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Surgical, obstetric, and anaesthesia care saves lives, prevents disability, promotes economic prosperity, and is a fundamental human right. Session two of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region discussed financing strategies for surgical care. During this session, participants made a robust case for investing in surgical care given its cost-effectiveness, macroeconomic benefits, and contribution to health security and pandemic preparedness. Funding for surgical system strengthening could arise from both domestic and international sources. Numerous strategies are available for mobilising funding for surgical care, including conducive macroeconomic growth, reprioritisation of health within government budgets, sector-specific domestic revenue, international financing, improving the effectiveness and efficiency of health budgets, and innovative financing. A wide range of funders recognised the importance of investing in surgical care and shared their currently funded projects in surgical, obstetric, anaesthesia, and trauma care as well as their funding priorities. Advocacy efforts to mobilise funding for surgical care to align with the existing funder priorities, such as primary health care, maternal and child health, health security, and the COVID-19 pandemic. Although the COVID-19 pandemic has constricted the fiscal space for surgical care, it has also brought unprecedented attention to health. Short-term investment in critical care, medical oxygen, and infection prevention and control as a part of the COVID-19 response must be leveraged to generate sustained strengthening of surgical systems beyond the pandemic.
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Background: Pacific Island Countries (PICs) face unique challenges in providing surgical care. We assessed the surgical care capacity of five PICs to inform the development of National Surgical, Obstetric and Anaesthesia Plans (NSOAP). Methods: We conducted a cross-sectional survey of 26 facilities in Fiji, Tonga, Vanuatu, Cook Islands, and Palau using the World Health Organization - Program in Global Surgery and Social Change Surgical Assessment Tool. Findings: Eight referral and 18 first-level hospitals containing 39 functioning operating theatres, 41 post-anaesthesia care beds, and 44 intensive care unit beds served a population of 1,321,000 across the five countries. Most facilities had uninterrupted access to electricity, water, internet, and oxygen. However, CT was only available in 2/8 referral hospitals, MRI in 1/8, and timely blood transfusions in 4/8. The surgical, obstetric, and anaesthetist specialist density per 100,000 people was the highest in Palau (49.7), followed by Cook Islands (22.9), Tonga (9.9), Fiji (7.1), and Vanuatu (5.0). There were four radiologists and 3.5 pathologists across the five countries. Surgical volume per 100,000 people was the lowest in Vanuatu (860), followed by Fiji (2,247), Tonga (2,864), Cook Islands (6,747), and Palau (8,606). The in-hospital peri-operative mortality rate (POMR) was prospectively monitored in Tonga and Cook Islands but retrospectively measured in other countries. POMR was below 1% in all five countries. Interpretation: Whilst PICs share common challenges in providing specialised tertiary services, there is substantial diversity between the countries. Strategies to strengthen surgical systems should incorporate both local contextualisation within each PIC and regional collaboration between PICs. Funding: None.
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Introduction New Zealand health training institutions have an important role in supporting health workforce training programmes in the Pacific Region. Aim To explore the experience of Pacific Island country-based doctors from the Cook Islands, Niue, and Samoa, studying in New Zealand's University of Otago distance-taught Rural Postgraduate programme. Methods Document analysis (16 documents) was undertaken. Eight semi-structured interviews were conducted with Pacific Island country-based students. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately, followed by a process to converge and corroborate findings. Results For Pacific Island countries with no previous option for formal general practice training, access to a recognised academic programme represented a milestone. Immediate clinical relevance and applicability of a generalist medical curriculum with rural remote emphasis, delivered mainly at a distance, was identified as a major strength. Although technologies posed some issues, these were generally easily solved. The main challenges identified related to the provision of academic and other support. Traditional university support services and resources were campus focused and not always easily accessed by this group of students who cross educational pedagogies, health systems and national borders to study in a New Zealand programme. Study for individuals worked best when it was part of a recognised and supported Pacific in-country training pathway. Discussion The University of Otago's Rural Postgraduate programme is accessible, relevant and achievable for Pacific Island country-based doctors. The programme offers a partial solution for training in general practice for the Pacific region. Student experience could be improved by tailoring and strengthening support services and ensuring their effective delivery.
