**2. Challenges**

#### **2.1 Economic and financial resources**

The world bank classifies countries according to their incomes into four groups; in 2022 there are 27 countries in low-income economy (LICs) with Gross National Income (GNI) per capita of \$1045 or less, 55 countries with Lower Middle-income economy (LMICs) with GNI per capita range of \$1046–\$4095, 55 countries in Upper Middle-income economy (UMICs) with GNI per capita range of \$4096–\$12,695, and 80 countries in high-income economy (HICs) with GNI per capita of \$12,696 or more [18].

The majority of LICs are struggling to meet the basic primary health problems such as vaccination, malnutrition, and infectious diseases, making it very hard to provide tertiary pediatric cardiovascular services [6]. Due to lack of awareness, some policymakers and even medical professionals in LICs consider pediatric cardiac services as a luxury and not an essential service [19].

LICs are struggling to provide the health services investment required for lifesaving CHD interventions. A study exploring associations between risk-adjusted CHD surgical mortality from 17 LMICs and global development indices [20] found a statistically significant positive correlation between under-five mortality and surgical mortality rate, and a negative correlation between specialist surgical workforce and CHD mortality: as specialist surgical workforce increases, congenital heart surgery mortality decreases, suggesting that adequate workforce is vital to quality congenital heart surgical capacity [20].

The association between outcome of CHD surgery and GNI per capita is well established; in LMICs, surgical mortality for CHD was found to be higher in countries with lower GNI per capita [21]. In addition, low health care expenditure per capita, poverty, malnutrition, and high under-five mortalities also play a significant role [20].

CHD is the second cause of mortality under 1 year of age, the first being infections [22].

There is a huge difference in mortality of CHD between HICs and LICs; in HICs, the mortality is 3–7% compared to 20% in LICs. Mortality figures from CHD in LICs are likely to be underestimated since access to the health services is difficult and the available data is not reliable most of the time. Most of the available data is from patients in tertiary centres rather than community-based studies [8].

## *2.1.1 Solutions and moving forward*

We recommend that LICs governments should look for innovative ways to finance pediatric cardiac services, using partnership models. Targeting potential partners such as private sector, insurance companies, nonprofit organizations and international organizations [11]. The system should be flexible to finance mainly the needed sectors in the community; this will ensure the funds will go a long way in helping many children.

Economic efficiency could be improved by the following measures:

Comprehensive care through dedicated cardiovascular programs and centres, these centres will have important roles including improving awareness, prevention, treatment, staff training and research. These centres will have a high-volume workload and this is likely to lead to more efficient manpower management and cheaper consumables.

The cost of consumables and drugs may also be reduced by tax breaks and by encouraging the production of some of these items locally [11] or purchasing the items in bulk.

At the cardiac centre level, prioritization of intervention types is crucial in the context of severe resource limitations; palliative, staged and off-pump operations may be more suitable and safer than complex interventions [11]; of course, this will raise an ethical and philosophical dilemma when a decision is reached not to intervene in patients with complex congenital defects such as single ventricle palliation [23].

Many studies from LMICs demonstrated that it is more cost-effective to adopt early screening programs [1, 24], streamlining of referral pathways, maintaining a balanced case mix with focus on correctable lesions and provide cost-effective intensive care management through the implementation of clinical protocols and best practices as well as to minimize the use of expensive drugs or treatment modalities [25, 26].

### **2.2 Health care system challenges**

For a health system to be effective, it has to be staffed by well trained and efficient medical, nursing, allied, and administrative staff. To be sustainable, it requires a robust infrastructure, real leadership, good governance, and continuing education program. In LICs the health system is usually not well planned due to a lack of information and unawareness of the local health needs and priorities. The health care system support usually comes from the government with some input from academic institutions and NGOs [21].

Poorly supported health care delivery systems remain a major problem in LICs, which can lead to poor management of CHDs in LICs. There is a clear disparity between the poor and affluent as well as urban and rural settings. In LICs more than 60% of the population reside in rural setting. In LICs the health services are

*Management of Congenital Heart Disease in Low-Income Countries: The Challenges and the… DOI: http://dx.doi.org/10.5772/intechopen.104830*

struggling to provide support for other services and some of these deficiencies could have an adverse effect on the pediatric cardiac services such as poor antenatal care, poorly controlled diabetes in pregnancy, and congenital rubella syndrome. Since the vaccination program is not well-established congenital rubella is still seen in LICs [8].

