where insurance cover or government subsidy is scarce, the costs incurred in running a program have to be met with largely by payments realized from the patients themselves A negative balance sheet may be looked at indulgently by the organization at the start, but sustained losses are not acceptable for long Financial viability is therefore a crucial consideration for a surgeon running a pediatric program in an LMIC, and this often governs the choice of patients who would be considered for surgery Because of these considerations, reducing costs of care is central to the viability of a program Table 88.5 presents strategies for reduction of costs of cardiac catheterization and Table 88.6 presents costcontainment strategies for pediatric cardiac surgery and intensive care Table 88.6 Cost Containment Strategies in Cardiac Surgeries and Intensive Care Source of Solutions Expense Reducing cost Maximize information from preprocedural echocardiograms, prudent use of cardiac magnetic of resonance imaging, computed tomography, and diagnostic catheterization and angiography preoperative investigations Cost of Greater use of off-pump operations whenever feasible (e.g., cavopulmonary shunt and consumables Fontan) Resterilization and reuse of cannulae and tubing, meticulously avoiding wastage of suture material Cost of Handcrafted conduits instead of commercially available conduits; Use of pericardium of Dacron prosthetic instead of polytetrafluoroethylene patches; efforts to repair valves as far as possible instead of implants replacing them; Using low cost locally manufactured products (e.g., the TTK Chitra heart valve79) Blood Consciously minimizing transfusion during open heart operations products Delayed Pragmatic case selection strategies, careful preoperative assessment for comorbidities, ensuring postoperative meticulous repair with no residual lesions, fast tracking strategies in low-risk cases recovery A critical element in establishing a new pediatric heart program involves pediatric cardiac intensive care In most LMICs, pediatric cardiac intensive care is yet to take roots as a distinctive discipline As a result, many models exist Pediatric heart programs are often attached to well-established adult cardiology, and cardiac surgery programs and postoperative care is sometimes delivered in a common setting with shared space, infrastructure, and personnel This model has several limitations because of major differences in care of adult and pediatric cardiac surgical patients.68 As the proportion of operated infants and newborns increase, it is imperative to designate a dedicated space for pediatric cardiac intensive care.68 A number of specific challenges need to be overcome in developing a postoperative unit in LMIC environments, and a detailed blueprint has been published previously.69 In addition to infrastructure, equipment, and personnel, it is vital to establish robust systems and protocols for patient assessment and monitoring, specific procedures and emergencies, communications, nurse training, and infection control Integrating Pediatric Health Care Into Universal Health Care Models Universal health coverage refers to the existence of a legal mandate for universal access to health services together with evidence indicating that the vast majority of the population has meaningful access The ability of a country to provide universal health care for all its citizens is a powerful indicator of its development Because comprehensive pediatric heart care that seeks to address all forms of pediatric heart disease is extremely resource intensive, only selected advanced economies with robust health systems and high gross domestic product can provide care for all cardiac conditions that affect children Even here, it can be quite challenging to provide comprehensive care for every single child with heart disease regardless of complexity.70 There are a number of challenges when it comes to developing a model that includes pediatric heart disease in universal health care packages They are: Competing pediatric health priorities that require fewer resources The massive burden of pediatric heart disease Paucity of comprehensive pediatric heart programs that can deliver costeffective pediatric care and their unfavorable geographic distribution A wide spectrum of possibilities results from a combination of a large variety of individual congenital heart defects and additional comorbidities This makes it difficult to develop a framework for prioritizing and delivering treatment under universal health care packages For LMICs it is necessary to develop a comprehensive national plan for pediatric heart disease that integrates developing new programs that are distributed in accordance with geographic needs, capacity building in all domains of pediatric heart care, and a pragmatic coverage plan that prioritizes potentially serious but correctable conditions.70 Recognizing the fact that this could take some years to establish, interim strategies that involve mobilizing all resources, public and private to deliver care should be implanted Training Programs to Suit the Needs of Pediatric Heart Programs in Low- and Middle-Income Countries One of the major obstacles to delivering care for children with heart disease in LMICs is the shortfall in trained personnel.71 There is a substantial deficiency of trained pediatric cardiologists, cardiac surgeons, anesthesiologists, and intensivists There is also severe shortfall of supporting nursing and technical staff such as perfusion technologists In the coming years this shortfall is likely to intensify further as the demands for newer pediatric heart programs grow Until recently, most doctors aspiring to become pediatric cardiologists or pediatric cardiac surgeons sought overseas training in North America, Europe, Australia/New Zealand, Egypt, and South Africa This is now becoming increasingly difficult Given the vast differences in the patient profile and health care environments, training programs in advanced nations do not prepare trainees for the challenges in low-resource environments Furthermore, a substantial proportion of trainees from the LMICs do not return to their countries of origin For these reasons it is imperative to establish robust training programs in various disciplines of pediatric cardiac care in LMICs Although a beginning has been made in selected institutions in a few countries (such as India, Sri Lanka, and Malaysia) to establish training programs in some of the disciplines (pediatric cardiology), much needs to be done.72–74 The situation with pediatric cardiac surgery is especially worrisome because the training period is long and perceptions that employment and career opportunities are unattractive.71 There needs to be a concerted effort on the part of professional bodies and health policy makers toward capacity building to address future requirements Quality Improvement Initiatives for Programs in Low- and Middle-Income Countries ... There are a number of challenges when it comes to developing a model that includes pediatric heart disease in universal health care packages They are: Competing pediatric health priorities that require fewer resources The massive burden of pediatric heart disease... to intensify further as the demands for newer pediatric heart programs grow Until recently, most doctors aspiring to become pediatric cardiologists or pediatric cardiac surgeons sought overseas training in North America, Europe,... Lanka, and Malaysia) to establish training programs in some of the disciplines (pediatric cardiology) , much needs to be done.72–74 The situation with pediatric cardiac surgery is especially worrisome because the training period is long and