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Anesthesia Development in Mongolia: Strengthening Anesthesia Practice in Mongolia Through Education and Continuing Professional Development

Lundeg, Ganbold MD, PhD*; Baric, Amanda FANZCA; Pescod, David C. FANZCA; Pescod, Keith BA(Hons), PhD

doi: 10.1213/ANE.0000000000002566
Global Health
Free

Anesthesia in Mongolia has undergone a period of major development over the past 17 years, thanks to the work of the Mongolian Society of Anesthesiologists (MSA) and the support of the World Federation of Societies of Anaesthesiologists and the Australian Society of Anaesthetists. The specialty has made major advances in training and in its standing among medical specialties in Mongolia. The MSA has produced members who are leaders in the development of anesthesia as well as emergency medicine and critical care. This has been achieved by engagement between the Ministry of Health and MSA, and with inexpensive but efficient programs to educate trainees and provide continuing professional development. There is now major work being done to achieve the Lancet Commission on Global Surgery goals of safe and accessible surgery for the population in a country that faces significant challenges of remote communities with vast distances.

From the *Department of Health Sciences, University of Mongolia, Ulan Bator, Mongolia

Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia

La Trobe University, Melbourne, Victoria, Australia.

Accepted for publication September 15, 2017.

Funding: None

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to David C. Pescod, FANZCA, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, 109 Grandview Ct, Beveridge, Melbourne, VIC 3753, Australia. Address e-mail to david.pescod@nh.org.au.

With a land size of 1,564,116 km2 and a population of just over 3 million people, Mongolia is one of the most sparsely populated countries in the world. Historically, the Mongolian people have been nomads in culture, shifting their animals and accommodation with the seasons. Over recent decades, the population has become more urbanized. About 30% of Mongolians still follow a nomadic lifestyle. The climate of Mongolia can be extreme with temperatures varying between −30°C during the long winters and over 40°C in summer. Poor or nonexistent road systems combine with harsh topography (forests, mountains, deserts, and steppes) making access to health services a challenge for large sections of the population.

Health care services are delivered at 3 levels including primary (soum and intersoum hospitals), secondary (aimag and district hospitals), and tertiary (central hospitals).

Modern health services in Mongolia began during the 1920s after gaining independence from China. The Soviet Union joined with the Mongolians in their battle for independence and maintained a close and strong influence on Mongolia’s social and economic development for the next 70 years. During this period, the Mongolian health service rapidly expanded, based on the model developed by Nikolai Semashko, the Commissar of Health in Moscow, and implemented in most Soviet-aligned countries. The Semashko plans provided health services with well-defined medical specialization from an extensive network of hospitals and clinics. When the Soviets withdrew during the late 1980s, Mongolia was left with 407 hospitals containing an estimated 16,503 beds for a population of <2 million.1 This vast, inefficient legacy consumed much of the country’s health budget for the repair and maintenance of rapidly deteriorating buildings and on duplicated services that were underutilized.

There were multiple adverse consequences of the Semashko model on anesthesia education and practice in Mongolia. The rapid development of the hospital and clinic network required the expeditious education of vast numbers of health workers including physicians trained to give anesthesia. Consequently, the first wave of Mongolian anesthesiologists during the 1960s generally received up to 4 months of training. In the following 20 years (1960–1980), anesthesia training was inconsistent and unstructured, consisting mainly of a 6-month residency though gradually increasing to a maximum of 18 months. The residency consisted of “on the job” training with no formal academic program. Senior anesthesiologists at the few training hospitals merely passed on their limited knowledge to the trainees thus compounding omissions and errors in anesthesia practice and diluting knowledge. Slipping out for tea and vodka, while leaving new trainees to perform anesthesia, was common.2 Some trainers had little interest in their young apprentices, but even dedicated trainers were the products of the same flawed training system. There was no access to modern textbooks, journals, or English language courses; English language journals were still deemed to be subversive in the 1980–1990s. Political and geographical isolation significantly limited exposure to Western advances in anesthesia, and much of modern anesthesia practice in Mongolia, reflected Russian training from >40 years earlier. The transition from a Russian-supported administration to a parliamentary democracy and the decentralization of the health system exacerbated an already fragile and ineffective situation.

The Mongolian government legislates the scope of practice of all doctors. Only doctors who have graduated from specialist training may administer anesthesia. There are no nonphysician anesthesia providers nor is there legal capacity to train physicians for a limited scope of anesthesia practice.

By the opening years of the 21st century, anesthesia practice in Mongolia faced a huge shortage of anesthesiologists, with 106 anesthesiologists nationwide,3 little interest from medical registrars to train in anesthesia, and an increasing exodus of senior anesthesiologists from the profession. The Mongolian Society of Anesthesiologists (MSA) was regarded as a dysfunctional society, disorganized and lacking educational or advocacy activities.

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THE WATERSHED

Anesthesia’s contribution to the Mongolian health system extends beyond the operating theater into all critical care areas, including intensive and emergency care services. A sustainable quality education system is essential for its practitioners’ training. There was an urgent need to resolve the quantity and quality of anesthesia specialists. In 2007, to increase the quantity of anesthetists, the Mongolian Minister of Health responded by signing decree A/171 that reduced the residency-training program from 18 to 6 months. This action accelerated, rather than reduced, the decline in anesthesiologists. During 6 months of anesthesia exposure, trainees were experiencing as few as 20 general anesthetics and were expected to deliver anesthesia in isolated, poorly equipped hospitals, which resulted in high mortality. The status of anesthesia declined further, encouraging more practitioners to abandon their profession and deterring others from entering it.

