the subsequent outcomes of these patients are areas for further investigation. The Lancet Commission on Global Surgery esti- mated that by 2030, there would be a deficit of 2.3 million surgical providers globally.1 Specialist surgical workforce is a key indicator as an inadequate workforce is a significant challenge to improving surgical capac- ity.1,10 The American Pediatric Surgical Association recommends one pediatric surgeon (including sub- specialists) per 100,000 children.30 Dell et al10 in 2018 highlighted the pediatric surgical density in South Africa with a national average of 0.26 pediatric surgeons per T A B L E 4 The selected Optimal Resources for Children's Surgery strategies for quality improvement in subspecialty units. Strategies Burns Colorectal Hepatobiliary Oncology Urology Physical resources Building Yesa Yes Yesa Yes Yesa Dedicated theater list Yes Yes Yes Yes Yes Financial resources Department of health Yes Yes Yes Yes Yes SFLL Yes Yes Yes Yes Yes Human resources (excluding doctors) Nurse Yes Yesa Yes Yes Yes Physiotherapist Yesb Yesb Yes Yes Yes Occupational therapist Yes Yes Yes Yes Yes Speech therapist Yes Yes Yes Yes Yes Dietician Yesb Yesb Yes Yes Yes Psychologist Yes Yes Yes Yes Yes Art facilitator Yesa Yesa Yesa Yesa Yesa Available processes SOP Yes Yes Yes Yes Yes Guidelines Yes Yes Yes Yes Yes Consultant supervision Office hours Yes Yes Yes Yes Yes After hours Yes Yes Yes Yes Yes Outcome data M and M review Yes Yes Yes Yes Yes Waiting list No No No No No Note: Provided by SFLL. aCompletely. bIn part. T A B L E 5 The annual publications and conference presentations for both degree and nondegree purposes. Year Publications Conference presentations Degree Non‐degree National International 2018 2 9 5 7 2019 3 11 9 15 2020 2 17 2 2 2021 7 26 7 6 WORLD JOURNAL OF SURGERY - 1305 14322323, 2024, 6, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/w js.12197 by U niversity O f W itw atersrand, W iley O nline L ibrary on [07/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense 100,000 children. Most surgeons were in major metro- politan areas, highlighting this resource's geographic and socioeconomic maldistribution. There is also a low density of pediatric surgeons in sub‐Saharan Africa.10 The Health Professionals Council of South Africa reg- ulates the number of training positions allocated to each training department. Following a strong motivation from the DPS, the CMSA has issued additional training posts, but the lack of funding for these posts by the National Department of Health has limited the utilization of these posts. In response to this, the Department has increased funded training posts from two to eight since 2010. By establishing the subspecialty units, more trainee posts were created due to the increased clinical demand. In 2017, Toobaie et al3 established that there should be 4700 pediatric surgeons in Africa. There are no full‐ time pediatric surgeons in more than half of African countries.13 The DPS recognized the global surgery burden from the sub‐Saharan countries and other South African provinces, and a supernumerary trainee training program was initiated. The supernumerary trainees complete the full requirements of pediatric surgical training and exams as stipulated by the CMSA.28 Once qualified, these trainees return to their respective countries and provinces, improving the pe- diatric surgical density and geographical distribution while maintaining a collaborative relationship with the DPS and Wits. The subspecialty units have attracted national and international trainees and qualified pedi- atric surgeons with special interest areas. The Global Pediatric Surgery Network proposed a model for networking and guidelines for international partnerships.13 Ethical and culturally sensitive practice in patient care and data mining for research is essential.13 Numerous trainees and qualified sur- geons from HIC have spent various amounts of time in the DPS. With a clear stance against exploitation and through long‐term collaboration, the DPS, in as- sociation with Wits, has shown that these relation- ships