Countries and colleges collaborate to improve access in Oceania and Southeast Asia

The independent island nations of the South Pacific (population 10,000–1 million each), Papua New Guinea (PNG) (7.5 million), and Timor-Leste (1.3 million) are low- and middle-income countries (LMICs) with limited access to safe, affordable surgery and anesthesia (see Table 1). Although all of these nations offer free national health care coverage, a high proportion of their populations still lack access to surgical care because of a shortage of appropriately trained health care workers, infrastructure, facilities, and geographic boundaries. The training of specialists in surgery, anesthesia, and obstetrics began through the University of PNG, Port Moresby, in 1975, but only since 1999 has this training been available at the Fiji School of Medicine, Suva, which is now part of Fiji National University for other Pacific Nations.^1,2 The Australia Timor-Leste Program of Assistance for Specialist Services (ATLASS) developed by the Royal Australasian College of Surgeons (RACS)  has employed a range of training programs in PNG, Fiji, Indonesia, and Malaysia to support a small cohort of physicians who have met specialist qualifications in the following areas: surgery, anesthesia, ophthalmology, obstetrics and gynecology (OB/GYN), and pediatrics.³

Table 1. LCoGS Metrics in Oceania

The Australia and New Zealand specialist medical colleges’ fellows have a long history of collaborating to provide support to the Asia-Pacific region, often through their specialty societies and in conjunction with specialty-specific nongovernment organizations. Since 1995, RACS, through its international development program RACS Global Health, has managed Australian aid-funded programs to provide specialist services, strengthen health care systems, build capacity, and provide continuing medical education and professional development for trained health care professionals.^4,5 The Australian and New Zealand College of Anaesthetists (ANZCA) has provided similar support, together with the Australian Society of Anaesthetists (ASA).⁶ The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) supports maternal health and the professional development of obstetricians in the Pacific, whereas the Australian College of Emergency Medicine has pioneered specialist training in PNG,^7,8 Myanmar,⁹ and the Pacific.

Today, surgical, anesthesia, and obstetric (SAO) specialists are in every country in this region with a population of more than 100,000, although the SAO density per 100,000 population is well below the desirable levels in most countries (see Table 1).¹⁰ The local health and clinical leadership has been established progressively in each of these island nations and is a direct result of localized training involving a university master of medicine qualification that represents at least four years of general specialist training, and two to four years of further subspecialist training (for example, in orthopaedics, urology, neurosurgery, or pediatric surgery).⁵ The workforce that provides safe anesthesia includes nonphysician anesthesia providers (NPAP), such as anesthesia scientific officers in PNG and nurse anesthetists in Timor-Leste, who typically work in the major health care centers under the supervision of a specialist anaesthetist.³

Principles of partnership and engagement

RACS Global Health and its partner colleges support the Paris Declaration on Aid Effectiveness and its five main principles: ownership, harmonization, alignment, results, and mutual accountability. The declaration was adopted in 2005 and expanded by the Pacific Islands Forum in 2007 to emphasize the need for development partners to make multi-year commitments and for a greater employment of local systems.^11,12 This collaboration has resulted in RACS-managed programs being increasingly and strategically directed in-country, incorporating needs assessment and evaluation of results led by local clinicians and their Ministries of Health.

The governance of Australian Aid programs demands that policies be put in place to ensure economical, efficient, and effective program outcomes; risk management; and procedures to manage adverse events and patient complaints. The RACS Global Health policies embrace inclusiveness, diversity, anti-discrimination, and child protection and govern team selection and standards—as well as requirements for transparency, sound financial management, evaluation and monitoring with timely reporting of outcomes, and assessment of impact (see Tables 2 and 3).

Table 2. Goals and outcomes alignment for RACS Global Health Program Development

Table 3. Generic evaluation and monitoring framework based on RACS Pacific Islands Program

Progress on global surgical metrics

In 2016, the RACS Annual Scientific Congress in Brisbane and the Pacific Islands Surgical Association (PISA) Symposium in Samoa provided an opportunity for member nations to present their first four The Lancet Commission on Global Surgery (LCoGS) metrics (see Table 1).¹³ Participants in these meetings agreed to advocate for using these metrics to inform national health planning in order to collect data to generate metrics 5 and 6, which are measures of catastrophic and impoverishing expenditure.

