Universal health coverage (UHC) means that all people including children have access to quality health services without financial hardship (1). Surgery and surgical health services have been recognized as an essential part of UHC by the World Health Organization (WHO) and World Bank (2). Despite this, the importance of surgical care has been underappreciated for several decades due to a preferential focus on infectious diseases in the public health discourse. The burden of surgical disease in children is considerable—one third of childhood deaths in the world are attributable to surgical conditions—and with expected surge in child population in Africa, this figure can be expected to increase (3). It has been estimated that about 85% of children in low- and middle-income countries (LMICs) have surgically correctable conditions by the age of 15 years (4). However, two thirds of the world's children, mostly in LMICs, do not have access to surgical care (5). Every year over 77.2 million disability-adjusted life-years (DALYs) could be averted by basic, life-saving surgical care (6). Furthermore, through early prevention and corrective interventions, costly secondary and tertiary interventions at later stages in the life course can be averted for improved health and wellbeing, enhanced socio-economic prospects, and reduced healthcare costs. Bangladesh and Zimbabwe are two LMICs that have made impressive improvements in maternal and child health, however, there remains a large unmet need for surgical services with children in both countries facing similar challenges globally. This article examines the state of children's surgical conditions in both countries, outlines the gaps that still exist and describes the devastation wrought by the COVID-19 pandemic in this key area of global health that has been neglected for decades. The article offers perspectives from two LMICs on strengthening surgical services in the context of health systems recovery following the COVID-19 experience to make and sustain progress toward UHC. It draws heavily on The Lancet Commission on Global Surgery report—a landmark publication that outlined the scale of the previously underappreciated problem and laid out global aspirations for scaling up access to surgical care to underserved regions by 2030 (7). It is a roadmap for global surgical efforts that described core indicators for monitoring of universal access to safe, affordable surgical and anesthesia care.

We conducted focused literature reviews adapting an approach which has been utilized previously in considering global surgery in a health systems context (8). This involved searching PubMed and Google Scholar with review of the first five pages of sources for each of the 6 components in the framework for surgical systems planning to categorize the effects of COVID-19 on surgical systems in the target countries (Table 1) (7). The findings were supplemented by the perspectives of local experts to identify key vulnerabilities in surgical systems of each country (Bangladesh and Zimbabwe). Key vulnerabilities were identified, discussed and presented for each country. The countries represent two diverse LMIC regions (Sub-Saharan Africa and South-East Asia, respectively) and have evolving demographics reflecting the broader global south, i.e., growing young populations and likely increased prevalence of children's surgical conditions in the twenty-first century.

Zimbabwe and Bangladesh were chosen because they are the home countries of the authors who have on-the-ground experience as well as understanding of sociocultural norms and the local health system. In the context of extremely scarce research on children's surgical care in both countries, an approach of using evidence augmented by the insights of experts and vice versa is a pragmatic solution in developing initial recommendations for policy, practice and future research.

A key step toward improving children's surgical services in the LMIC context is through institutionalized planning and policy instruments such as NSOAPs. Bangladesh does not currently have an NSOAP. A dedicated plan for surgical and obstetric care, that prioritizes children can put this neglected area on the radar of key decision makers at local, national and global levels. Furthermore, it can be utilized to bring the surgical community together in the country to advocate and leverage national ansd international funding, resources and in-kind support. Simply having a dedicated NSOAP, however, will not be enough to bring much needed attention to the children's surgery agenda. There will need to be specific considerations for common children's surgical conditions in line with national contexts in each NSOAP. Furthermore, the plans will need to be adequately funded with credible implementation plans in a reasonable time and provision made for monitoring and evaluation. Importantly, the NSOAP should not exist or be implemented in isolation and should link to multi-year national health policies and plans, and their planning cycles, such as the national health sector strategic plan and essential package of health services.

Impacts on the SAO workforce were particularly influential in curtailing surgical care during the pandemic. This in addition to the pre-emptive cancellation of children's surgery was devastating to the 15-year campaign to expand access to surgery globally described by the Lancet Commission on Global Surgery report. Cancellations of elective surgery were common around the world but were not supported by evidence. The risk of infection in children remained low in Bangladesh (37) Cancellations in children in particular are controversial because children's beds did not provide useful surge capacity for COVID-19 in the target countries (29). And children have comparatively low perioperative mortality after COVID-19 infection (38). The excess mortality caused by untreated surgical disease may therefore still exceed the potential risk of COVID-19 related nosocomial infection or perioperative COVID-related death.

Governments should consider protection of SAO workers as the most important resource during and outside of pandemics (22). The promotion of their mental health and safety and retention is of utmost importance. The pandemic revealed preexisting vulnerabilities and stressed SAO workers to the limit. A more sustainable healthcare workforce will contribute to resilience for future pandemics. The Lancet Commission report made no specific mention of children's surgery, an important oversight. There is an urgent need to develop indicators for children's surgical care in addition to those for adults as well as bellwether procedures for children.

A common theme in both countries is the opportunity borne out of necessity for increased utilization of information and communication technologies (ICT) to facilitate links between central hospitals and distant facilities in districts and rural areas. Use of consultation prior to surgery, planning of surgery and decision-making for transfer and patient flow are just some of the applications of ICT that can mitigate the negative effects of the pandemic and improve efficiency and effectiveness in health systems.

The paucity of research and granular data (incomplete, non-interoperable, inaccessible and unpredictable) at subnational, community and rural levels is a barrier to the development and implementation of an evidence-based National Surgical, Obstetric and Anesthesia Plan with necessary considerations and resources for children's surgery in Bangladesh and other LMICs. For implementation of the NSOAP and scale up of children's surgical services, there is a need to conduct population needs assessment and cost assessment. It is criticaI to understand the service needs according to target population criteria such as children's age, sex, socioeconomic and education group, religion, geographical location (e.g., urban, rural, or tribal) and health sector (e.g., public, private, not-for-profit, informal).

There exist noteworthy limitations in the deliberations and conclusions drawn in this perspective piece including the risk of bias (e.g., citation bias) using non-systematic methods There is currently a dearth of literature in global pediatric surgery especially relating to the impacts of the COVID-19 pandemic in these countries and the effects varied widely across many LMICs. This manuscript is aimed at emphasizing those unique impacts in the context of Zimbabwe and Bangladesh and may have relevance for other LMIC country contexts as they progress with health systems recovery and making and sustaining progress toward UHC.

Bangladesh and Zimbabwe are examples of LMICs with a significant burden of pediatric surgical disease with major implications for broader individual and population health, psychosocial health and economic development. Current surgical services are unable to meet this demand with improvements needed in quality, access, equity, financial protection aligned with universal health coverage/sustainable development goals. The pandemic severely limited health system capacity for surgery and surgical systems resilience has been tested to the limit during this period. Urgent resuscitative attention and investment is needed from policy to practice levels to improve infrastructure, attract, retain and train the surgical and allied health workforce and improve service delivery access with equity considerations to meet the 2030 goals of the Lancet Commission report and make and sustain progress toward UHC.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

TC and DM contributed to conception, design of the study as well as literature review, and manuscript writing. KL and TB were involved in concept development, manuscript writing, and critical review. TTA, NT, and SM were involved in data acquisition and critical review. DM wrote the first draft of the manuscript. TTA, NT, SM, and TB wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.