Africa constitutes less than one fifth of the world’s population yet contributes 25% of the global burden of disease . Where children under the age of 15 years make up 26% of the world’s population, they make up 43% of the population in sub-Saharan Africa. Furthermore, it is estimated that the population of many African countries will at least double by 2050, with Africa’s youth rising to 35% of the world youth total by then . Surgical conditions account for 6–12% of all paediatric visits and contribute to up a third of all childhood mortalities . According to Bickler’s group, about 90% of children living in low- and middle-income countries (LMICs) will have a surgical treatable condition by the age of 15 years  and, if not treated, can cause severe morbidity and mortality . Surgical conditions thus play a significant role in the overall burden of paediatric disease in LMICs. Recently, Butler’s group used population data from four LMICs and concluded that there is a high burden of unmet surgical need, with almost 20% of children requiring surgery and 62% of those children having at least one unmet surgical need .
Irrespective of its importance, little attention is given to paediatric surgical care in LMICs. Until recently, paediatric surgical care was seen as ‘the neglected step child of global health’ and, as it was not considered an essential service, excluded in many funded programmes both nationally and internationally . Paediatric surgical care is generally seen as an expensive specialty due to the peculiar surgical conditions, distinct anaesthetic challenges and unique perioperative needs. Moreover, the care of these children could be lifelong and require frequent follow-ups until adulthood.
There is a significant volume of operative procedures globally with an estimation of 312.9 million operations in 2012 . Due to the socioeconomic conditions in resource-constrained LMICs, differences exist between developing and developed countries in the patterns of disease and practice of paediatric surgical care . Despite the perceived burden of paediatric surgical diseases in developing countries, there is scarce epidemiological data, making it difficult to assess the actual surgical burden of the paediatric population .
In a review of the surgical workforce in South Africa in 2017, Dell published results showing that there were only 5.55 paediatric surgeons per one million population under 14 years of age, with an average age of 39.5 years and 55% male (Dell, 2017). This only left a workforce of only thirty giving a ratio of one specialist to every two million population. These figures fell far below developed countries such as the United States of America (USA) of one paediatric surgeon to approximately one hundred and eight thousand children as at 2006 (Polley et al. 2009).
South Africa is one of the pioneers of the practice of paediatric surgery in Africa. Nevertheless, a dearth of specialist paediatric surgeons in South Africa is a major obstacle in the effective delivery of paediatric surgical care. In 2015, Dell reported 0.80 paediatric surgeons per million total population in South Africa, with four provinces in the country not having one, compared to 8.20 paediatric surgeons per million total population in the USA . This falls short of the one paediatric surgeon per 500,000 population recommended internationally .
The Chris Hani Baragwanath Academic Hospital (CHBAH) in Soweto, Johannesburg, is one of the institutions in sub-Saharan Africa making giant strides in the provision of paediatric surgical services in the State sector. It is the biggest hospital in the Southern Hemisphere and the fourth largest in the world. Its main catchment area is in Soweto serving a local population of over three million people . CHBAH also acts as a major referral centre for the Gauteng Province and neighbouring provinces. The Paediatric Surgical Unit of the CHBAH is a highly specialized one managing complex cases from hepatobiliary to colorectal pathologies. There are two theatres dedicated to the paediatric surgical unit at the CHBAH (a neonatal theatre and a general paediatric theatre). Elective operative procedures are performed four times a week at the neonatal theatre and three times a week at the general paediatric theatre. Emergency surgeries are performed any time of the day and week on availability of an anaesthetist. The large population it serves coupled with multiple referrals and limited resources makes theatre days very busy with many cold cases waiting.
Few studies, if any, have investigated the burden of operative paediatric surgical procedures in South Africa. Therefore, this study aimed to look at the scope of operative paediatric surgical procedures at the CHBAH based in Johannesburg, South Africa, and reports on:
The numbers of elective and emergency procedures over the 12-month study period
The most common procedures performed with respect to age, gender and subspecialty