Paediatric Surgery In Nepal: Improving Access to Children's Surgery
Jessica Ng (Paediatric Surgery Trainee, MBBS, BSc, MRCS, PG Cert)
May - June 2017
Background and objectives
Nepal is one of the poorest countries in Asia. Nepal’s challenging rugged and mountainous terrain which is vulnerable to catastrophic earthquakes has limited the development of its infrastructure. The country is landlocked by two of the most rapidly growing economic giants, China and India, and the neighbouring wealth has not spilled over to Nepal.
Development is severely inhibited by poor infrastructure combined with political unrest. A devastating earthquake in 2015 destroyed any progress made in infrastructure and recovery has been slow due to political instability. However, during my time in Nepal this year, there was a feeling of positivity among the current generation who have great community spirit which is driving recovery locally.
I have been part of six previous visits to Nepal with the charity Health Partnership Nepal (HPN) which is an institutional link between St George’s University Hospital and Nepal Medical College and Teaching Hospital (NMCTH). The Royal College of Surgeons of England International Travel Award supported another opportunity for me to travel to Nepal and work with our institutional partners to execute a sustainable strategy to improve access to better surgery for children. The objectives of the 2017 visit with a co-ordinated HPN team was to:
i) provide training and access to surgery for children in rural Nepal, and
ii) to complete a needs assessment of the paediatric surgery service at our partnering tertiary hospital, NMCTH.
Summary of activities
1. Rural surgical outreach project in Charikot
A government health post in Charikot was chosen as the location for the rural surgical outreach project. It is located in the Dolakha district which has a population of 180,000. It is 130 km west of Kathmandu and is approximately six hours drive from the capital. The health post was recently developed into a small hospital which offers free health care through a government and not-for-profit healthcare organisation collaboration. Services are delivered by Nepali doctors who are either government sponsored and/or employed by the not-for-profit organisation. With HPN, I helped organise a two-week visit which incorporated training for the local health care workers alongside provision of free surgical intervention for patients at the Charikot health post with a focus on children requiring surgery.
Six months prior to the visit to Charikot, local doctors referred any suitable paediatric surgical cases to our outreach project for further assessment and operative management if required. The HPN team consisted of paediatric and general surgeons, anaesthetists, theatre staff, junior doctors, nurses, medical students from UK and NMCTH. The first week of the visit allowed us to develop a rapport with the existing health care workers, initiate training with staff and complete the physical set up of the patient pathway. The training focussed on improving the theatre's environment which included overall theatre set up, cleaning/sterilisation techniques, safe instrument handling, introducing the Early Warning Scoring System and WHO checklist.
In the second week we started specialist assessment and operating over four days for paediatric and adult surgical cases. We provided daily 'protected training sessions' for both UK and Nepali healthcare workers and medical students. Training was tailored to the Nepali healthcare workers learning needs. We delivered interactive and practical sessions on post-operative care (from theatre to ward), paediatric trauma management, paediatric life support, management of common surgical conditions of childhood.
2. Needs assessment of paediatric surgery service at NMCTH
There are only three hospitals with paediatric surgical specialists in Nepal. Since 2009 HPN has been working with and supported a NMCTH surgeon, Dr Ritesh Shrestha, in his paediatric surgery training. Ritesh is now one of two paediatric surgeons working in a recently established paediatric surgery service at NMCTH. Over the last few years this service and supporting specialists teams, such as neonatal and paediatric intensive care units, have made impressive progress.
Prior to the 2017 visit, I worked with Ritesh via long distance communication to complete a comprehensive written needs assessment tool children’s surgery at NMCTH and in Nepal as provided by the Global Initiative for Children’s Surgery. The visit to Nepal provided the opportunity to undertake a site visit over a week. I met the teams involved to gain further understanding of the current set up of the paediatric surgery service, staff engagement (clinical and management) and institutional culture.
During the rural outreach project in Charikot we completed 31 operations. This included 15 children (86% male, median age 7 years (range 2-16 years). The majority of operations on children included inguinal herniotomies and circumcision for pathological phimosis. There was one complication of post-operative bleeding following circumcision who returned to theatre within 24 hours. Five children had their operation completed by the HPN team at NMCTH due to high risk co-morbidities or complexity of the procedure. All patients have been followed up at 6-8 weeks post operation by a lead clinician at Charikot Hospital with no further complications to date.
Qualitative feedback from Charikot Hospital staff was obtained two months following our visit. There has been notable improvement in cleaning/sterility techniques, safe instrument handling, post-operative care and adherence to WHO safety check list peri-operatively. The routine use of the WHO checklist during this outreach project also had an impact among the NMCTH surgical teams as the clinicians who worked with HPN started using the WHO checklist during their theatre lists. I feel this demonstrates the positive effect we had in changing behaviour through example as the benefits were recognised by those using the checklist.
It is recognised that one of the barriers to access to surgery for children is the lack of infrastructure within the healthcare system. There are no clear referral pathways for patients who need specialist care especially for the poorer community. The rural outreach project help develop a new link between Charikot Hospital (primary and secondary care) and NMCTH (tertiary care) for referral patients who require specialist care such as paediatric surgery and it supported by HPN.
On-site needs assessment at NMCTH
Systems change and improvement in larger institutions can be an arduous task. At NMCTH I came across pockets of teams within the institution who appear ready for change. Much progress has been made by those providing surgical care for children. This has been a result of collaborative working between individuals who developed a relationship whilst completing specialist training in India. The group used what they perceived as a better system experienced in India as a blueprint for advancement of their own service. Examples of recent progress include improving the ward environment for children establishing a PICU and NICU.
A on-site needs assessment was completed over several days and the areas identified are summarised below:
- Safer sterilisation and instrument handling techniques
- Implementation of the WHO checklist for surgical procedures
- Access to sufficient quality surgical instruments for children (for open and laparoscopic procedures)
- Availability of specialist equipment: central venous lines (including peripherally inserted lines), pre-formed silos for gastroschisis
- Access to parental nutrition
- Improvement of theatre environment for children undergoing surgery e.g. pre-operative area, recovery area
- Surgical ward area for children – currently there is a paediatric ward, however the nursing staff are not experienced/trained to care for post-operative surgical patients. Children who have surgery stay on the surgical ward which has predominantly adult patients
- Improving ancillary services such as paediatric anaesthesia, radiology and histopathology through training
- Formal training in paediatric surgery in Nepal
- Training and support in research
Lessons learnt and future actions
Change in healthcare systems in developing countries can be challenging as most institutions have a very hierarchical system which acts as a barrier. Change is dependent on emerging groups within the institution who see the benefit of simple cost-effective interventions to improve quality and provide safer patient care. This should be balanced with appropriate advancements in equipment and techniques to help bridge the gap that exists between low/middle-income countries and high-income countries.
It is appreciated that implementing new ways of working and improvements can take years. Spending time developing relationships with the people who are identified as being ready for change is of great value because these individuals have the potential to spread this culture within their institution. By working with different disciplines including doctors, theatre staff and nurses, this has helped amplify this effect.
The next steps would be to revisit these healthcare institutions following the evaluation of the needs assessment. Achievable goals within a year would be to:
i) provision of improved surgical instruments and equipment at NMCTH;
ii) complete an audit on adherence to WHO checklist;
iii) revaluate safer sterilisation and instrument handling;
iv) initiate specialty training links for paediatric anaesthesia, radiology and histopathology.
I will continue the valuable links with the individuals and teams I have met in Nepal to help implement these specified goals and reassess the needs of our partnering centres.