can be mutually beneficial. The contribution of the visiting trainees and surgeons to the workforce, surgeries performed, and research is regarded as invaluable by the DPS. Zanini et al in 2021 demon- strated that of the European surgical trainees (both pre and postqualification) who visited the DPS, operative experience was higher in South Africa for all general and index pediatric surgical cases than in their country of origin, except for minimally invasive surgery.31 The results of this study demonstrate that resources are available for the selected OReCS strategies for quality improvement in the subspecialty units of the DPS. CHBAH is a public hospital funded by the provincial Department of Health. Major obstacles exist in pediatric surgery service delivery in South Africa.32 OReCS acknowledges private organizations often supplement low‐resource healthcare facilities. Thus, affiliated with the DPS, the SFLL charity was launched in 2015 with the specific intention of improving clinical care and supporting training and research within the DPS, enhancing the pediatric surgical service provided.11 SFLL has built the building where most of the subspe- cialty units operate, contributes to numerous day‐to‐day aspects of this care, and as part of their contribution to holistic patient care, SFLL built a parental sleepover facility to allow parents to be part of their children's care. SFLL also improved existing facilities, including the burns and ICU, general pediatric surgery wards, and neonatal and main theater waiting areas. In 2002, Bickler and Rode4 highlighted, “We do not advocate wholesale changes to existing structures, as many are very successful, but consider that existing services should be built on and that community participation should be encouraged”. Community participation is important in progressing global pediatric surgery in Af- rica.9 Our colorectal and urology units have established patient support groups, and SFLL has initiated numerous community‐based primary prevention programs. The establishment of the subspecialty units facili- tated focused research, which has impacted the quality‐ of‐service delivery of the units. That also contributed to the international body of knowledge, specifically that of a low‐resource setting. This increased research de- mand for the subspecialty units lead to the employment of a full‐time researcher by SFLL. The role of healthcare researchers is emphasized as an OReCS strategy to create a database that can inform both local and na- tional policy. To ensure prospectively collected data, OReCS recommends databases with a point‐of‐care (mobile device interface), which includes online and offline modes and has remote cloud storage.12 SFLL sponsors administrative staff to maintain the de- partment's electronic database. Limitations of this study are that it was done retro- spectively at one hospital and may not represent other contexts. OReCS describes quality improvements to outcomes of care. These strategies were, in some part, reflected in the M and M reviews; however, to adequately measure the improvement of services, each subspecialty should have documented outcomes, including outpatient follow‐up. Other outcome improve- ment strategies the department does not employ include assessment of quality of life, risk‐adjusted mortality, and financial risk protection. Regarding process improve- ment, waiting lists exist for each subspecialty; however, the length of time to surgery and timeliness of care are process improvement strategies not measured by the department. On appraisal of the clinical burden, sub- specialty units in trauma and neonatal surgeries will be valuable additional units. For subspecialty training to progress, fellowship posts by the CMSA are necessary. 