Over the past decade, increasing awareness of inequitable access to pediatric surgical services has driven global research and advocacy efforts [12]. A pivotal advancement in these efforts has been the development of pediatric surgery assessment tools, which offer a comprehensive overview of the readiness and capabilities of healthcare facilities to deliver pediatric surgical care.

Our study highlights a critical shortage of human resources for pediatric surgery in Burkina Faso, a country with a population of over 9.5 million children. Only 7/26 facilities reported having a full-time pediatric surgeon on staff during the month preceding the assessment, with the majority of these surgeons concentrated in tertiary hospitals located in the capital city. This corresponds to an approximate ratio of 0.07 pediatric surgeons per 100,000 children, which is well below the international recommendation of at least 1 qualified pediatric surgeon per 100,000 children (1/3). This raises significant concerns about equitable access to specialized care, particularly for children in rural or underserved regions, leaving many areas without adequate pediatric surgical expertise. This situation mirrors the broader challenges across sub-Saharan Africa, where there is, on average, only one pediatric surgeon for every six million children aged 0 to 14 [13]. To address this challenge, Burkina Faso, like many other countries in the region, relies on general surgeons to perform pediatric surgery. In Burkina Faso, this mainly concerns second-level hospitals, which also refer all children under five years old to third-level hospitals. However, efforts to address this issue are underway in Burkina Faso; since 2017, an advanced diploma in pediatric surgery has been offered and 40 additional scholarships were approved by the Council of Ministers in 2024. These initiatives represent a promising step toward strengthening the country’s pediatric surgical workforce and improving access to care.

While Burkina Faso has a significant number of anesthesiologists with good experience in the field, some with less than a year of training, none have undergone specialized dedicated training in pediatric anesthesia for over a year. This reflects broader global challenges identified by Kempthorne et al. in 2017, who link higher anesthesia-related mortality in low-resource settings to insufficient specialized training and resources, emphasizing the critical need for further development in this area [14].

Furthermore, less than 50% of nursing staff are specialized in pediatric care, which highlights a significant gap in expertise for delivering high-quality pre- and postoperative care. This issue is concerning as it appears that most nurses learn on the job and are not prepared to care for children. Aware of this challenge, Burkinabé health authorities have supported the implementation of a specialized training program for nurses, training over 350 professionals between 2020 and 2024, notably through the pediatric surgery development plan implemented with the Geneva University Hospitals [15]. Moreover, the basic curriculum for nurses has been supplemented with new teaching units specific to pediatric surgery.

The condition of infrastructure and material resources presents a significant challenge in Burkina Faso, as in many other countries in low resource settings [16], while efforts to expand infrastructure in this field are crucial, as highlighted by Ameh et al. [17].

With only one facility in the entire country being fully dedicated to pediatrics and a mere two facilities equipped with operating rooms and postoperative recovery units dedicated to children in the public sector, the situation underscores the neglect of specialized pediatric infrastructure, which is essential to perform quality and safe surgery [6]. The limited prioritization of pediatric-specific surgical needs, even in tertiary institutions, leads to delays in the management of children needing surgery. Of interest, our study’s findings highlight a notable deficit in material resources at tertiary hospitals, especially compared to secondary-level facilities and private clinics. This disparity, which is most likely often due to the reliance on faith-based or partner-supported secondary institutions, underscores a significant gap in essential equipment at higher-level hospitals, which should ideally be best equipped to manage complex pediatric cases. It should also be added that level-2 regional hospitals received substantial support through a government policy to respond to COVID-19, including a significant amount of equipment, particularly for critical care.

The assessed GAPS outcome parameters of pediatric surgical care in Burkina Faso show a mixed picture. Out of 26 facilities, 22 reported a 30-day follow-up rate above 50% after major procedures. This suggests that the majority of facilities maintain postoperative follow-up for a significant proportion of patients, reflecting efforts to ensure continuity of care. However, the fact that only 46% of institutions utilize capnography for ventilation monitoring raises concerns about the adequacy of respiratory care practices in a significant portion of the healthcare system. While follow-up rates in pediatric surgery are promising in Burkina Faso, the limited use of capnography, recognized as an essential safety tool, raises concerns, as its absence could contribute to higher risks of respiratory complications and poor outcomes in low-resource settings [18]. The limited implementation of minimally invasive techniques further highlights barriers to surgical gold-standard access, as these modalities are only available in one of the six tertiary-level hospital and in two private clinics (Table 4). This lack of advanced surgical capabilities restricts the range of conditions that can be efficiently treated. Similarly, a study on laparoscopic surgery in low- and middle-income countries identifies challenges such as insufficient training and institutional capabilities, which further hinder the widespread adoption of these techniques [19].

Finally, education and training are critical to improving pediatric surgery capabilities. While some third-level hospitals are affiliated with universities and offer formal training programs, our study shows that the overall participation in continuing medical education in Burkina Faso is low. This suggests a need for systemic improvements to ensure that healthcare professionals stay updated on best practices in pediatric care. Indeed, as evidenced in many low- and middle-income countries, the lack of comprehensive pediatric surgery residency or fellowship programs presents significant barriers to accessing high-quality care [20].

Last but not least, the observed limited research activities across the country suggest an opportunity to strengthen the evidence-based improvements in pediatric surgery, which could help to guide future reforms and enhance the quality of care.

Upon comparison of the various levels of the healthcare system, in our study, we observed notable differences. Our findings highlight deficiencies in infrastructure and equipment within tertiary-level facilities, which handle the majority of pediatric cases. These high-level facilities do not appear to be adequately equipped to manage the case volume and complexity, but have the most specialized human resources. In terms of surgical volume, only data from the Charles-de-Gaulle Pediatric Hospital in Ouagadougou are considered reliable: the total number of pediatric surgery cases between 2022 and 2024 amounted to 10′ 209, with 72 recorded deaths. However, in other hospitals, data are not disaggregated, and as such, pediatric surgical data cannot be identified. This currently represents a weakness in the health information system.

In contrast, secondary-level hospitals show to have sufficient equipment, largely due to collaborations and partnerships, but, inversely, lack of trained professionals, such as pediatric surgeons and anesthesiologists, most needed to utilize these resources effectively. These observations will hopefully advise the development of the upcoming National Strategy for Pediatric Surgery 2026–2030 of the Burkinabé Ministry of health, to ensure that decisions and resource allocation are optimized, to address these disparities and strengthen the pediatric surgical ecosystem.