The EACTS recommended such a center be headed by a fully trained cardiac surgeon with appropriate national certification and experience in the full spectrum of congenital heart repairs. The defining feature is the necessity of an interdisciplinary approach requiring the participation of several disciplines and professionals—surgeons, cardiac anesthesiologists, intensive care specialists, pediatricians, pediatric and interventional cardiologists, imaging experts, neonatologists, perfusionists, scrub nurses, ICU and ward nurses, and administrators.

The procedures should exceed 250 operations per year, covering the full spectrum of congenital cardiac pathology for a catchment area of 4 to 6 million inhabitants, from the neonate to the adult. Research facilities for advanced educational needs and specialty development are recommended. An advanced quality assurance system and public reporting of results are essential.

Staffing requirements include at least two fully qualified surgeons, each performing a minimum of 125 procedures annually, a specialized team of anesthetists devoted to congenital heart surgery, a specialized team of perfusionists, and an entire supporting paramedical staff including dedicated physiotherapists and a psychologist consultant to cater for the needs of patients and parents. Pediatric nurses trained to run the wards, operating rooms, and intensive care units are a special requirement.

At least two fully equipped operating rooms should be available based on one operating room per 250 major cardiac procedures per year. A dedicated pediatric intensive care unit is staffed variably by pediatric cardiologists, neonatologists, pediatric intensivists, and pediatric anesthetists working closely with the congenital heart surgeons. Depending on the complexity, the average number of beds required is 6 to 8 per 250 cardiac patients per year. The nurse/patient ratio in this ICU should be 1:1 full-time equivalent for complex patients and 0.5:1 for uncomplicated patients.

In addition, a step-down unit of 2 to 4 intermediate beds equipped with monitoring and telemetry is necessary. There should be a dedicated pediatric/neonatal ward. Optimally, there should be 10 to 12 beds per 250 patients per year with at least one wound treatment room.

Rooming-in facilities allowing the permanent presence of the mother or another family member should be available.

Rehabilitation facilities for children should be available. Outpatient facilities should be available for echocardiography, electrocardiography, and radiology.

On-site support facilities should include a department of general pediatrics, a department of pediatric cardiology with all diagnostic and therapeutic facilities, and a unit of cardiac pathology.

Centers should also have access to neonatology, adult cardiology, electrophysiology, an adult cardiologist specialized in congenital heart disease, staff with special experience in extracorporeal membrane oxygenation (ECMO) and mechanical assist devices, and specialized laboratories relevant to subspecialty work such as transplant immunology, virology, and others.

The justification for investment in CHD treatment is the long-term survival and quality of life afforded to affected children. The public health significance of the interventions is the impact on child mortality, specifically neonatal, infant, and under-5 mortality rates (U5MR).

From a public health and policy perspective, child health interventions, particularly in LMICs, are judged based on their impact on the United Nations (UN) sustainable development goals (SDG) 3.2—to reduce neonatal mortality to less than 12 per 1000 live births and U5MR to below 25 per 1000 live births by 2030. For CHD treatment to have any meaningful impact on the SDG 3.2, resources devoted to CHD care must be commensurate with the disease burden in the country.

CHD affects approximately 1 newborn per 100 live births, with a relatively stable incidence worldwide, amounting to roughly 1,300,000 new cases annually. Roughly 90% of births affected by CHD occur in LMICs where treatment is either suboptimal or unavailable, resulting in about 66% of preventable deaths from congenital malformations in these countries.

Regarding disease burden, Africa represents a special case with important future implications. Africa’s child population is estimated to reach 1 billion by 2055, making it the largest child population among all continents. Since 2017, sub-Saharan Africa has been the region with the highest number of births; this trend is forecasted to persist for the rest of the century. The population of sub-Saharan Africa has grown consistently between 2.6% and 2.8% per annum in the last 20 years compared to the current global rate of 1.18% per year. Hans Rosling drew attention to Africa’s dramatic rise in population when he labeled it “the biggest change of our time.” On current trends, Africa is projected to have 730 million births between 2015 and 2030 and approximately 1.8 billion births between 2015 and 2050, by which time Africa will account for 42% of all global births. The implications of the persistently high fertility rate for the burden of CHD in Africa will be enormous in the coming decades because children account for nearly half (47%) of Africa’s population.

South Asia ranks second on the population growth charts, but even here, there has been a decline (from 2% to 1.5% per annum) in the last 20 years. Rapid population growth poses a major problem for access to CHD treatment as the number of new cases per year exceeds the facilities available to provide care.

