Lack of children’s hospitals: challenge in delivering comprehensive care for children in LMICs.

 

Children don’t get sick as often as adults. Cardiovascular diseases and killer tumors are luckily not as prevalent as in adults. But these facts can never overshadow the peculiar and sophisticated care children require when they develop or are born with certain ailments. In the global south, there is a rapidly expanding demography resulting in a very youthful population. Despite their significant share, the resource allocated towards them is not equitable. This has resulted in an unfortunate scenario where child care is always fighting for limited resources with its adult counterpart. This is especially true in delivering a higher-level care at general and tertiary hospitals. There is a long held wrong belief that sees children as the miniaturized version of adults; which unfortunately is shared by some in health care.  This belief for long has shackled the progress of pediatric care in LMICs. Regrettably, it is too frequent an occurrence for us health care providers working with kids, to be told a certain medication, laboratory test or imaging is available; but not for children. As long as we continue to provide high level child care in ‘adult hospitals’ this reality will only continue.

Small children exhibit a remarkable growth and physiologic changes otherwise not seen in later life. When a child is born, it loses around ten percent of its weight just in a week’s time. In four months, it doubles its birth weight and triples it in a year. This otherwise healthy adaptation in children highlights the remarkable physiologic plasticity which makes pediatric care uniquely challenging. The medications used in children have to be cautiously titrated to the size and age of the child. Instruments used in managing for sick children also have to be curtailed to their diminutive size and delicate nature of their body. Children’s limited vocabulary, emotional and mental maturity also adds another tier of complexity in managing for sick babies. The rather belated realization of this uniqueness of children has required specially trained physicians who can tend to their special needs. After the second half of the 19th century children’s hospitals started pop up in some industrialized countries.

Hôpital Necker Enfants Malades, is considered the first dedicated children’s hospital, built in 1801 in Paris. It was later followed by Great Ormond Street Hospital for Children in London (1852). The child center care practice was later expanded in many developed countries.  Not only was this a radical shift in child centered care, but it has greatly helped in advancing nutrition, research and innovation that has helped both adults and children. Currently there are around 250 children’s hospitals in the US, one for every 20 adult hospitals. Despite some improvement in health care, LMICs lag behind in delivering comprehensive child centered care. One of the bottlenecks is the lack of dedicated children’s hospitals as a part of the health care system.

Some of the few specialized higher-level care that cater to specific pediatric illnesses are distributed in a haphazard fashion. This has created another stratum of obstacle for the children and their care givers. Multiple anomalies are not uncommon conditions in children, especially with congenital diseases. For example, in my country Ethiopia, children born with such congenital anomalies visit five or more hospitals each month because there are no comprehensive centers that can give the multidisciplinary care they deserve. One of my patients is a 5 years old resilient boy born with multiple anomalies. He was operated at our center for his complex esophageal and bowel anomalies. But for his spina bifida (congenital lower spine anomaly), heart condition, foot deformity and poor vision he is on follow up at 5 different clinics all at separate hospitals. His mother has stopped her education and work, because of the multiple visits at different centers. Her usual question is ‘why can’t I get all the services at one center?’. This is unfortunately the reality for many of our patients. Such erratic follow-ups have become a source of frustration and financial drain to the care givers. In a country where half of the population is less than fifteen years, it is puzzling there are no child centered hospitals.

Centralization and institutionalization of child care pulls in limited human power and resources in a singular center where multidisciplinary care can be offered for children. This is especially true for a tertiary level care, mostly given at health institutions affiliated universities.  Establishment of children hospitals in LMICs is long overdue. We health care providers working with kids should be advocates for the largest but peripherally pushed segment of our population.

About the author: Ephrem N. Kerego (MD, FCS-CESA), Assistant Professor of Pediatric Surgery at SPHMMC. The author is passionate about health care equity and global surgery. He is keen follower of global affairs and armature painter. He can be reached at ephrem.nidaw@sphmmc.edu.et

Competing interests: None

Handling Editor: Neha Faruqui

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