Discussion
Our study evaluates essential pediatric congenital care delivery in a country that has implemented a federally funded UHC system. Our results suggest that while there is variation in the individual procedures performed by surgeons, there are very few differences with respect to which procedures are performed in the public versus private sector and even fewer differences in procedures performed among different levels of hospitals. Furthermore, although pediatric surgeons are distributed in both the public and private sectors, surgical infrastructure and reimbursement issues remain the primary issues reported by surgeons in both sectors.
Brazil has 1514 registered pediatric surgeons according to the most recent Demografia Medica 2020, representing 0.3% of all medical specialists in the country and a workforce ratio of 0.72 pediatric surgeons/100 000 persons. Pediatric surgeons are unevenly distributed throughout the country, concentrated in the southeast region (52.6%), followed by the south (17.1%) and northeast (16.8%), with fewer pediatric surgeons in the midwest (9.2%) and north (4.3%).25 This distribution of professionals is likely determined by market availability, remuneration level, the structure of support services (pediatric intensive care unit, clinical neonatal care, high-level anesthesia), and the quality of life offered to professionals.25 Another explanation for the oversupply of pediatric surgeons in the wealthier regions suggested by Aguiar et al is the large pediatric population assisted by private health insurance plans in these regions.26 Notably, 70% of private insurance users are concentrated in the southeast region.25 27
Brazilian public and private health systems coexist not only in financing and management but also in the provision and use of health services. All Brazilians are covered by the SUS, and almost 100% use it for vaccines, prehospital care, and pharmaceutical assistance, while 75% of Brazilians depend exclusively on it. Users transfer between the systems based on opportunity and the ability to pay for health services to avoid bottlenecks as do health professionals, according to working conditions and remuneration.27 This complex interplay between the public and private system in Brazil results in many physicians working in both systems risking unnecessary duplication of services, but also promoting knowledge exchange and reducing public sector burden.28 29 Our results demonstrating the challenges in establishing a balance of pediatric surgery providers to address the demands of both systems mirror this complexity.
In Brazil, it is also common for highly specialized providers to have to work outside of their specialized training domain, which disrupts the availability of specialized care. One possible cause is fewer job offers for specialists in the public health service (SUS), the largest employer of doctors in the country, which employs mainly emergency workers and general specialty doctors.25 Our results corroborate that pediatric surgeons still work as general surgeons, even in places with a shortage of pediatric surgeons.25
Of the 23 essential interventions outlined as essential interventions for congenital care, Brazilian pediatric surgeons provide over half of them, the rest of which represent procedures provided by other surgical subspecialties.17 Brazilian pediatric surgeons operate on all pediatric surgical diseases, except for ophthalmological, ear, nose and throat, orthopedic, cardiac, and neurosurgical diseases. They also treat children’s urological, thoracic, and reconstructive plastic surgeries for congenital diseases. This range of care is different from pediatric surgery care distribution in most European and North American countries and makes capacity assessments for pediatric surgical care between countries difficult.25 The objective of investigating the performance of pediatric surgeons using the DCP3 priority list is not to assess if these surgeons would perform all the protocol procedures but instead to measure the contribution of these professionals in the care of children with congenital malformations according to a validated and recognized priority guide. Understanding which procedures are performed, in which places, and with which resources can help in more strategic planning for allocating resources and professionals. Most importantly, in a continental country such as Brazil, we need to understand the disparities of surgical education and provision of care within the country. Our results indicate that Brazilian pediatric surgeons are receiving homogeneous training and practice broadly across the country. The mixed private–public health system contributes to competition that maintains high-quality care in the public system and offers Brazilian surgeons opportunity for better income without foregoing working in the public system entirely.