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Medicina General , Médicos Generales , Servicios de Salud Rural , Medicina General/educación , Humanos , Nueva Zelanda , Islas del PacíficoRESUMEN
Introduction: Thoracoscopic repair of esophageal atresia and tracheo-esophageal fistula (EA/TEF) is challenging. We addressed this by designing a fully synthetic simulator of the procedure and described the design process and how its content validity was assessed. Methods: An iterative design and assessment of content validity was undertaken in three stages. Data were collected from participants who trialed the model and completed a survey of their experience (adapted from Barsness et al.). Results: The model was trialed by participants of varying experience. Each design refinement improved the model's fidelity and validity. For the last iteration of the simulator, the observed averages (out of a maximum of 5) were: value as a training tool 4.8, relevance 4.6, physical attributes 4.5, realism of material 4.25, realism experience 4.17, and ability to perform tasks 3.77. Conclusion: An iterative design process based on end-user feedback has led to a synthetic simulator that has achieved a high level of content validity. This model has advantages over other EA/TEF simulators in that it is relatively inexpensive and does not use animal tissue, thus removing ethical and procurement issues. It was rated highly for its value and relevance to training.
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Simulación por Computador , Atresia Esofágica/cirugía , Toracoscopía/métodos , Fístula Traqueoesofágica/cirugía , Atresia Esofágica/diagnóstico , Femenino , Humanos , Recién Nacido , Masculino , Encuestas y Cuestionarios , Fístula Traqueoesofágica/diagnósticoRESUMEN
Pacific island countries and territories (PICTs) face the challenge of a growing cancer burden. In response to these challenges, examples of innovative practice in cancer planning, prevention, and treatment in the region are emerging, including regionalisation and coalition building in the US-affiliated Pacific nations, a point-of-care test and treat programme for cervical cancer control in Papua New Guinea, improving the management of children with cancer in the Pacific, and surgical workforce development in the region. For each innovation, key factors leading to its success have been identified that could allow the implementation of these new developments in other PICTs or regions outside of the Pacific islands. These factors include the strengthening of partnerships within and between countries, regional collaboration within the Pacific islands (eg, the US-affiliated Pacific nations) and with other regional groupings of small island nations (eg, the Caribbean islands), a local commitment to the idea of change, and the development of PICT-specific programmes.
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Atención a la Salud , Neoplasias del Cuello Uterino/epidemiología , Niño , Femenino , Humanos , Islas del Pacífico/epidemiología , Papúa Nueva Guinea/epidemiología , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/cirugía , Indias Occidentales/epidemiologíaRESUMEN
This Series paper describes the current state of cancer control in Pacific island countries and territories (PICTs). PICTs are diverse but face common challenges of having small, geographically dispersed, isolated populations, with restricted resources, fragile ecological and economic systems, and overburdened health services. PICTs face a triple burden of infection-related cancers, rapid transition to lifestyle-related diseases, and ageing populations; additionally, PICTs are increasingly having to respond to natural disasters associated with climate change. In the Pacific region, cancer surveillance systems are generally weaker than those in high-income countries, and patients often present at advanced cancer stage. Many PICTs are unable to provide comprehensive cancer services, with some patients receiving cancer care in other countries where resources allow. Many PICTs do not have, or have poorly developed, cancer screening, pathology, oncology, surgical, and palliative care services, although some examples of innovative cancer planning, prevention, and treatment approaches have been developed in the region. To improve cancer outcomes, we recommend prioritising regional collaborative approaches, enhancing cervical cancer prevention, improving cancer surveillance and palliative care services, and developing targeted treatment capacity in the region.
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Detección Precoz del Cáncer , Neoplasias/epidemiología , Humanos , Neoplasias/patología , Neoplasias/terapia , Islas del Pacífico/epidemiología , Cuidados PaliativosRESUMEN
From 2012 to 2014, 18 New Zealand general and rural medical practitioners worked in the Cook Islands on a visiting programme to achieve the following objectives: (1) assess and assist with the capacity of the Cook Islands medical workforce; (2) assist with the infrastructure to improve clinical records and audit; (3) assist with developing a General Practice training programme for the Cook Islands; and (4) develop a training post for the Division of Rural Hospital Medicine in the Cook Islands. Each visiting doctor spent a minimum of 4 weeks in the Cook Islands. This study presents the results of a questionnaire undertaken to evaluate their experiences. There were challenges, but for most, the experience was overwhelmingly positive. There were synergies with rural practice in New Zealand. Working alongside local clinicians and being immersed in the Cook Islands health system led to better understanding of the Cook Islands perspective of rural and remote medicine. The findings provide insight into the early phase of an ongoing programme between the Cook Islands Ministry of Health and New Zealand, which has led to the development of a reciprocal training programme for generalist doctors.