1306 - GOVENDER ET AL. 14322323, 2024, 6, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/w js.12197 by U niversity O f W itw atersrand, W iley O nline L ibrary on [07/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense 5 | CONCLUSION The subspecialty units in the DPS at CHBAH respond to the global surgery need by meeting the majority of OReCS strategies in the clinical service provided. SFLL contributes substantially toward the physical and human resources, research, and training. The DPS employs OReCS quality improvement by training trainees and fellows, including those from sub‐Saharan countries, contributing to the pediatric surgical workforce in South Africa and beyond. The DPS research quantifies the local disease burden, advocates for equitable resources, and provides a global surgical service for children in need. AUTHOR CONTRIBUTIONS T. R. Govender: Conceptualization; data curation; formal analysis; methodology; writing – original draft; writing – review and editing. J. Scribante: Formal anal- ysis; project administration; supervision; validation; visualization; writing – review and editing. T. Govender: Conceptualization; formal analysis; methodology; proj- ect administration; supervision; writing – review and editing. A. Withers: Conceptualization; methodology; project administration; supervision. J. A. Loveland: Conceptualization; formal analysis; methodology; proj- ect administration; resources; supervision; visualization; writing – original draft; writing – review and editing. CONFLICT OF INTEREST STATEMENT None declared. ETHICS STATEMENT Approval to conduct the study was obtained from the University of the Witwatersrand (Wits) Human Research Ethics Committee (Medical) (M220501). A retrospective descriptive research design was followed. ORCID T. R. Govender https://orcid.org/0000-0001-7937- 749X J. Scribante https://orcid.org/0000-0002-2221-5024 T. Govender https://orcid.org/0000-0002-9613-7938 A. Withers https://orcid.org/0000-0001-5941-9824 J. A. Loveland https://orcid.org/0000-0002-3341- 0749 REFERENCES 1. Meara, John G., Andrew J. M. Leather, Lars Hagander, Blake C. Alkire, Nivaldo Alonso, Emmanuel A. Ameh, Stephen W. Bick- ler, et al. 2015. “Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development.” Lancet 386(9993): 569–624. https://doi.org/10.1016/s0140‐ 6736(15)60160‐x. 2. Mullapudi, Bhargava, David Grabski, Emmanuel Ameh, Doruk Ozgediz, Hariharan Thangarajah, Karen Kling, Blake Alkire, John G. Meara, and Stephen Bickler. 2019. “Estimates of Number of Children and Adolescents without Access to Surgical Care.” Bulletin of the World Health Organization 97(4): 254–8. https://doi.org/10.2471/blt.18.216028. 3. Toobaie, Asra, Sherif Emil, Doruk Ozgediz, Sanjay Krishnas- wami, and Dan Poenaru. 2017. “Pediatric Surgical Capacity in Africa: Current Status and Future Needs.” Journal of Pediatric Surgery 52(5): 843–8. https://doi.org/10.1016/j.jpedsurg.2017. 01.033. 4. Bickler, S. W., and H. Rode. 2002. “Surgical Services for Chil- dren in Developing Countries.” Bulletin of the World Health Or- ganization 80(10): 829–35. 5. Debas, H., P. Donkor, A. Gawande, D. Jamison, M. Kruk, and C. Mock. 2015. DCP 3 Essential surgery. World Bank Group. 6. Price, Raymond, Emmanuel Makasa, and Michael Hollands. 2015. “World Health Assembly Resolution WHA68.15: Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage— Addressing the Public Health Gaps Arising from Lack of Safe, Affordable and Accessible Surgical and.” World Journal of Surgery 39(9): 2115–25. https://doi.org/10.1007/s00268‐015‐ 3153‐y. 7. Assembly, W. H. 2015. World Health Organization, Sixty‐eighth World Health Assembly. WHA68.15. Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage. 8. Truché, Paul, Haitham Shoman, Ché L. Reddy, Desmond T. Jumbam, Joanna Ashby, Adelina Mazhiqi, Taylor Wurdeman, et al. 2020. “Globalization of National Surgical, Obstetric and Anesthesia Plans: The Critical Link between Health Policy and Action in Global Surgery.” Globalization and Health 16(1): 1–8. https://doi.org/10.1186/s12992‐019‐0531‐5. 9. Ameh E. A., Bickler S. W., Lakhoo K., Nwomeh B. C., Poenaru D. Paediatric Surgery: A Comprehensive Text for Africa. 2011;2: 358–65. 10. Dell, Angela, Alp Numanoglu, Marion Arnold, and Heinz Rode. 2018. “Pediatric Surgeon Density in South Africa.” Journal of Pediatric Surgery 53(10): 2065–71. https://doi.org/10.1016/j. jpedsurg.2017.11.067. 