Andersons pediatric cardiology 2256
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newbornsinseveralregionsthatarenowwitnessingrapidandsubstantial
improvementsinhumandevelopmentindices.17
Notwithstandingthedeclineincommunicablediseases,RHDisstillquite
prevalentinLMICs,particularlyamongthepoorestandmarginalizedsectionsof
thepopulationsthatareoftenleftisolatedbydysfunctionalhealthsystems.18
MostLMICshavelargepocketsofpoorandmarginalizedpopulationsthat
includetheruralpoor,migrantlaborers,andtheirfamiliesandresidentsofurban
slums.OtheracquiredchildhoodheartdiseasessuchasKawasakidiseaseand
myocarditisandcardiomyopathyarealsolikelytobesubstantialproblemsin
termsofabsolutenumbersinLMICsasawhole.
Perhapsasaconsequenceofthedemographictransitioninpediatricheart
disease,pediatricheartcarehasstartedtodevelopasadistinctentityinmany
LMICsinthepast30years.Itisgrowingrapidlyintermsofnumberofnew
programs,caregivers,andpatientnumbers.19Giventheprojectionsforthenext
20to50yearsintermsofeconomicgrowthandhumandevelopment,itislikely
thatmuchoftheglobalactivityintermsofpediatricheartcarewillshifttothe
currentLMICs.19
However,thereareseveralchallengesindeliveringpediatricheartcarein
termsofhumanandmaterialresources,infrastructure,anddeficienciesin
systemsofhealthcaredeliveryinalmostallLMICs.20Socioeconomicissues
suchaspoverty,ignorance,andlimitationsinprimaryhealthcarealterthe
demographyofthepatientpopulation,therebypresentingadditionaltherapeutic
challenges.21
HealthSystemChallengesinLow-andMiddleIncomeCountries
Comprehensivepediatricheartcarerequiresthepresenceofarobustpediatric
heartprogramthatissupportedbyeffectivehealthsystems.Box88.1liststhe
essentialrequirementsfordevelopingasuccessfulcomprehensivepediatric
cardiacservice.20Thefirstsixrequirementsrelatetospecificattributesofthe
program,andthelastfourrequirementsrelatetohealthsystemsintheregion.
Pediatriccardiacprogramscannotfunctioninisolation.Theireffectivenessis
closelylinkedtothehealthcareenvironmentoftheregiontheyserve.
Box88.1
MinimumRequirementsforDevelopinga
SuccessfulComprehensivePediatricCardiac
Service
■Robustinfrastructure
■Qualityequipment
■Highlevelofskillamongcaregivers
■Cohesiveteamwork
■Supportiveadministration
■Sustainablesystemsandservices:educationandtraining
■Easygeographicaccess
■Well-developedandmaturereferralbase
■Favorableeconomicsandhumandevelopmentintheregion
■Asystemforcharitablecare
■Ethicalpracticeenvironmentthatisnottotallyprofitdriven
ModifiedfromKumarRK.Deliveringpediatriccardiaccarewithlimited
resources.AnnPediatrCard.2014;7:163–166.
HealthSystemChallengesinCongenitalHeart
DiseaseCare
AnumberofhealthsystemchallengesinLMICscomeinthewayofdeliveryof
comprehensivepediatricheartcaretoeverychildbornwithCHD.Theseare
listedinTable88.1.Dysfunctionsinprimaryhealthcaretranslateinto
deficienciesinantenatalcare.PrenataldiagnosisofCHDisnowwellestablished
inmanyadvancednations,whereasubstantialproportionofnewbornswith
criticalCHDareidentifiedbeforebirth.Thisenablesterminationofpregnancies
insomeofthefetuseswithcriticalCHDwhendetectionisbeforethelegallimit
forabortion.FormanyotherfetuseswithCHD,directeddeliveryatcenterswith
facilitiesforcomprehensivepediatricheartcareisfacilitated.Thislargely
eliminatesthechallengesofhavingtotransportnewbornswithcriticalCHD.In
mostLMICs,prenataldiagnosisofCHDisexceptionalandlargelylimitedto
smallpopulationsaroundselectedpediatriccardiaccentersthathaveawelldevelopedfetalcardiologyservice.Whenoneconsidersthefactthatacountry
likeIndiahasapproximately26millionbirthseveryyear,itiseasytounderstand
thatuniversalantenatalscreeningispracticallyimpossible.
Table88.1
HealthSystemBarriersforDeliveringComprehensiveCarefor
InfantsandNewbornsWithCongenitalHeartDisease(CHD)
Category
DetectionofCHD
Referraltopediatricheart
program
Transport
Treatment
SpecificHealthSystemChallenges
VerylimitedfacilitiesforprenataldiagnosisofCHD
Homedeliveries
LimitedawarenessamongcaregiversaboutclinicalCHDdiagnosis
Limitedaccuracyofpulseoximeterwhenperformedbyuntrainedpersonnel
LimitedexpertiseinechocardiographyforCHD
Limitedawarenessoftreatmentoptions
Absenceofpediatricheartcentersintheregion
Limitedawarenessoninitialmanagement
Genderbiasandsocioculturalfactors
Poorlydevelopednewborntransportsystemsinmostlow-andmiddle-income
countries
Geographicdistances
Costoftransport
Massiveshortfallofcomprehensivepediatricheartprogramswithfacilitiesfor
newbornandinfantsurgery
Failuretointegratepediatricheartcareintouniversalhealthcaremodels
Predominantlyprivatizedhealthcare
Inabilitytoaffordoutofpocketexpenses
Eveninadvancednationswithwell-developedsystemsforperinatalcare,
thereispotentialforanumberofcriticalCHDstobemissedatbirthunless
specificCHDscreeningprogramsareinstituted.Thisisbecausesymptomsand
signsareuncommoninmanynewbornswithCHDinthefirst48hoursafter
birth.22Newbornpulseoximeterscreeningisnotmandatedandthereforeoften
notundertakeninmostLMIChealthcaresettings.Furthermore,anumberof
deliveriescontinuetohappenathomeandarelargelyunsupervised.23Newborn
screeningislargelyimpossibleinthesecircumstances.Eveninthedeliveries
thathappenundermedicalsupervisioninhospitals,CHDtendstobemissed
becauseoflimitedawarenessamongthehealthcarepersonnel,including
pediatricians.21Becauseoftheextraordinarypaucityofpediatricheartprograms
ininstitutionswithpostgraduatetraining(residency)programsinpediatrics,
mostpediatricresidentshavelittleornoexposuretopediatriccardiologyintheir
