Background:
Establishment of pediatric cardiac services in developing countries is a major challenge. Once established, it is even bigger a challenge to cater for the needs of very large populations. In Pakistan with population of 16 millions, about 4000 babies require urgent open heart surgery each year.

Objectives:
To analyze difficulties and propose solutions, in establishing a pediatric cardiac program.

Methods:
The Children’s Hospital Lahore is the only public sector children’s hospital in the country where we established a congenital cardiac program and neonatal interventions and open-heart surgeries are being performed. It is a multidisciplinary hospital, with all the support facilities. In a developing country, there are numerous challenges like paucity of centers and personnel, limited resources, overcrowding, illiteracy, and infection control.

Results:
Pediatric cardiac program at CH started in 1999. The problems faced include recruitment of trained staff and equipment and lack of resources for ongoing financial needs. So far we have performed surgery on >1500 children, with an overall mortality of 7% in the year 2008. The cost for an open heart surgery is about US $1200 and for a closed heart surgery is US $250. This is still too much for a poor patient. The current waiting list for routine open heart surgery is over 3 years.
Conclusions:
Despite improved infrastructure and skills, the logistics, affordability, staffing, late presentation, nutritional status, infection, and unfavorable economics continue to negatively influence the overall results. With continued determination and philanthropic support, establishment of pediatric cardiac program is still possible.