The majority of interventions were performed by surgeons working in both the public and private sectors suggesting that human resources exist to provide the full range of congenital surgical care in the public sector. As our results demonstrate, pediatric surgeons at Brazilian private institutions were less likely to provide general anesthesia or blood transfusions themselves, which may reflect better availability of anesthesia providers in the private institutions. Successful strategies for increasing capacity for children’s surgical care in LMICs have consisted of expansion of the local pediatric workforce coupled with infrastructure development.30 31 Our results in Brazil suggest that Brazil’s UHC healthcare workforce is able and willing to perform the majority of complex congenital operations. Five per cent of pediatric surgeons work at first-level hospitals and perform complex surgery, which suggests that either regional triage to larger hospitals is not possible or that surgeons feel comfortable performing these operations at smaller, rural hospitals. Although surgeons report that they perform complex cases in first-level hospitals, the number of surgeons who reported barriers to care was systematically higher at first-level and second-level hospitals and at public hospitals when compared with private facilities. This reflects the under-resourced nature of first-level and even second-level hospitals with respect to surgical care.32 33 We also found that barriers to pediatric surgical care were more pronounced in public hospitals in Brazil, specifically the lack of access to equipment. This finding parallels other literature exploring barriers to provision of surgical care where lack of infrastructure has been shown to be the primary driver.34 35
In response to these barriers to surgical care provision and to better guide governments, a number of countries have begun to develop and implement National Surgical, Obstetric, and Anesthesia Plans (NSOAPs), which may help to coordinate efforts to scale up surgical infrastructure.36–38 Although a number of countries in Latin America have adopted systems of UHC, none have implemented an NSOAP yet.39 This underscores the need to develop context-specific plans, integrated into UHC systems, such as Brazil’s healthcare system, that specifically address inequities in access to surgical care and more specifically, children’s surgical care. Furthermore, an understanding of the differences in procedures performed in the public and private sector could help with further identification of indicator procedures that have been developed as markers of surgical capacity and delivery similar to the Bellwether procedures.40 41 Addressing the lack of access to equipment and beds available to pediatric patients in public hospitals will be an important next step in improving the distribution of access to pediatric surgical care in the country.
Based on our results, the next challenges on promotion of quality pediatric surgical care in Brazil rely on (1) access, (2) transfer of care to higher-level facilities, and (3) availability of medications, (4) surgical equipment, and (5) other pediatric subspecialties such as pediatric anesthesia. These barriers are different from those faced by low-income countries, suggesting that categorizing barriers and problems for LMICs generally may be insufficient. Successful interventions in a low-income country, such as increasing the number of providers, may not be useful in an upper middle-income country such as Brazil. Future study directions include developing an understanding of how these barriers are affecting child mortality and disability and developing a priority agenda to address these barriers to achieve better equity in healthcare delivery and to advise health policymakers on allocation. These studies might also include qualitative interviews of healthcare professionals working in pediatric surgery to gain a more in-depth understanding of these barriers to providing high-quality care for children.
Our study has several limitations. First, our findings may be a narrow representation of all pediatric surgeons from Brazil. Surgeons participated voluntarily and may have had reasons to do so, resulting in self-selection bias. As the survey was distributed through online platforms, a surgeon’s utilization habits for these platforms directly affected their exposure to the study. Not all pediatric surgeons in the country received the survey. In an attempt to adjust for this bias, we weighted responses by state to account for selection bias. After weighting the response data by regional distribution, there were no significant differences between the weighted and unweighted data. Additionally, our sample, representing one-fourth of all pediatric surgeons in Brazil, had a similar regional distribution to the reported regional distribution for the national pediatric surgeon workforce in both Demografia Medica 2018 and 2020. Another possible limitation is recall bias given that data for each surgeon on which procedures they perform are based on self-reporting with no measure of operative volume, skill, expertise, or outcomes. Additionally, we surveyed only pediatric surgeons, and no other surgical specialists who may also perform congenital operations. Further studies are needed to understand the role of other surgical subspecialists in the delivery of children’s congenital surgical care within the context of Brazil’s UHC system.
In conclusion, pediatric surgeons perform congenital operations equally across Brazil, in both the public and private sectors, as well as across various hospital tiers from district hospitals to large referral centers. While the majority of pediatric surgeons in Brazil work in public sector hospitals, few work solely in the public sector, and those who do face a number of barriers related to infrastructure, transfer arrangements, and access to other pediatric subspecialists. Policies and incentives that support pediatric surgeons working in the public sector may increase the quality of care of congenital surgical care, promoting better health outcomes. These policies and guidelines must consider that interventions for congenital anomalies take place across all hospital levels within the public and private sector and that coordinated systems to support public hospitals are needed.
