Access to quality healthcare is a basic right of every individual both young and old. In fact, WHO’s Healthcare Act of 1946 states that right to healthcare is a fundamental human right which should be available and accessible for everyone when and wherever needed. However, due to multiple reasons ranging from lack of infrastructure, manpower to cost of healthcare delivery; healthcare is not always available to people in India. According to the World Bank,fve billion people—two thirds of world population—lack access to safe and affordable surgical, anaesthesia and obstetric (SAO) care while a third of the global burden of disease requires surgical and/or anaesthesia decision-making or treatment.
Paediatric Surgical Care
India currently faces several challenges with regards to healthcare facilities in rural areas; access to paediatric surgical care is one of them. Although there are varied reasons for this, the chief among them are lack of paediatric surgeons. Sadly, the paediatric surgical care providers are often located at the district hospitals or the nearest city. “More than 80 per cent of the children’s surgical care is usually trauma and other emergencies,” says Prof Vrisha Madhuri, Sr Professor, Head Paediatric Orthopaedic Surgery, CMC-Vellore. Other reasons for seeking surgical care are infections, congenital problems, deformities and neuromuscular problems arising from either congenital or acquired causes. “Children in India as well as other LMIC have very poor access to surgical care because their surgical care is available mostly in metros and larger cities,” she added.
In case of surgical emergency, the paediatric patient has to be rushed to the city for further treatment. This results in heavy loss to lives during emergencies and puts additional pressure on parents and also on the specialist hospitals that are already overcrowded. “We find that most children especially in rural areas are not able to access orthopaedic healthcare when it lies beyond 10 km from their home,” Dr Madhuri explained. One of the ways to greatly narrow down these difficulties and increase access to care is by empowering available manpower to provide surgical care.
One such commendable idea is the Providers course for Children’s Surgery conceived by Prof Kokila Lakhoo, Consultant Paediatric Surgeon, University of Oxford, Oxford University Hospitals and Prof Madhuri; at the Global initiative for Children’s Surgery (GICS) meeting at the Royal College of Surgeon in London in May 2016.
On hearing of this unique initiative, Dr Alexander Thomas, President, AHPI felt it would be an excellent way to improve quality of healthcare delivery at the grassroots. Having closely worked with the government of Karnataka over many years, and also having been the Secretary of the Task Force for health policy, he was able to convince the then Principle Secretary, Health, Ajay Seth and the present Secretary Javed Akhtar of the usefulness of this project.
“We have been doing outreach work to provide training for surgeons in remote areas as part of mission in Vellore. In 2016, we planned a new initiative which was meant to reach out to govt district centers by providing training for surgical teams which included nurses, anaesthetists, orthopaedic and general surgeons. We soon realized that the problem is vast and there was a need to train trainer teams so that there could be a cascade effect and also each trainer team could locally connect with district hopsitals to provide consultations and referral services for the local district providers,” says Prof Madhuri.
When Prof Madhuri shared her concerns with Dr Thomas, he agreed to the need and decided to make the course a reality. With his vision, Karnataka govt became the first state to agree to this initiative, and were part of the pilot training projects in Vellore. In fact, with AHPI and Dr Thomas’s guidance, the government at the administrative levels supported the program and funded the trainees.
Speaking about the nature of the course, Dr Lakhoo said “The format of the course is one of small group breakout sessions addressing skill acquisition and reinforcement and is taught by a multidisciplinary faculty. Each breakout session contains guidance on equipment and props needed for the session (most of which is widely available), guidance on how to teach the session and the learning objectives to be achieved.” After training a few district Hospital teams, the trio team consisting of the Royal College of surgeons, CMC Vellore and the Bangalore Medical College hosted a ‘training of trainer’ course in which teams from other parts of the country and from abroad were trained. Through this course professional teams which include a paediatrician, general surgeon, orthopaedic surgeon, anaesthetist and nurse to handle paediatric emergencies, were trained.
The trainers were paediatric surgeons, orthopaedists, anaesthetists and nurses from BMRCI, Indira Gandhi Institute, Bangalore and CMC, Vellore. “The sessions dealt with childhood emergency medications like analgesics and sedatives, triaging during paediatric emergencies and dosing. Other upskills like fastening hip spica/ immobilization, intercostal drainage tube insertion, vascular access and paediatric airway management were explicated using mannequins,” Dr Lakhoo explained.
