Assessment of pediatric surgical needs, health seeking behaviors and health systems in the rural district of Tando Mohammad Khan Sindh, Pakistan

Background Surgical conditions are responsible for up to 15% of total DALY lost globally. Worldwide estimates have found that approximately 4.8 billion people have no access to surgical care. Within South Asia, greater than 95% of the population does not have access to care for conditions that require surgical management. Considering that greater than 50% of the population in the least developed regions worldwide is children, the surgical burden amongst children in LMICs is immense. In this study we use the SOSAS and PediPIPES in TMK district to assess the surgical needs of children under-5, quality of health facilities, and care seeking behavior in the community. Material and Methods The research was reviewed and approved by the Aga Khan University (AKU) Ethical Review Committee (ERC) and the National Bioethics Committee (NBC). Confidentiality of all collected data was assigned high priority at each stage of data handling. Data was collected through the SOSAS and PediPIPES survey tools between November 2019 and February 2020 from a total of 3,643 households in the TMK, Sindh, Pakistan. The SOSAS survey was conducted by research associates trained for data collection. Household mothers provided information about their children and data was recorded electronically. Health facilities were assessed using PediPIPES survey form. Information was collected on hard copies from all 39 health care facilities in the district, including RHCs, BHUs, DCDs, and DHQ. Data was collected by core team and entered onto an excel sheet. Results A total of 3,643 households participated and information of 6,371 children was collected. A total of 1,794 children were identified to have 3,072 lesions that required surgical attention. We categorized the lesions requiring surgical care according to six regions of the body. Head and neck accounted for the greatest number of lesions (n = 1,697) and the most significant unmet surgical need (16.6%). The chest region had 102 lesions and the least unmet surgical need of 5.9%. The back accounted for 87 lesions with an unmet surgical need of 6.9%. The abdomen had 493 lesions and an unmet surgical need of 13.4%. A total of 169 lesions were found on buttocks/groin/genitalia region with an unmet surgical need of 14.8%, while extremities presented with 296 lesions amounting to 11.8% unmet surgical need. A total of 39 health facilities, consisting of one DHQ, three RHCs, 14 BHUs and 21 DCDs, were surveyed. Trained staff were only present at the DHQ. Basic procedures such as suturing, wound debridement, I&D were performed more commonly than the more complex procedures. Most hospitals were found to have a good availability of equipment and supplies. PediPIPES scores and indices were calculated for the 39 health facilities in the area. The DHQ was found to have the highest score. Conclusions This study holds great significance for evaluation of pediatric surgical burden in Pakistan. It provides important insight into the burden of children’s operative disease in Pakistan’s rural district of TMK. The results show a significant need for provision of surgical care and has important implications for the global operative community as well as for strengthening the local health system in Pakistan. This data is useful preliminary evidence that emphasizes the need to further evaluate interventions for strengthening surgical systems in rural Pakistan. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial N/A ### Funding Statement Funding was received for this work from Bill and Melinda Gates Foundation. Funders had no role in data collection, data analysis and manuscript writing. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The research was reviewed and approved by the Aga Khan University (AKU) Ethical Review Committee (ERC) and the National Bioethics Committee (NBC). Confidentiality of all collected data was assigned high priority at each stage of data handling. The research participants were informed about the purpose, methods and benefits and intended uses of the research. Informed verbal consent was obtained. Respondents were free to stop interviews at any time or skip any questions they did not want to answer. They had the right to ask questions at any point before, during or after the interview. All interviews were conducted by trained staff and in conditions of privacy. The respondents were informed about their rights. All data files were password-protected. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Not Applicable All data generated or analysed during this study are included in this published article and its supplementary information file.