The concern is that for sub-Saharan Africa, where healthcare investment has been essentially stagnant in the last 20 years, infrastructure and service delivery must now grow more than 2.8% per annum to make gains in improving access to congenital heart surgery. Based on UN population projections, Africa will become the epicenter of CHDs by 2050 simply because of the percentage of global births expected in Africa. Substantial and strategic healthcare investments are needed to meet the UN’s SDG 3.2 target of reducing the U5MR to less than 25 per 1000 live births. The changing demographics in Africa will require an additional 4.2 million health workers above current growth to meet World Health Organization (WHO) minimum standards by 2030.

The distribution of pediatric cardiac surgeons is heavily skewed in favor of high-income economies. The global average is a density of 1.99 pediatric cardiac surgeons per million children under 15 years of age but varies from 11.1 in North America to 0.19 in sub-Saharan Africa. Between 2006 and 2016, the estimated global mortality from CHD in the pediatric population decreased by 21% (from 239,399 to 188,426), yet 91% (171,762) of the deaths in 2016 were considered preventable. Roughly 76% (130,767) of preventable deaths occurred in infancy, half of which occurred in the neonatal period alone. This indicates that public health efforts to reduce U5MR attributable to CHD are best targeted at neonates and infants. The average daily mortality rate during the neonatal period is nearly 30-fold higher than during the postneonatal period.

While 96.4% (165,609) of the 2016 excess mortality occurred in LMICs, 10 countries—India, China, Nigeria, Indonesia, Pakistan, Sudan, the Philippines, Afghanistan, Brazil, and Mexico—made up the largest burden (roughly 59% or 100,557) of excess CHD mortality in 2016. Mortality for CHD remains unacceptably high in low-resource settings, principally because the disease burden far outstrips resources made available for its treatment.

Although GNI does not completely summarize a country’s development level or its citizens’ welfare, it is a valuable indicator correlating with nonincome welfare measures such as life expectancy at birth and child mortality. Especially significant is its correlation with U5MR ( Table 55.2 ), the ultimate target of child health interventions, and, specifically, the UN’s SDG 3.2. Geographically, the World Bank describes seven regions in four income groupings. For the 2023 fiscal year, the thresholds are as shown in Table 55.2 . Countries are reassigned on July 1 each year based on their GNI per capita estimate for the previous calendar year. On the basis of financial resources available for development of congenital heart care, the world’s most underserved regions are countries in the low-income and lower-middle-income brackets where total health expenditure (THE) is less than US $100 per capita per year ( Fig. 55.2 and Table 55.2 ). This contrasts with US $552 per capita per year in upper-middle-income countries and US $5639 per year in high-income countries.

Low-income and lower middle-income economies of 2023 fiscal year.

Admittedly, there are essential differences in healthcare service pricing across the different countries and regions of the world. That notwithstanding, there is only so much one can do with purchasing health care if all that is available is US $100 or less per person per year.

Because resource limitation is more consistent in low- and lower-middle income countries, our narrative focuses on these countries (found in Africa, Asia, and Latin America; Fig. 55.2 ). There are 82 countries in the low-income and lower middle-income country categories; sub-Saharan Africa has the highest concentration of countries in the low-income category (24 out of 28) where THE averages US $35 per capita per year. The gross financial constraints in low- and lower-middle-income countries impose severe limitations of human and material resources for healthcare delivery, particularly for congenital heart surgery along the whole patient care pathway.

Resource constraints in many pediatric cardiac surgery centers in these countries lead to restricted access to congenital heart surgery or higher standardized mortality ratios (SMR) for congenital heart surgery. Analysis of data from 31 IQIC sites in 17 low-resource settings (Afghanistan, Argentina, Brazil, China, Colombia, Costa Rica, Guatemala, India, Malaysia, Mexico, Pakistan, Peru, Russia, Serbia, Uganda, Ukraine and Vietnam), some in upper-middle-income countries, showed an overall in-hospital mortality rate of 5.0% (at least 50% of cases in Risk Adjustment for Congenital Heart Surgery [RACHS] category 1 or 2). Country-level mortality rate ranged from 1.7% to 25.0%, and SMRs ranged from 0.40 to 4.85. There was a general trend toward lower SMR with increased national income and health expenditure per capita. There was a clear demonstration that even for similar levels of national income per capita, substantial variation in SMRs exists. For example, Afghanistan and Pakistan have much higher SMRs (3.0 and 2.6) than India (0.9), although they are at similar income per capita levels. Similarly, China, Serbia, and Peru have similar income per capita levels yet vary widely in SMR: 0.46, 1.6, and 4.85, respectively.