11. Goodman, Laura, Etienne St‐Louis, Yasmine Yousef, Maija Cheung, Benno Ure, Doruk Ozgediz, Emmanuel Ameh, et al. 2017. “The Global Initiative for Children 's Surgery: Optimal Re- sources for Improving Care.” European Journal of Pediatric Surgery 28(01): 051–9. https://doi.org/10.1055/s‐0037‐1604399. 12. Grabski, D., E. Ameh, D. Ozgediz, K. Oldham, F. A. Abantanga, and N. Abdulraheem. 2019. “Optimal Resources For Children’S Surgical Care I.” Guidelines for Different Levels of Care. 13. Butler, Marilyn W., Doruk Ozgediz, Dan Poenaru, Emmanuel Ameh, Safwat Andrawes, Georges Azzie, Eric Borgstein, et al. 2015. “The Global Paediatric Surgery Network: A Model of Subspecialty Collaboration within Global Surgery.” World Jour- nal of Surgery 39(2): 335–42. https://doi.org/10.1007/s00268‐ 014‐2843‐1. 14. Qin, Rennie, Barnabas Alayande, Isioma Okolo, Judy Khanyola, Desmond Tanko Jumbam, Jonathan Koea, Adeline A. Boatin, Henry Mark Lugobe, and Jesse Bump. 2024. “Colonisation and Its Aftermath: Reimagining Global Surgery.” BMJ Global Health 9(1): e014173. https://doi.org/10.1136/bmjgh‐2023‐014173. 15. The World Bank. 2020. Population data, population ages 1‐14 (by %) 2020. [Internet]: Available from: https://data.worldbank. org/indicator/SP.POP.0014.TO.ZS?locations=ZG. 16. The World Bank. 2021. The World Bank on South Africa: Overview. [Internet]: [cited 2021 Dec 26]. Available from: https:// www.worldbank.org/en/country/southafrica/overview#1. 17. Winchester, Margaret S., and Brian King. 2018. “Decentraliza- tion, Healthcare Access, and Inequality in Mpumalanga, South Africa.” Heal place 51(51): 200–7. https://doi.org/10.1016/j. healthplace.2018.02.009. 18. Kon, Zeida R., and Nuha Lackan. 2008. “Ethnic Disparities in Access to Care in Post‐Apartheid South Africa.” American WORLD JOURNAL OF SURGERY - 1307 14322323, 2024, 6, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/w js.12197 by U niversity O f W itw atersrand, W iley O nline L ibrary on [07/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://orcid.org/0000-0001-7937-749X https://orcid.org/0000-0001-7937-749X https://orcid.org/0000-0001-7937-749X https://orcid.org/0000-0002-2221-5024 https://orcid.org/0000-0002-2221-5024 https://orcid.org/0000-0002-9613-7938 https://orcid.org/0000-0002-9613-7938 https://orcid.org/0000-0001-5941-9824 https://orcid.org/0000-0001-5941-9824 https://orcid.org/0000-0002-3341-0749 https://orcid.org/0000-0002-3341-0749 https://orcid.org/0000-0002-3341-0749 https://doi.org/10.1016/s0140-6736(15)60160-x https://doi.org/10.1016/s0140-6736(15)60160-x https://doi.org/10.2471/blt.18.216028 https://doi.org/10.1016/j.jpedsurg.2017.01.033 https://doi.org/10.1016/j.jpedsurg.2017.01.033 https://doi.org/10.1007/s00268-015-3153-y https://doi.org/10.1007/s00268-015-3153-y https://doi.org/10.1186/s12992-019-0531-5 https://doi.org/10.1016/j.jpedsurg.2017.11.067 https://doi.org/10.1016/j.jpedsurg.2017.11.067 https://doi.org/10.1055/s-0037-1604399 https://doi.org/10.1007/s00268-014-2843-1 https://doi.org/10.1007/s00268-014-2843-1 https://doi.org/10.1136/bmjgh-2023-014173 https://data.worldbank.org/indicator/SP.POP.0014.TO.ZS?locations=ZG https://data.worldbank.org/indicator/SP.POP.0014.TO.ZS?locations=ZG https://www.worldbank.org/en/country/southafrica/overview#1 https://www.worldbank.org/en/country/southafrica/overview#1 https://doi.org/10.1016/j.healthplace.2018.02.009 https://doi.org/10.1016/j.healthplace.2018.02.009 https://orcid.org/0000-0001-7937-749X https://orcid.org/0000-0002-2221-5024 https://orcid.org/0000-0002-9613-7938 https://orcid.org/0000-0001-5941-9824 https://orcid.org/0000-0002-3341-0749 Journal of Public Health 98(12): 2272–7. https://doi.org/10. 2105/ajph.2007.127829. 19. Statistics South Africa. General household survey. Pretoria. 2018. 20. Smith, Emily R., Tessa L. Concepcion, Kelli J. Niemeier, and AdesojiO.Ademuyiwa. 2019. “IsGlobalPediatricSurgery aGood Investment?”World Journal of Surgery 43(6): 1450–5. https://doi. org/10.1007/s00268‐018‐4867‐4. 21. National Health Act. 2011. 2003 South African Department of Health: No. R 655. 22. Overview of Chris Hani Baragwanath Academic Hospital‐ Parliament Research Unit. 2022. 