The course content and materials were closely specified to assist delivery by local faculty. “Interest in running this course has been expressed by centres in countries like Malawi and Ethiopia to establish their providers course for Children’s Surgery in District General Hospitals,” Dr Lakhoo said. As a whole, the out-turn of this course and the training camps were highly meritorious.
Speaking on the objectives of the course, Dr Lakhoo added, “The whole plan is to take this course worldwide with CMC-Vellore as the super hub and every country create a hub and spoke model using the specialist hospital as a hub and the district hospital as a spoke.”
May 2016 – Conception of the CMC-Vellore RCSENG course after the first Global Initiative for Children’s Surgery meeting at Royal College of Surgeon’s, England.
June 2017 and May 2018 – Preparation of the draft manual and its initial implementation.
February 11, 2019 – Richard Stewart, President British Association of Paediatric Surgeons and Prof Lakhoo who is also Chair, GCIS along with educationist Gill Vessey meet Indian peer professionals like Prof Anand Alladi, Professor and Head of Department, Paediatric Surgery, Deepti Vepakomma, Associate Professor, Bangalore Medical College & Research Institute (BMCRI), Prof Madhuri and the local team of professionals to discuss further steps.
February 13, 2019 – One-day program on “Training the Trainers” course conducted by Vessey.
February 14, 2019 – The Surgical provider course with 26 delegates comprising 5 trainee teams from 3 different states viz, Chattisgarh, Karnataka and Tripura.
February 15 and 16, 2019 – An interactive session with the subject matter experts and the delegates on crucial topics like infective pathology, treating congenital anomalies, caudal analgesia, safe practices in OT, stomal care, critical care, pre and post-operative care. Expository inputs on resection procedures like herniotomy, orchidopexy with reference to WHO practice checklist were discussed to apprise paediatric doctors and nurses as well.
GICS and BAPS – The helping hand
The Lancet Commission on Global Surgery reports that about 5 billion people in the LMIC do not have access to affordable and quality surgical care. One half of this population are children. The British Association of Paediatric Surgeons (BAPS) and GICS along with The Royal College of Surgeons of England have been working together for better access to surgery across the globe.
In fact, BAPS has supported and trained paediatric surgeons from the LMIC by providing funded scholarships and fellowships to trainees from Africa, Asia, South East Asia and Middle East. Dr Stewart, the President of BAPS said that the institution trains physicians by conducting annual training courses and medical conferences in these countries like the Pan-African paediatric surgery Association, ASEAN countries of South East Asia and the SAARC countries of Asia Conferences. “We will continue to support International training and the development of partnerships with LMIC surgical associations,” confirmed Dr Stewart. “Collaborating with the RCSEng International Affairs Committee and with contacts established through the GICS we will take the Providers Course for children’s Surgery in District General Hospitals to other centers within India and worldwide. BAPS will also continue to develop partnerships, providing training with the aim of LMIC centers themselves becoming independent training centers,” he added. The GICS and BAPS have plans to further their cause by forming partnership programs with the local governmental organisations and equip these nations to be self-sustaining in paediatric surgical care and child-patient care.
Impact of the Course
It is too soon to assess in absolute numbers what impact this cources has had on the availability of pediatric surgical care but a study is underway and will soon be able to answer this very question. “The project adopted and funded by the government of Karnataka trained ten teams and plans to train more children’s hospitals as trainers creating a cascade effect. Global Initiative for Children’s Surgery endorsement has resulted in expressed interest from Africa and South-Asia,” shares Dr Lakhoo.
In addition the course manual, with inputs from Oxford trainers, is being submitted for WHO endorsement. This will further help to translate the vision of GICS and take this course global.
Goodman LF, St-Louis E, Yousef Y, Cheung M, Ure B, Ozgediz D, Ameh EA, Bickler S, Poenaru D, Oldham K, Farmer D. The global initiative for children’s surgery: optimal resources for improving care. European Journal of Pediatric Surgery. 2018 Feb;28(01):051-9.