In September 2017, the PNG Medical Society’s 53rd medical symposium in Port Moresby centered on access to safe, affordable surgery and anesthesia and resulted in a demonstration of regional and cross-specialty consensus by the presidents of PISA, RACS, ANZCA, and RANZCOG.

Perspectives from the colleges and associations

PISA

PISA was inspired by global health forums organized at the RACS, which took place in Melbourne, Australia, in conjunction with the annual meeting of the Alliance for Surgery and Anesthesia Presence in October 2012, and a follow-up regional meeting in March 2013, which was attended by the president of the PISA, other surgeons from the Pacific, and representatives of RACS, ANZCA, and RANZCOG. This meeting achieved consensus on the importance of measuring perioperative mortality rate (POMR) as a global surgical/anesthesia metric.¹⁴

At their annual meeting in Nadi, Fiji, in April 2013, the leaders of Pacific region clinical services agreed to start collecting data pertaining to the POMR. This process was relatively straightforward, as it only required the collection of the number of operations performed in the operating theater (denominator), and the number of patients who died in the hospital after a procedure (numerator).¹⁴ Having proved its feasibility, POMR became the entry point for health care leaders in the Pacific to recognize the value of the other LCoGS indicators when presented by John G. Meara, MD, DMD, MBA, FACS, co-chair of the LCoGS, and David Watters, OBE, ChM, FRCSEd, FRACS, a co-author of this article, at the RACS Global Health triennial forum in October 2015. The success of this presentation resulted in a collaborative effort to report these metrics in the Pacific based on the involvement of senior clinicians working with heads of clinical services and directors of health.¹⁰ It is crucial that our Ministries of Health become more directly involved in this practice.

RACS

Since 1995, 17 countries across the Asia-Pacific have partnered with RACS Global Health projects and programs featuring clinical activities, which have resulted in the provision of consultant services to more than 221,733 individuals and more than 43,055 procedures performed (see Table 4). Education and training are key to providing these clinical services, with RACS Global Health facilitating more than 100 workshops and courses, including the American College of Surgeons Advanced Trauma Life Support^® course since 1993, resulting in the instruction of an estimated 2,087 health professionals across the Asia-Pacific. Visiting medical teams (VMTs) offer skills transfer, mentoring, and professional development and provide essential surgery, such as pediatric surgery, cardiac surgery, club foot management, and cleft lip and palate repair. The programs include the Pacific Islands program (PIP),⁴ the ATLASS program,³ The East Timor Eye Program (ETEP), and a Myanmar program that has included primary trauma care, emergency medicine, surgical skills, and the management of surgical emergencies (see Table 4). Other programs in Southeast Asia include the Asia Paediatric Surgery Education Project and the Eastern Indonesia program (Nusa Tenggara Timur and Papua).

Table 4. RACS Global Health-Managed Programs and Partners in the Asia-Pacific Region

RACS continues its more than 40-year relationship with PNG through a program in which its fellows visit as examiners, as members of VMTs, and through the provision of traveling fellowships and scholarships. Further discussions are ongoing to expand our support to health education and clinical services in PNG. Since 1988, the RACS scholarship program has benefited 225 individuals from 34 countries. Evaluation of the impact of returning scholars in their home country suggest that these scholars go on to become high-profile leaders, offering many new and expanded services to their patients.^15,16

ANZCA

Safe and affordable access to anesthesia is a pillar of global health. ANZCA has a number of programs and scholarships managed and supported by its Overseas Aid Committee. The focus of ANZCA’s educational outreach has been PNG, where teams of specialist anesthetists have been providing training, capacity development, and essential resources for more than 20 years. The ASA and the New Zealand Society of Anaesthetists (NZSA) have been providing similar support in the Pacific Islands, including Fiji, Tonga, the Solomon Islands, and Micronesia. The ASA Overseas Development and Education Committee former chair, Rob McDougall, MD, also has led global collaboration with the World Federation of Societies of Anaesthesiologists (WFSA). The building of in-country and within-region capacity to self-train has been paramount. We have further supported in-setting appropriate standards for practice, as well as assisting with resources and delivery of both education and care.⁶ We have collaborated with other colleges’ activities to help deliver primary trauma care courses.¹⁷ Throughout the Asia-Pacific region, anesthetists are partners in the delivery of all the surgical clinical outreach programs. To this end, they are involved in coordination with RACS, ASA, and other involved societies or specialist groups, such as Interplast or Orthopaedic Outreach. Anesthesia teaching and training also extends to Mongolia, Cambodia, and Laos.

