Despite surgical diseases comprising a large proportion of the global burden of disease, most people around the world are unable to obtain safe and affordable surgical or anesthesia care. In 2015, three major events highlighted the dire need for surgical care, particularly in LMICs: the Lancet Commission on Global Surgery, the World Bank's third edition of its Disease Control Priorities (DCP-3) publication, and the World Health Assembly Resolution 68.15.1, 2, 3 The Lancet Commission estimated that 5 billion people do not have access to safe and affordable surgical and anesthesia care when needed. Unacceptable disparities are seen between LMICs, where 94% of the population lacks surgical care, and HICs, where only 14.9% lack surgical access.2 The Lancet Commission proposed recommendations to improve access to safe, affordable surgical and anesthesia care in LMICs and provided a template for national surgical plans.

Despite advances in the prioritization of surgery globally, discussion of the surgical care of children was not included in these publications. Children, however, are disproportionately affected, and an estimated 1.7 billion children had no surgical healthcare access in 2017. In low-income countries (LICs) and LMICs, only 3% and 8%, respectively, of the pediatric population have access to surgery, compared to 85% of the pediatric population in HICs.4 The lack of safe surgical care means that mortality and morbidity rates can be high for easily treatable surgical conditions, such as appendicitis, fractures, hernias, and congenital anomalies.2,5

The lack of affordable and safe surgical or anesthesia care in LMIC is multifactorial. Inadequate infrastructure with poor roads, scarcity of safe water, and lack of reliable power and transportation are all contributing factors. Malnutrition, cultural beliefs, poverty as well as limited medical resources, facilities, and a trained workforce also all impact the ability to access safe and affordable surgical care.6, 7, 8

The unmet surgical need of the world's pediatric population is a public health matter. Humanitarian efforts by civil society organizations (CSO) and the voluntary sector are indispensable to addressing this gap in surgical access for the world's most vulnerable populations. Historically, humanitarian efforts have focused on directly delivering surgical services to underserved populations, but in recent years, they have expanded their services to workforce training, capacity building, infrastructure development, advocacy and policy engagement, and academic research.9 In this chapter, we will discuss the current roles undertaken by CSOs and the voluntary sector in global pediatric surgery.

The World Health Organization (WHO) in 2017 defined a civil society as “a social sphere separate from both the state and the market. The increasingly accepted understanding of civil society organizations (CSOs) is that of non-state, not-for-profit, voluntary organizations formed by people in that social sphere.” Examples of CSOs include: “Activist groups, charities, civic groups, campaigns, sports clubs, social clubs, community foundations, community/local associations, consumer organizations, cooperatives, churches, cultural groups, environmental groups, foundations, lobbies, men's groups, policy institutions, political parties, private voluntary organizations, professional associations, religious organizations, social associations, social enterprises, support groups, trade unions, voluntary associations, women's groups.”10