Geographical access is fundamentally dependent on availability of facilities and trained personnel. Clear differences exist in the availability of cardiac surgery centers in high income versus low-income countries. An earlier survey showed significant inequality in distribution of the approximately 4000 cardiac surgical centers in the world. In North America, each center was serving approximately 120,000 people. In Europe and Australia, the corresponding figure was 1 center per 1 million people. In Asia, it was 1 center per 16 million people, while in Africa the figure was 1 center per 33 million people.

The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database includes 95% of congenital heart surgery centers in the United States, with almost 40,000 operations per year. The overall mortality after congenital heart surgery in the United States for children, infants, and neonates is 1%, 2.8%, and 8.8% respectively. Perioperative outcomes after congenital heart surgery in Europe are comparable. One of the major factors responsible for the improvement in mortality from CHD in high-income economies is the creation of highly specialized multidisciplinary units for medical and surgical care of these patients.

However, in many LMICs, the situation is quite different, with gross inadequacies in geographic and financial access to surgical repair that limit survival of children born with CHD. The 2017 Global Burden of Disease report showed that CHD mortality in low-income countries declined by only 6% since 1990, compared to a steady decline of over 50% in high-income countries.

The current status of center availability is of interest, particularly in the lowest-income regions of the world ( Fig. 55.2 ). Countries in Africa, Asia, and a few countries in Latin America are the most constrained regarding resources, and the inadequacies are not uniform in these regions. Countries in the sub-Saharan regions excluding South Africa are most affected in Africa. In Asia, some countries in the Middle East, South Asia, East Asia, and the Pacific are most constrained. Only a few countries in Latin America belong to the lower middle-income category; the majority are far better off even though centers from several of these countries (like Brazil, Argentina, and Mexico) still report their results as coming from low-resource settings. Our narrative will largely focus on low- and lower-middle-income countries because of their pressing need.

The Sustainable Development Goals (SDGs) adopted by the UN in 2015 were developed to promote healthy lives and well-being for all children, the principal metrics being the neonatal mortality rate (NMR) and the U5MR. From a resource allocation perspective, every child health intervention is judged on its potential and actual contribution to lowering the U5MR. According to WHO country data, global U5MRs in 2020 ranged from 2 per 1000 live births to 115 per 1000 live births; the rate in the highest-mortality country was about 65 times higher than in the lowest-mortality country. Globally, infectious diseases, including pneumonia, diarrhea and malaria, along with pre-term birth complications, birth asphyxia/trauma, and congenital anomalies remain the leading contributors to U5MR.

The SDG Goal 3.2 has two targets: (1) Reduce NMR to less than 12 per 1000 live births in every country and (2) Reduce U5MR to less than 25 per 1000 live births in every country. U5MR contributes to 85% of all deaths to children under age 15; NMR is responsible for 38% of U5MR. The global U5MR in 2020 was 37/1000 live births (5 million under-5 deaths in 2020); sub-Saharan Africa and southern Asia accounted for 53% of global births but more than 80% of under-5 deaths. Half of all under-5 deaths in 2020 occurred in five countries: Nigeria, India, Pakistan, the Democratic Republic of Congo, and Ethiopia; Nigeria and India alone account for almost a third of all deaths. Sub-Saharan Africa continues to have the highest U5MR worldwide at 74 per 1000 live births—14 times higher than Europe and North America. As of 2020, 125 countries had already met the SDG target for U5MR and 16 more countries were expected to do so by 2030. However, 54 countries were offtrack and not expected to achieve the target by 2030 on current trends. Strategic efforts are still lacking in sub-Saharan Africa and southern Asia.