We have implemented the successful global Lifebox pulse-oximetry project in the Pacific region through a partnership between Lifebox, ASA, NZSA, Interplast Australia & New Zealand, and ANZCA. A course developed by ANZCA faculty of pain medicine physicians, the Essential Pain Management Program, has not only become accessible to local educators across the Pacific, but also has been taken up globally following its success in the Asia-Pacific.¹⁸

Coordination between colleges and societies is necessary to avoid duplication of effort and assist in managing resources. The ANZCA and ASA overseas committees work collaboratively with the RACS Global Health Committee and have a single volunteering database for anesthetists.

One of the great achievements in addressing the anesthesia workforce’s needs has been the establishment of a WFSA Global Anesthesia Workforce Survey and map, to which ANZCA Fellows from the Asia Pacific have made a major contribution.¹⁹

RANZCOG

For 25 years, RANZCOG has supported OB/GYN colleagues and women’s health professionals in the Western Pacific region. From a logistical and organizational perspective, RANZCOG has found it mutually beneficial to collaborate with RACS in the PIP and ATLASS Programs. The RANZCOG also has provided education and training in gynecology surgery in PNG. Collaboration between colleges, as well as with regional partners and clinical organizations, strengthens and informs the training activities we provide both together and individually. Such a collaborative approach avoids the potential for silos, which can easily occur in the absence of effective communication and cooperation.

RANZCOG support for OB/GYN colleagues in the Pacific is typically delivered through networking and resources available to Pacific OB/GYN trainees, which continues through formal associate membership of RANZCOG and is available to graduates with the master of medicine qualification from the Pacific medical schools. At present, 52 practicing OB/GYN specialists in the Pacific have an associate membership in RANZCOG. Associate membership requires participation in a compulsory continuing professional development (CPD) program. Our evaluation of this program has revealed that it motivates and stimulates practicing OB/GYN specialists to focus on their professional development throughout their career while reducing feelings of isolation.²⁰ These specialists and trainees also have benefited from more than 150 scholarships or short-term traveling fellowships since 1995. Building a culture of research is another key goal to improve access to and delivery of care in the future. A research workshop has been made available regularly through the Pacific Society for Reproductive Health,²¹ and the first RANZCOG Global Health research grant was awarded in 2016 to a Papua New Guinean OB/GYN specialist.

A priority for RANZCOG is reducing maternal and perinatal mortality, and improving access to safe surgery and anesthetic services is fundamental in cases where cesarean section is the best or only option for the safety of the mother and her baby.²² Cesarean section rates are less than 10 percent in most Pacific Island countries; however, they are increasing to 20 percent in Fiji.

Scholarships

RACS, ANZCA, ASA, and RANZCOG offer short-term traveling fellowships to their annual scientific or subspecialty meetings, as well as a range of three- to 12-month hospital placements for specialist training or extended scope of practice. These opportunities are normally awarded after obtaining the relevant specialist qualification from the scholar’s home country. A number of specialty groups offer similar opportunities, such as Orthopaedic Outreach, the Asia Pacific Orthopaedic Association, Interplast Australia and New Zealand, and ANZCA’s pain faculty. RANZCOG has facilitated resident placements or exchanges, often with Australians or New Zealanders filling positions in the Pacific, rather than vice versa, due to licensure requirements. ANZCA also offers a scholarship to enable a trainee to accompany a VMT to expose them to global health issues, as do some orthopaedic VMTs.

Summary

The development programs described in this article have fostered professional networks between individuals and institutions across the Asia-Pacific. The specialist medical colleges, together with the scholarships they provide, have generated great opportunities for professional collaboration and partnership in the region. The work of the LCoGS, with its clearly defined messages and achievable metrics, has inspired surgeons, anesthetists, and obstetricians to become more engaged in public health and to advocate for safe, affordable, and timely access to emergency and essential surgery.¹³

To realize the goals of World Health Assembly Resolution 68.15 by 2030 and help our colleagues in the LMICs of our region deliver services to their populations, ongoing and sustained support is needed.²³ The leadership, ownership, and strategic direction of these initiatives should be established by the individual countries themselves. The people of the Pacific and Southeast Asia deserve quality health care, but this goal can only be achieved with access to safe, affordable surgery and anesthesia.