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Creación de Capacidad , Medicina General/educación , Capacitación en Servicio , Rol del Médico , Servicios de Salud Rural , Humanos , Nueva Zelanda , Polinesia , Encuestas y CuestionariosAsunto(s)
Creación de Capacidad/organización & administración , Educación Médica/organización & administración , Personal de Salud/educación , Promoción de la Salud/organización & administración , Competencia Profesional/normas , Educación en Salud/organización & administración , Humanos , Programas Nacionales de Salud/organización & administración , Nueva Zelanda , Rol ProfesionalRESUMEN
INTRODUCTION: Conventional surgical aid to emerging countries often does little to build capacity or infrastructure. An evolving model in the South Pacific has been designed to promote local expertise by training local surgeons to a high standard and helping establish sustainable pediatric surgical services in those regions. This review identifies the key elements required to improve and expand local specialist pediatric surgical capacity in Vanuatu. It highlights some of the challenges that face external agencies in helping to create sufficient local infrastructure to achieve these goals and describes how the impediments can be overcome. METHODOLOGY: We conducted a review of the program that provides a sustainable pediatric surgical service to the small and poor Pacific nation of Vanuatu through the involvement and support of the Pacific Island Project administered by the Royal Australasian College of Surgeons. RESULTS: A needs assessment must be done from the recipient's perspective and can be achieved by collaboration between an external agency and existing local surgeons. The key to a sustainable service is identifying and training high quality young indigenous doctors early and providing mentorship and support, including after their return. A sustainable and viable service requires an adequately resourced position for the new surgeons(s) within a framework of a long term strategic plan for the specialty and adequate infrastructure in place on their return. Development of rapport with government and influencing strategic health priorities is a prerequisite of a new national specialty service. CONCLUSIONS: (1) Establishing long term viable pediatric surgical capability can only be achieved through the local health system with local leadership and ownership. (2) Internal capability includes governance, alignment with ministry of health priorities and policies, and effective clinical leadership. (3) Selection of person(s) to be trained is best done early, and he/she must be supported throughout training and afterwards. (4) Long term dependence on a single person makes the service vulnerable. (5) Ultimately, a service configuration that ensures children have timely access to quality specialist advice and which reflects the needs of the population is the main determinant of clinical outcomes.
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Cirugía General/organización & administración , Liderazgo , Pediatría/organización & administración , Niño , Humanos , VanuatuRESUMEN
INTRODUCTION: The unmet global burden of surgical disease is substantial. Currently, two billion people do not have access to emergency and essential surgical care. This results in unnecessary deaths from injury, infection, complications of pregnancy, and abdominal emergencies. Inadequately treated surgical disease results in disability, and many children suffer deformity without corrective surgery. METHODS: A consensus meeting was held between representatives of Surgical and Anaesthetic Colleges and Societies to obtain agreement about which indicators were the most appropriate and credible. The literature and state of national reporting of perioperative mortality rates was reviewed by the authors. RESULTS: There is a need for a credible national and/or regional indicator that is relevant to emergency and essential surgical care. We recommend introducing the perioperative mortality rate (POMR) as an indicator of access to and safety of surgery and anaesthesia. POMR should be measured at two time periods: death on the day of surgery and death before discharge from hospital or within 30 days of the procedure, whichever is sooner. The rate should be expressed as the number of deaths (numerator) over the number of procedures (denominator). The option of before-discharge or 30 days is practical for those low- to middle-income countries where postdischarge follow-up is likely to be incomplete, but it allows those that currently can report 30-day mortality rates to continue to do so. Clinical interpretation of POMR at a hospital or health service level will be facilitated by risk stratification using age, urgency (elective and emergency), procedure/procedure group, and the American Society of Anesthesiologists grade. CONCLUSIONS: POMR should be reported as a health indicator by all countries and regions of the world. POMR reporting is feasible, credible, achieves a consensus of acceptance for reporting at national level. Hospital and Service level POMR requires interpretation using simple measures of risk adjustment such as urgency, age, the condition being treated or the procedure being performed and ASA status.