The leading causes of global under-5 deaths in 2019 were neonatal disorders (37.3%), lower respiratory infections (13.3%), diarrheal diseases (9.9%), congenital birth defects (9.4%), and malaria (7.1%). CHDs are major contributors to the deaths attributable to congenital birth defects (9.4%) but the size of the contribution exhibits geographical variation. Globally, CHD deaths are responsible for approximately 50% of the deaths due to all congenital birth defects but varies from as low as 25% in sub-Saharan Africa, to about 50% in South Asia, to a high of 70% in East Asia. Thus potentially, appropriate treatment for CHD delivered in a timely manner could reduce global under-5 deaths by about 4.7% (half of 9.4%). The global optimum U5MR is 1.44 per 1000 live births. If all countries reduced mortality to the global optimum, the contribution of congenital anomalies to U5MR will substantially increase, making it the second commonest cause of under-5 death after neonatal disorders. The implication is that the further away from optimum the U5MR is, the smaller the potential impact of birth defects (and thus CHD) on the U5MR. Low-income countries with competing health priorities and limited resources often face crucial tradeoffs on the pathway to SDG 3.2 target of getting U5MR below 25 per 1000 live births. CHD care often comes off worse in the tradeoffs. Unless strategic advocacy is undertaken to bring CHD to the national healthcare agenda in these countries, the outlook for children born with CHD will remain perennially bleak.

Weak and often dysfunctional national health systems characterize many low-resource countries. The health system consists of resources , their organization and management , and the financing mechanisms available to purchase service delivery . Managing these five principal health system components requires health planning, administration, regulation, and legislation. Options for financing health care include governmental tax revenues, foreign aid (in some low-income countries), statutory social insurance, voluntary insurance, charity, and out-of-pocket spending (OOPS) by individual households. Fundamentally flawed processes are often employed in many low-income countries to organize and manage healthcare resources. The result is a dysfunctional health system that underperforms its resources.

Many low-resource countries lack clear national health policies integrated with national development components. Their national health plans lack a clear strategy with well-defined goals and policies. Health planning efforts tend to be fragmentary and not directed toward supporting a broad national agenda. Furthermore, clear and logical healthcare priorities are rarely laid down apart from those prescribed by international donors and funders. Realistic criteria for the development of priorities are formulated even more rarely. The most important drawbacks include lack of an overall health policy, political will to provide the necessary resources, and an effective executive structure to implement the decisions.

Promoting access to congenital heart surgery in low-resource settings as a national priority will require significant buy-in from political and community leaders leading to distinct representation in national health strategic plans (NHSP). The process will involve building and communicating a compelling, evidence-based report on how congenital heart care contributes to national health and economic targets. Congenital heart surgery has been widely excluded from national and international health agendas and poorly represented in NHSPs, mainly because its significance in attaining national health targets (such as the infant and U5MRs in SDG 3.2) is poorly communicated and appreciated.

Compared to communicable diseases, priority given to diseases amenable to surgical care is low in developing countries. This is evident when NHSPs of these countries are scrutinized. For example, in a 2014 systematic review of the NHSPs of 43 sub–Saharan African states, HIV and malaria had 3772 mentions across all the policies, compared to 376 for surgery. And of the total 4064 health targets mentioned, only 2% were related to surgical conditions or surgical care. The NHSP defines the nation’s health status and sets out action plans to achieve priority targets and performance indicators for monitoring and evaluation.

In the last decade, attention was drawn to the heavy burden of surgical disease worldwide, particularly in LMICs. In 2015, the high burden of disease amenable to surgical treatment in low-resource settings was highlighted in several publications based on the work of the Lancet Commission on Global Surgery. ^, Subsequently, the World Health Assembly Resolution 68.15 on strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage was passed in support. As a result, several developing countries rallied to the call for increasing access to surgical, obstetric, and anesthesia care with the development of national surgical, obstetric, and anesthesia plans (NSOAPs) to be incorporated into their country’s NHSP. The NSOAPs have been developed as a policy strategy for countries to increase access to treatment of diseases amenable to surgical care and are now recognized components of universal health coverage necessary for a resilient health system. Planning begins with defining the gaps in access to safe, timely, affordable, and quality surgical care, identifying and prioritizing solutions, and creating a costed and funded implementation plan.

Strategic planning addressing six domains—infrastructure; workforce; service delivery; financing; information management; and governance—is needed to improve access to surgical care at the national level. Guidelines for developing NSOAPs have been published and may be adapted for prioritizing congenital heart care. A handful of low-resource countries, principally in Africa, have thus far developed and launched their NSOAPs. Still, almost all the published NSOAPs distinctly lack cardiac (including congenital heart) surgery representation.

To improve access to CHD treatment, congenital heart surgery must be specifically prioritized and not implicitly buried within other health strategies. Meanwhile, our congenital heart surgery community and professional associations must seek more active participation in advocacy for high-level political commitment to congenital heart care.