For a health care system to be functioning well and delivering good service, it has to be affordable, accessible and the population has to be aware of the services [27]. Unfortunately, the health care delivery system in LICS is struggling with all of these three factors.

The costs are excessive for most families [21]. Affordability is one of the main reasons for delayed interventions and the associated high morbidity and mortality [21]. Most of the LICs are trying to provide pediatric cardiac services in public hospitals either free or for a reduced cost but such hospitals lack funding and resources and are extremely busy and overwhelmed [19, 21].

LICs have very few pediatric cardiac centres [26], and they are always located in the main cities. Patients who live in non-urban setting sometimes have to travel long journeys to access such services. Inaccessible services will lead to late presentation and delayed diagnosis, and both are associated with high morbidity and mortality [21, 27].

Awareness of the parents, allied health workers and the health care professionals in LICs is not adequate about pediatric cardiac disease. Parents in HICs are aware and well informed about pediatric cardiac disease. The robust health system in HICs also has several safety mechanisms in the system to detect and diagnose pediatric cardiac disease early such as fetal diagnosis [24], routine neonatal check post-delivery, oxygen saturation screening [1], routine primary health check, and routine school health screening. Lack of awareness in LICs is one of the most important factors contributing to late presentation, missed and delayed diagnosis [6, 27].

In the poorest parts of Africa and Asia, the pediatric cardiovascular services are limited. Some of the larger cities have facilities for diagnosis and intervention of selected and straightforward conditions in older children but infant and newborn services are limited.

The preoperative phase requires earlier detection. Fetal echocardiography and screening programs are not readily available in LICs which leads to delay diagnosis. One study from Sudan showed the antenatal diagnosis was 1% compared to the figures of 10−15% in the HICs [17].

There are many barriers to accessibility and affordability in the process from diagnosis to management [5]. The waiting list in the cardiac centres in LICs is getting longer because of the increase workload and the inability of the existing centres to cope. The waiting list is especially long for stable patients who tend to be pushed down in the list because of the urgent and sick cases.

Postoperative critical care has witnessed slow but steady progress in the developing programs. Cardiac intensive care remains a bottleneck for the waiting list in LICs due to increased length of stay for patients secondary to increased morbidity. In developing programs, the cardiac intensive care unit (CICU) is usually integrated with the general pediatric ICU [5]. While this is useful in terms of reducing the cost and sharing of financial and human resources, this could create a problem for bed availability as pediatric ICU patients may occupy the cardiac ICU beds affecting the waiting list adversely. The teamwork philosophy approach has had a major positive effect on the outcome of cases [25].

The poor economic and financial situation will have a detrimental effect on attracting and retaining trained cardiac physicians and nursing staff [5]. The team that looks after pediatric cardiac disease consists of surgeons, physicians, nurses

and technicians, all are highly trained and receive specialized training that is lengthy and expensive. The LICs must invest in them so the respective countries can develop and maintain pediatric cardiac services. This staff will require continuing job training and reasonable pay and benefits. Unfortunately, most of the time this does not happen and the staff either start working in the private sector, usually in adult centres or migrate abroad to richer countries leading to a brain drain which is a major problem in the LICs [6, 28].

#### *2.2.1 Solutions*

The health care systems in LICs need to be reformed to improve the delivery of primary and secondary health care. Pediatric cardiac services are very specialized that need a health system with robust infrastructure [11].

Antenatal care services providers, pediatricians and primary care providers should have increased awareness of aforementioned health care issues. Programs targeting CHD include, screening programs such as fetal echocardiography, oxygen saturations in the newborn prior to discharge, and neonatal examinations should be established.

Creative solutions to tackle access and geographic barriers to care have been used in countries such as India, Brazil, Vietnam, and Morocco. These in-country programs operate mobile health care units that are staffed with trained cardiac clinicians and equipped with portable electrocardiogram and echocardiogram equipment. These units provide outreach services to non-urban communities increasing accessibility to the services, raise awareness of CHD, provide education to local clinicians, and screen children for structural heart disease [8].

Pediatricians with an interest in cardiology, especially in non-urban areas should be provided with support from pediatric cardiologists such as telemedicine facilities and satellite clinics. These services should be easily accessible to the residents of nonurban areas and could improve the care of the children by providing early diagnosis and referral to specialized centres. The above approach is cost-effective since the training is shorter compared to the pediatric cardiology training.

Human resources are the most valuable asset; there is a great need for healthcare workers to be trained, sustained, and retained in LICs [6, 28].
