Although the waiting time has been assessed and characterised, our study has limitations. Regarding the research design limitations, the study was realized during a relatively short period and was monocentric. The time period between referral from primary care provider to consultation with a paediatric surgeon, has not included in the overall waiting time. This time period could be very variable and influenced by multiple factors linked to the patient and his or her entourage or to the health structures that refer the patient.

Concerning the impact limitations of the results, some specificities in our practice can influence the WT and so limitate the transposability of our results: frequencies of conditions, differences for the surgical indication, realisation of pre-anaesthetic consultation, and reception capacities of the department. Waiting time may be also significantly influenced by social and economic factors.

The mean WT mean in our study was 69.2 days, and most patients (62.6%) had a WT of less than two months. A WT of 3–6 months for surgery is regarded as excessive by several Organisation for Economic Co‑operation and Development (OECD) countries [2, 11].

The longest delay in our patients was during the time between when the surgery was proposed and the first pre-anaesthetic visit. Our institution offers a limited number of pre-anaesthetic consultations each week. Acquiring the proper laboratory tests for the pre-anaesthetic consultation may have also contributed to the delay in patient management.

In our study, WTs varied greatly depending on the patient’s condition to another. WTs do not always correspond with the severity of the patient’s condition [1]. The Saskatchewan classification system was established by a panel of Canadian paediatric surgeons and proposed WTs for certain conditions [1, 12]. Our study identified 22 conditions; the WT for 11 of these conditions exceeded the acceptable WT recommended by the Saskatchewan classification system. These 11 conditions had the shortest recommended WTs (Table 3).

A Canadian study that evaluated WTs according to the same classification system demonstrated that 27% of paediatric patients underwent surgery after the recommended waiting period [13]; however, it was difficult to compare waiting times between studies because the surgical management differed between study populations. For example, we treated anorectal malformations and omphaloceles beyond the neonatal period because our anaesthesia and intensive care departments were not equipped to handle these cases at an earlier age.

None of our patients required emergency surgery for disease-related complications. In contrast, a multicentre study established a correlation between long WTs for inguinal hernia repair and a higher incidence of hernia incarceration or emergency department visits [8]. A longer study in our department could certainly better assess the risk of complications when the waiting time is too long.

Our study identified several factors that contributed to longer WTs. Patients living in rural areas may have had significantly longer WT because the distance made it difficult for them to access our service. Moreover, the financial burden for traveling and other expenses, as well as the lack of people and places in town for receiving the patient and his family, may have forced families to return home prior to receiving complete care. The accessibility of paediatric surgical departments is a major issue in Africa because one-third of the population lives in rural areas, whereas 90% of paediatric surgeons practice in tertiary healthcare institutions located in the major cities [14].

Patients with comorbidities had significantly longer mean WT (100.9 days) than patients without comorbidities because comorbidities had to be managed prior to surgery, which compounded the total WT. Patients with more severe conditions likely had more comorbidities, which explained why these patients also had relatively longer mean WT compared with patients with less severe conditions. For example, patients with Hirschsprung’s disease had a mean WT of 84.4 days, whereas patients with hydroceles had a mean WT of 39.9 days. Among patients with anaemia requiring transfusion, the lack of blood products was identified as a key factor in prolonging WT [3].

The postponement of surgery also had a significant impact on the WT of our patients. The reasons for postponement are multifactorial [15]. In our study procedures were mostly postponed because the operating theatre was unavailable. In other studies there was also a too short operating time [3, 15]. Surgery is also commonly delayed when patients with respiratory infections or uncontrolled comorbidities cannot be cleared for surgery [15].

The combination of two phenomena favours the occurrence of long WTs: a supply of care limited by insufficient resources of the health system; a demand for care favoured by no or low patient participation in the costs of care [2]. Since 2006, patients up to 5 years of age in Niger are assured free access to healthcare; however, in public healthcare infrastructures there is a lack of human and material resources [16].

Some of the surgical indications in our study are managed with day surgery in other countries. In Nigeria and several OECD countries, day surgery constitutes more than 50% of all surgical activities [2, 9]. Day surgery development has been one of the solutions that proved effective in reducing significantly the surgical WT [6].

Overall, long WTs for elective procedures can be reduced by expanding care capacity, rationing and/or prioritising demand, and restructuring the intake assessment and/or referral process [4]. While augmenting health care supply with the appropriate human and material resources, it is necessary but not enough; reducing WT by acting on the demand of care is a more economic measure [17, 18]. In our context a second operating room is building and the department is the site of formation of paediatric surgeon. A waiting list for pre-anaesthetic consultation could also be established. Better patient management protocols in surgical departments should also be considered. An Indian study demonstrated that 39% of elective procedures were cancelled for preventable reasons [15]. Establishing a priority list with explicit guidelines may partially reduce the WT for patients with the most serious conditions [2, 4]. The priority list should account for the severity of the patient’s condition and his area of residence.