Otherwise known as medical tourism, OMT is where patients and their families travel from their home country to another to seek health care. It has become a widespread phenomenon thriving in destination countries (such as India, Thailand, Malaysia, South Africa, and Turkey) and attracting significant expenditure in countries of origin, some of which spend as much as 12% of their entire national health budget in sending patients abroad for cardiac surgical care. In 2016, Africans spent roughly US $6 billion on OMT (Nigerians alone spent US $1 billion). Not surprisingly, sub-Saharan Africans constitute the largest contributors to the Indian OMT market in numbers and revenue.

In the last two decades, OMT has assumed important status for congenital heart patients. For example, between May and October of 2009, 11% of 1372 patients admitted to one Indian congenital heart center were from outside India. The majority were from Malaysia (45%), Nigeria (23%), and Tanzania (15%). Ages ranged from 1 month to 39 years (mean 61 months). Cheaper cost and superior expertise compared to the home country were the two main drivers of OMT. Patients were either self-funded or obtained funding from governments and philanthropists. It seems counter-intuitive that LMICs would serve as medical tourism destinations. However, much of the “business” driving OMT in countries such as India is based in the private sector of destination countries, and locals may not have the financial means to access the services that foreigners can afford. In 2010, an average of 3000 Nigerians traveled to India for medical purposes each month, spending around US $200 million for medical care.

OMT is sometimes organized and funded by governments. In Malaysia, poor availability of pediatric cardiac services compounded by long waiting times and high costs led the government to allocate funds through the Pediatric Cardiothoracic Program (PCP), in which patients are transported to India for heart care. Between August 2008 and September 2012, 241 Malaysian patients received care in India through the PCP. The postoperative mortality rate was 1.7%, and the program was considered beneficial to patients and the government.

While OMT provides access to otherwise unavailable care, problems with hidden costs, postoperative follow-up, quality of care, and adverse outcomes have become important concerns. OMT provides a useful avenue for patients with sufficient financial resources to avoid waiting lists or obtain treatment otherwise unavailable in their home countries, but the practice has also raised important ethical issues, including the large financial contribution of the poorest continent (Africa) to OMT revenue in countries such as India, the lack of available high-quality care to most citizens of some destination countries who have no health insurance coverage for the same services, and the investment of public funds used to train local providers. Further, OMT may subsidize the construction of for-profit hospitals, effectively transferring benefits from local indigent patients to comparatively wealthier international ones.

The overwhelming burden of pediatric cardiac surgery needs in humanitarian settings has prompted mutual interest between humanitarian organizations and pediatric cardiac surgeons in low-resource settings. This collaboration has arisen from the realization that provision of congenital heart surgery requires expensive structured programs and consistent, high-level economic support. Several humanitarian cardiology and cardiac surgery programs have been developed to meet this need in low-resource settings. In 2014, a survey identified 80 NGOs working in 92 low-resource countries.

Most of these NGOs had headquarters in the United States, Europe, and Asia-Western Pacific regions (outside of the regions where they run programs). Still, a substantial proportion (29%) represented local initiatives or in-country subsidiaries of multinational NGOs. The majority (42%) operated in South and Central America. Africa had 18%, Europe and Asia had 17% each, while Asia-Western Pacific had 6% of NGO activity.

Roughly half (51%) of the NGOs organized 2 to 5 missions annually. Most (87%) NGOs provided education, diagnostics, surgical, and/or catheter-based interventions. Most (59%) focused on operations in children and infants, but 41% performed neonatal operations not requiring cardiopulmonary bypass. In between missions, 26% of partner sites did not perform interventions.

In 2020, another survey identified 86 NGOs providing cardiac surgery services in 96 low-resource settings. Five performed adult cardiac surgery only, 56 performed pediatric cardiac surgery only, and 25 performed both adult and pediatric cardiac surgery. Of the 38 NGOs exclusively performing pediatric cardiac surgery with available volume data (67.9%), a median of 100 operations (4–837) per year were performed. As of May 2020, these NGOs had been operating for a median of 21 years (IQR: 15-29) funded by individual donations ( n = 58), corporations ( n = 37), foundations ( n = 36), and fundraising campaigns or events ( n = 14).

