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Barriers to Surgical Care Among Children in Somaliland: An Application of the Three Delays Framework

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There are complex barriers that increase delays to surgical care in low- and middle-income countries, particularly among the vulnerable population of children. Understanding these barriers to surgical care can result in targeted and strategic intervention efforts to improve care for children. The three-delay model is a widely used framework in global health for evaluating barriers associated with seeking (D1), reaching (D2), and receiving health care (D3). The goal of our study is to evaluate reasons for delays in the surgical care for children in Somaliland using the three-delay framework.


Data were collected in a cross-sectional study in Somaliland from 1503 children through a household survey. Among children with a surgical need, we quantified the number of children seeking, reaching, and receiving care along the surgical care continuum, according to the three-delay framework. We evaluated predictors of the three delays through a multivariate logistic regression model, including the child’s age, gender, village type, household income level, region, and household size.


Of the 196 children identified with a surgical condition, 50 (27.3%) children had a delay in seeking care (D1), 28 (20.6%) children had a delay in reaching care (D2), and 84 (71.2%) children had a delay in receiving care (D3), including 10 children who also experienced D1 and D2. The main reasons cited for D1 included seeking a traditional healthcare provider, while lack of money and availability of care were main reasons cited for D2. Significant predictors for delays included household size for D1 and D3 and condition type and region for D2.


Children in Somaliland experience several barriers to surgical care along the entire continuum of care, allowing for policy guidance tailored to specific local challenges and resources. Since delays in surgical care for children can substantially impact the effectiveness of surgical interventions, viewing delays in surgical care under the lens of the three-delay framework can inform strategic interventions along the pediatric surgical care continuum, thereby reducing delays and improving the quality of surgical care for children.

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We want to thank the Global Initiative for Children’s Surgery (GICS) for its support of this work. GICS (www.globalchildrenssurgery.org) is a network of children’s surgical and anesthesia providers from low-, middle-, and high-income countries collaborating for the purpose of improving the quality of surgical care for children globally.


Funding was provided by Duke Global Health Institute, Duke University and Baylor University.

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Correspondence to Emily R. Smith.

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Concepcion, T.L., Dahir, S., Mohamed, M. et al. Barriers to Surgical Care Among Children in Somaliland: An Application of the Three Delays Framework. World J Surg (2020). https://doi.org/10.1007/s00268-020-05414-4

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