Letter to the Editor: Current Landscape of Children's Surgery in Africa: A Multicenter Analysis of 16,000 Cases

We read with great interest the recent article by Hsu et al. describing a 5-year multicenter analysis of pediatric surgical care across 17 hospitals in 11 African countries, as well as the accompanying commentary, Pediatric Surgery in Low-Income Countries—From Neglect to Necessity [1, 2]. The authors are to be commended for assembling a substantial dataset on children's surgical outcomes in Africa and for clearly demonstrating the profound inequities in perioperative mortality, particularly among neonates and children undergoing emergency procedures, when compared with high-income settings. The study reinforces that solutions to these disparities must be systems-based and multidisciplinary. We agree with the authors that improving pediatric surgical outcomes in Africa requires coordinated investments in infrastructure, equipment, critical care, medications, and workforce development. However, we wish to highlight a notable gap in emphasis in the article: the limited attention given to current pediatric anesthesia workforce development, despite its central role in perioperative safety and outcomes. Africa has the fastest population growth rate globally, and by 2050, nearly 40% of the world's children will reside on the continent [3]. Yet, most African countries have few or no fellowship-trained pediatric anesthesiologists. Where they do exist; they are typically concentrated in urban academic centers, leaving large regions without consistent access to expert pediatric perioperative care. This workforce gap directly contributes to the very mortality patterns described by Hsu et al., particularly during emergencies, nights, and weekends when senior expertise is least available. Since 2022, the Paediatric Anaesthesia Training in Africa (PATA) collaboration has addressed this gap through regionally embedded pediatric anesthesia fellowship programs in Nigeria, Uganda, Zambia, Kenya, and recently, Ethiopia. These 12–24-month fellowships train anesthesiologists to work alongside pediatric surgeons in institutions that already provide pediatric surgical care, with an emphasis on specialist-led training, supervision, and support for the broader anesthesia workforce, thereby strengthening existing systems rather than creating parallel ones. To date, this approach has substantially increased the number of fellowship-trained pediatric anesthesiologists in participating countries by more than 140%, with graduates remaining in their home countries and assuming leadership, teaching, advocacy, and quality improvement roles. By August 2026, 38 pediatric anesthesiologists would have been trained. We do not suggest that training pediatric anesthesiologists alone will resolve the complex challenges outlined in this important study. However, the data presented by Hsu et al. raises an important question: Who provides expert pediatric perioperative care during emergencies when resources are limited and specialist care is unavailable? Strengthening pediatric anesthesia capacity through specialist-led training, supervision, and support for the broader anesthesia workforce is a pragmatic, evidence-based step toward addressing this reality. Finally, we note that during the study period, National Hospital Abuja had a fellowship-trained pediatric anesthesiologist, a detail not reflected in Table 1 of the article. Accurate documentation of existing specialist capacity is essential for workforce planning and policy advocacy. We applaud the authors for advancing the global conversation on children's surgical care in Africa and hope future analyses will more explicitly and consistently consider pediatric anesthesia workforce development when discussing strategies to improve perioperative outcomes. Maryrose O. Osazuwa: writing – original draft, writing – review and editing. Gacii Vernon Mark: writing – review and editing, writing – original draft. Hazel Mumphansha: writing – review and editing, writing – original draft. The authors have nothing to report. All authors are Program Directors in their respective countries, for the Paediatric Anaesthesia Training in Africa Fellowship Program. Maryrose O. Osazuwa is a member of the Global Initiative for Children's Surgery. The authors have nothing to report.