The impact of humanitarian cardiac surgery has been assessed, including outcomes, cost-effectiveness, and impact on disease burden. Outcomes of congenital heart surgery programs in low-resource settings may be gleaned from the registry of the International Quality Improvement Collaborative (IQIC) published for enrolling institutions between 2013 and 2015 for 31 sites in 17 countries (Afghanistan, Argentina, Brazil, China, Colombia, Costa Rica, Guatemala, India, Malaysia, Mexico, Pakistan, Peru, Russia, Serbia, Uganda, Ukraine, and Vietnam). The data included 24,917 operations performed in children (<18 years of age). The overall in-hospital mortality (number of deaths before hospital discharge divided by the total number of RACHS-classified surgical cases) was 5.0%, but country-level mortality rate ranged from 1.7% to 25.0%. There was variation in the proportion of RACHS categories, but all countries had at least 50% of cases in low-complexity categories (RACHS 1 or 2). SMR—observed in-hospital mortality rate divided by the mortality rate that would be expected given the country’s patient case mix—was the main outcome measure; an SMR greater than 1.0 indicates higher than expected mortality based on patient case mix and vice versa. Country level SMRs ranged from 0.40 to 4.85 with significant variation, including superior results in many countries with low national income per capita. The SMR was less than 1.0 in institutions based in 47% (eight: China, Ukraine, Vietnam, Russia, Colombia, Malaysia, Argentina, and India) of the 17 countries studied.

Several factors combine to affect the outcomes of humanitarian congenital heart surgery adversely. Delayed diagnosis and referral in low-resource settings ensure that pathology is often significantly advanced when the patient reaches the surgical team. Important comorbidities relevant in the postoperative period may not have been identified before the commencement of the mission or during the short period available for evaluation by the visiting team. Infectious disease, malnutrition, and anemia are common in many low-resource settings, which may impair postoperative recovery. Financial constraints limit the ability of patients and families to pay for items not covered by humanitarian assistance (like hospital stay, boarding, and lodging for parents and guardians) and also compromise compliance with appropriate follow-up. All these may combine in less endowed settings to increase mortality and morbidity associated with humanitarian cardiac surgery missions.

Questions about cost, resource allocation, and cost-effectiveness always arise in discussions of congenital heart surgery in low-resource settings. The competing healthcare needs in these settings make such discussions unavoidable. Much of the funds made available by Western governments, international public health organizations, and philanthropic corporations go toward global health interventions deemed to be highly cost-effective, and these fall in the categories of infectious disease prevention or treatment, maternal and child care, sanitation, and clean water provision among others. Congenital heart surgery, perceived as expensive, unaffordable, and of low public health significance in low-income countries, does not make the list of priorities. In addition, cost-effectiveness data on which to base recommendations for resource allocation toward congenital heart surgery have been sparse.

Such data are only recently becoming available from analyzing humanitarian missions in low-resource settings. From one such report in 2015, a total of 446 patients underwent congenital heart surgery in 10 LMICs at a mean age of 3.7 ± 5.4 years (37 neonates, 156 patients younger than 1 year), and estimated cost per procedure was US $6831. There were 27 uniquely identifiable cardiac malformations—atrial septal defect, VSD, patent ductus arteriosus, tetralogy of Fallot, and single ventricle being the commonest. The estimated cost-effectiveness of an intervention was US $171 per disability-adjusted life year (DALY) averted. Each patient potentially gained 39.9 years of life expectancy, 3.5 years of schooling, and US $159,533 GNI per capita.

In context, recent reviews reported cost-effectiveness values of US $13 (per DALY) for circumcision, US $109 for procedures for hydrocephalus, US $136 for ophthalmic surgery, and US $82 for other common general surgical operations. The results support the notion that congenital heart surgery is highly cost-effective in LMICs, offers substantial societal benefits, and should be considered among “Essential Pediatric Surgical Procedures” for its considerable economic value. ^, Generally, interventions with a maximum cost-effectiveness ratio (CER) of less than that country’s GDP per capita are considered very cost-effective; those with a CER of less than three times the GDP per capita are cost-effective, and all others are judged not cost-effective.

From the outset, most humanitarian efforts primarily aim to provide clinical services at the patient level and then assist the local team in establishing independent programs. Yet, from a policy and sustainability perspective, public health impact on disease burden is often limited for humanitarian missions with marginal caseloads and where local team surgical activity is minimal between missions. One center in Nigeria reported their experience with six different teams visiting at different periods over 7 years conducting 266 open-heart operations (38 cases per year) in children and adults. At the end of the period, local team gains were judged as far from desirable because of inadequate skills transfer.

In terms of treatment access, missions only benefit a lucky few. Nigeria has the heaviest burden of congenital heart disease prevalence in Africa (more than 50,000 CHD births a year; Fig. 55.3 ) ; the impact of humanitarian cardiac surgery on the burden of disease in such a country and many other LMICs is minimal unless long-term measures link these efforts to scalability.

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