23. Hopkins, Kathryn L., Khuthadzo Hlongwane, Kennedy Otwombe, Janan Dietrich, Mireille Cheyip, Nompumelelo Kha- nyile, Tanya Doherty, and Glenda E. Gray. 2019. “De- mographics and Health Profile on Precursors of Non‐ communicable Diseases in Adults Testing for HIV in Soweto, South Africa: A Cross‐Sectional Study.” BMJ Open 9(12): e030701. https://doi.org/10.1136/bmjopen‐2019‐030701. 24. Braa, J. 2017. Decentralisation, Primary Health Care and In- formation Technology in Developing Countries — Case Studies from Mongolia and South Africa. 25. Langer, Jacob C., and Teresa To. 2004. “Does Pediatric Sur- gical Specialty Training Affect Outcome After Ramstedt Pylo- romyotomy? A Population‐Based Study.” Pediatrics 113(5): 1342–7. https://doi.org/10.1542/peds.113.5.1342. 26. Zanini, A., N. Maistry, G. Brisighelli, T. Gabler, D. Harrison, C. Westgarth‐Taylor, A. Withers, J. Loveland, and N. Patel. 2021. “The Burden of Disease and Pathology at a Rapidly Expanding Tertiary Paediatric Surgical Unit in South Africa.” [Internet] World Journal of Surgery 45(8): 2378–85: Available from. https://doi.org/10.1007/s00268‐021‐06144‐x. 27. Surgeons for Little Lives. https://www.surgeonsforlittlelives.org 28. Mantica, Guglielmo, Pietro Fransvea, Francesco Virdis, Timothy C. Hardcastle, Hilgard Ackermann, Carlo Terrone, Gianluca Costa, André Van der Merwe, Genoveffa Balducci, and Elmin Steyn. 2019. “Surgical Training in South Africa: An Overview and Attempt to Assess the Training System from the Perspective of Foreign Trainees.” World Journal of Sur- gery 43(9): 2137–42. https://doi.org/10.1007/s00268‐019‐ 05034‐7. 29. Davenport, Mark, Evelyn Ong, Khalid Sharif, Naved Alizai, Patricia McClean, Nedim Hadzic, and Deirdre A. Kelly. 2011. “Biliary Atresia in England and Wales: Results of Centralization and New Benchmark.” Journal of Pediatric Surgery 46(9): 1689– 94. https://doi.org/10.1016/j.jpedsurg.2011.04.013. 30. O'Neill, James A., and Roger Vander Zwagg. 1980. “Update on the Analysis of the Need for Pediatric Surgeons in the United States.” Journal of Pediatric Surgery [Internet] 15(6): 918–24: Available from. https://doi.org/10.1016/S0022‐3468(80) 80304‐6. 31. von Sochaczewski, Christina Oetzmann, Andrea Zanini, Sonia Basson, Giulia Brisighelli, Antonio Di Cesare, Tarryn Gabler, Valerio Gentilino, et al. 2021. “Globalization in Pediatric Surgical Training: The Benefit of an International Fellowship in a Low‐To‐ Middle‐IncomeCountryAcademicHospital.”European Journal of Pediatric Surgery 32(04): 363–9. https://doi.org/10.1055/s‐0041‐ 1734029. 32. Botchway, Maame Tekyiwa, Deirdre Kruger, Charles Adjei Manful, and Andrew Grieve. 2020. “The Scope of Operative General Paediatric Surgical Diseases in South Africa—the Chris Hani Baragwanath Experience.” Annals of Pediatric Surgery 16(1): 44. https://doi.org/10.1186/s43159‐020‐ 00052‐w. 1308 - GOVENDER ET AL. 14322323, 2024, 6, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/w js.12197 by U niversity O f W itw atersrand, W iley O nline L ibrary on [07/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://doi.org/10.2105/ajph.2007.127829 https://doi.org/10.2105/ajph.2007.127829 https://doi.org/10.1007/s00268-018-4867-4 https://doi.org/10.1007/s00268-018-4867-4 https://doi.org/10.1136/bmjopen-2019-030701 https://doi.org/10.1542/peds.113.5.1342 https://doi.org/10.1007/s00268-021-06144-x https://www.surgeonsforlittlelives.org https://doi.org/10.1007/s00268-019-05034-7 https://doi.org/10.1007/s00268-019-05034-7 https://doi.org/10.1016/j.jpedsurg.2011.04.013 https://doi.org/10.1016/S0022-3468(80)80304-6 https://doi.org/10.1016/S0022-3468(80)80304-6 https://doi.org/10.1055/s-0041-1734029 https://doi.org/10.1055/s-0041-1734029 https://doi.org/10.1186/s43159-020-00052-w https://doi.org/10.1186/s43159-020-00052-w Responding to the need: An evaluation of the subspecialty units in a pediatric surgical department in a limited resource se ... 1 | INTRODUCTION 2 | MATERIALS AND METHODS 3 | RESULTS 4 | DISCUSSION 5 | CONCLUSION AUTHOR CONTRIBUTIONS CONFLICT OF INTEREST STATEMENT ETHICS STATEMENT