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Anestesia/normas , Periodo Perioperatorio/mortalidad , Indicadores de Calidad de la Atención de Salud , Procedimientos Quirúrgicos Operativos/normas , Accesibilidad a los Servicios de Salud , Mortalidad Hospitalaria , Humanos , Alta del Paciente , Ajuste de Riesgo , Factores de TiempoRESUMEN
We describe the case of a boy who had 9 recurrences of intussusception, for which no pathological lesion at the leadpoint was identified. A contrast follow-through study revealed a follicular/nodular mucosal pattern, particularly prominent in the terminal ileum and caecum. Patients with multiple recurrences usually have an identifiable lesion at the leadpoint, but sometimes recurrences may be due to lymphoid hyperplasia, as presumed in our case. No further recurrences occurred after a two month tapering course of oral prednisolone.
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Glucocorticoides/uso terapéutico , Enfermedades del Íleon/tratamiento farmacológico , Intususcepción/tratamiento farmacológico , Enfermedades Linfáticas/complicaciones , Prednisolona/uso terapéutico , Agammaglobulinemia/complicaciones , Humanos , Enfermedades del Íleon/diagnóstico , Lactante , Intususcepción/etiología , Laparoscopía , Masculino , RecurrenciaAsunto(s)
Hernia Ventral/cirugía , Laparoscopía/métodos , Técnicas de Sutura , Adolescente , Ciclismo/lesiones , Humanos , Masculino , Mallas QuirúrgicasAsunto(s)
Traumatismos Abdominales/complicaciones , Hernia Ventral/etiología , Tomografía Computarizada por Rayos X/métodos , Traumatismos Abdominales/diagnóstico por imagen , Adolescente , Diagnóstico Diferencial , Estudios de Seguimiento , Hernia Ventral/diagnóstico por imagen , Humanos , MasculinoRESUMEN
AIM: To determine trends in the scope of use of minimally invasive surgical (MIS) techniques in children as a predictor of future operative workload and operating theatre requirements. METHOD: A retrospective review was conducted of all paediatric patients less than 16 years of age who underwent minimally invasive surgical procedures at Christchurch Hospital, New Zealand between 1996 and 2007. RESULTS: There were 1693 children who received 1826 MIS procedures during a period in which 11,893 operative procedures were performed. MI case-weights, an indirect measure of the financial burden and technical difficulty of the procedures, represented 29% of the workload of the unit overall. There was a rapid rise of the number of MIS procedures from 1996 to 2000, but since then the scope and volume has changed little. CONCLUSION: Use of MIS in children increased rapidly until 2000 since which time it has remained relatively constant. Recent additional applications have involved a small number of rare low-volume and more complex procedures. These observations may assist in the planning of theatre allocation requirements for MIS in children.
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Auditoría Clínica , Procedimientos Quirúrgicos Mínimamente Invasivos/tendencias , Niño , Humanos , Nueva Zelanda , Estudios RetrospectivosRESUMEN
BACKGROUND: The aim of the study was to review the degree to which the long-term outcome and ongoing morbidity in Currarino syndrome (CS) has been established. METHODS: Analysis of previously published reports that have included long-term outcome data in CS and review of five additional patients with CS. RESULTS: Overall, long-term outcomes of children born with CS are not well described. Malignancy has been reported in six children of approximately 300 CS patients: four children with malignancy had a recurrence after primary excision. Malignancy has also occurred in four adults. Ongoing morbidity related to constipation, faecal incontinence, neurogenic bladder, urinary incontinence and presacral abscess, and more rarely meningitis, brain metastases, developmental delay and unusual gait. Almost certainly, previous reports have under-estimated the true incidence of these problems, given the methodology and focus of these series. CONCLUSIONS: There is paucity of information on the long-term outcomes in CS. Few authors have focused on ongoing symptoms, such that we speculate the true incidence of long-term urinary and bowel dysfunction may have been under-estimated in CS. Greater emphasis on the functional assessment of these systems during childhood may help predict the long-term outcome in CS. The most severe cases are diagnosed during infancy and childhood, and these are also the ones who are more likely to have ongoing long-term morbidity.