References

1. Watters DA, Theile DE. Progress of surgical training in Papua New Guinea to the end of the 20th century. Aust N Z J Surg. 2000;70(4):302-307.
2. Watters DA, Scott DF. Doctors in the Pacific. Med J Aust. 2004;181(11-12):597-601.
3. Guest GD, Scott DF, Xavier JP, et al. Surgical capacity building in Timor-Leste: A review of the first 15 years of the Royal Australasian College of Surgeons-led Australian Aid programme. ANZ J Surg. 2017;87(6):436-440.
4. Watters DA, Ewing H, McCaig E. Three phases of the Pacific Islands Project (1995–2010). ANZ J Surg. 2012;82(5):318-324.
5. Kevau I, Watters DA. Specialist surgical training in Papua New Guinea: The outcomes after 10 years. ANZ J Surg. 2006;76(10):937-941.
6. Cooper MG, Wake PB, Morriss WW, Cargill PD, McDougall RJ. Global safe anaesthesia and surgery initiatives: Implications for anaesthesia in the Pacific region. Anaesth Intensive Care. 2016;44(3):420-424.
7. Curry C, Annerud C, Jensen S, Symmons D, Lee M, Sapuri M. The first year of a formal emergency medicine training programme in Papua New Guinea. Emerg Med Australas. 2004;16(4):343-347.
8. Aitken P, Annerud C, Galvin M, Symmons D, Curry C. Emergency medicine in Papua New Guinea: Beginning of a specialty in a true area of need. Emerg Med (Fremantle). 2003;15(2):183-187.
9. Phillips GA, Soe ZW, Kong JH, Curry C. Capacity building for emergency care: Training the first emergency specialists in Myanmar. Emerg Med Australas. 2014;26(6):618-626.
10. Guest GD, McLeod E, William WRG, et al. Collecting data for global surgical metrics: A collaborative approach in the Pacific Region. BMJ Glob Health. 2017;2:e000376. doi:10.1136/bmjgh-2017-000376.
11. The Paris Declaration on Aid Effectiveness (2005) and the Accra Agenda for Action (2008). Available at: www.oecd.org/dac/effectiveness/34428351.pdf. Accessed November 21, 2017.
12. Pacific Aid Effectiveness. Principles Pacific Islands Forum Secretariat, 2007. Available at: www.forumsec.org/resources/uploads/attachments/documents/Pacific_Aid_Effectiveness_Principles.pdf. Accessed November 21, 2017.
13. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
14. Watters DA, Hollands MJ, Gruen RL, et al. Perioperative mortality rate (POMR): A global indicator of access to safe surgery and anaesthesia. World J Surg. 2015;39(4):856-864.
15. RACS Global Health. Sharing the benefits. Surgical News. 2014. Available at: www.surgeons.org/media/20877795/july_2014_sn_sharing_the_benefits.pdf. Accessed March 19, 2018.
16. Masterton JP, Moss D, Korin SJ, Watters DA. Evaluation of the medium-term outcomes and impact of the Rowan Nicks Scholarship Programme. ANZ J Surg. 2014;84(3):110-116.
17. Wilkinson D, McDougall R. Primary trauma care. Anaesthesia. 2007;62 Suppl 1:61-64.
18. Goucke CR, Jackson T, Morriss W, Royle J. Essential pain management: An educational program for health care workers. World J Surg. 2015;39(4):865-870.
19. Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth J. The WFSA Global Anesthesia Workforce Survey. Anesth Analg. 2017;125(3):981-990.
20. Ekeroma A, Walker C. Pacific Associate membership program evaluation. O&G. 2016;18(3):74.
21. Ekeroma AJ, Kenealy T, Shulruf B, McCowan LM, Hill A. Building reproductive health research and audit capacity and activity in the Pacific Islands (BRRACAP) study: Methods, rationale and baseline results. BMC Med Educ. 2014;19(6):121-130.
22. Dennis AT. Reducing maternal mortality in Papua New Guinea: Contextualizing access to safe surgery and anaesthesia. Anesth Analg. 2018;126(1):252-259.
23. World Health Organization. Emergency and essential care. Events. World Health Assembly. Strengthening emergency and essential surgical care and anaesthesia in the context of universal health coverage. Available at: www.who.int/surgery/wha-eb/en/. Accessed April 19, 2018.