In 2001, a member of the Australian Society of Anaesthetists (ASA), representing the World Federation of Societies of Anaesthesiologists (WFSA), attended the Mongolian Society’s 40th anniversary meeting. This encounter became the catalyst for change in the development of the anesthesia profession in Mongolia. The ASA was invited to return by the Mongolian Society, and this ongoing relationship became essential to the success of collaborative learning and development. From 2002, teams of 10 or more ASA anesthesiologists visited Mongolia regularly for 10–14 days annually, providing thematic anesthesia seminars, primary trauma courses, and many hospital teaching visits in Ulaanbaatar and the aimag (regional) secondary-level hospitals. During the early years, educational interventions consisted of didactic lectures in English, translated by a few Mongolian anesthesiologists with some knowledge of English.

There were some obstacles including a very limited shared language, only brief annual visits and inaccurate assumptions about Mongolian anesthesia practice. The Australian team was teaching anesthesia practice that was very different from what the Mongolian anesthesiologists had long accepted as dogma. The Australians could only educate to facilitate change when they developed a better understanding of what the Mongolian practice was and where it had come from. This highlights the need for any visiting teams to understand local practices and the rationale behind them. Over the ensuing years, a rewarding level of trust, understanding, commitment, and friendship developed and flourished between members of ASA and MSA as they planned, worked, and socialized together.

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THE LAST DECADE

By 2007, Mongolian anesthesia had strong leadership and a trusted international partnership. In particular, the Bangkok Anaesthesia Regional Training Centre (BARTC), established in 1996 with support of the WFSA and the Royal College of Anesthesiologists of Thailand, was of crucial importance to anesthesia development in Mongolia. BARTC’s strategy from its inception has been “to train future trainers to form a critical mass and enable them to teach junior colleagues and students in their own countries.”4 It certainly did so in respect to Mongolia. By 2016, 26 Mongolians had graduated from BARTC’s educational program, and many had benefited from the refresher courses that it, in conjunction with the MSA, held in Mongolia. Consequently, BARTC-trained Mongolian anesthesiologists formed the core of the MSA executive and a driving force in the development of anesthesia education and advocacy throughout Mongolia.

Drawing on that international support, the time had arrived for Mongolia to establish a new anesthesia training course. The MSA believed that a course of guaranteed duration and rigorous curriculum, together with a continuing postgraduate anesthesia education program, would raise the standards and status of anesthesia in Mongolia. It would empower the MSA, stimulate recruitment, reduce the number leaving practice, help ensure the maintenance of standards in rural areas, and lead to a significant reduction in morbidity and mortality.

Within the ASA, there was a wealth of anesthesia education experience applicable to low- and middle-income countries. This included anesthesia refresher courses in Micronesia and nurse anesthetist education in East Timor, but it was the ASA’s highly successful implementation of a Diploma of Anaesthesia at the Fiji School of Medicine that appeared particularly relevant to the proposed anesthesia training program for Mongolia. The Fijian format of a 12-month, case-based modular training program was ideally suited for adaptation for Mongolia. Anesthesiologists from the ASA Overseas Development and Education Committee consulted with senior Mongolian anesthesiologists to construct a development program for “the teaching and maintenance of anesthesia in Mongolia.”

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A FORMAL AGREEMENT BETWEEN SOCIETIES TO HELP WITH ADVOCACY AND FUNDING

Since 2008, the MSA and ASA signed a memorandum of understanding (MOU) “Anaesthesia Advancement in Mongolia” prepared largely by Mongolian anesthesiologists. This document empowered the MSA and ASA to lobby governments and official bodies from both countries to support and fund elements of a plan for improvement. The opening paragraphs of the MOU described the status of anesthesia. Within the MOU, the term “anesthetist” is used interchangeably for anesthesiologist.

The image of the peri-operative physician in Mongolia is low. Anaesthetists are poorly educated in modern anaesthesia and practice on a daily basis most aspects of anaesthesia with inadequate equipment and recurrent shortages of drugs.

Continuing maintenance of standards for anaesthetists in Mongolia suffers from vast distances, pressure of clinical work and a virtual absence of continuing post-graduate education for the qualified anaesthetists present. Workforce shortage adds to this negative spiral. This negative cycle fails to inspire young doctors to join the ailing profession.

There has been a shortage of anaesthetic manpower for the last few decades, compounded by significant departure from the specialty by many of the anaesthetic consultants. Even in the capital city Ulaanbaatar, hospitals are lacking anaesthetists and the conditions in Aimag hospitals are more complicated and dire. This issue and problem are well known at all levels of the Health Department and Ministry in Mongolia.

In 2008, the MSA, in collaboration with the ASA, produced a strategic plan for the development of anesthesia in Mongolia. The plan had 3 major objectives:

  • Advancement of anesthesia training
  • Improvement in postgraduate training
  • Support for the academic activities of the MSA

The plan defined essential and future actions within each objective, the latter actions being dependent on the success of the former, and obtaining additional funding. Essential actions in the advancement of anesthesia training included the following:

  • Establishment of a combined project management committee from the members of the MSA and ASA.
  • Establishment of an anesthesia education center and the appointment of an Anesthesia Education Advancement Coordinator.
  • Translation into Mongolian of the textbook, Developing Anaesthesia,5 written specifically for anesthesia in low–middle income countries.
  • Design by ASA members of a curriculum and course material, the final content to be determined by the MSA with each member of the executive committee taking responsibility for editing and translating specific modules. The course material to be specific to the changing Mongolian health environment and in Mongolian language.
  • National accreditation of anesthesiologists would remain in the hands and be the responsibility of the Mongolian Accreditation Organ for Health Facilities.

Given the vast distances involved, difficulty and cost of travel, and significantly disadvantaged working conditions in rural Mongolia, the plan included Australian trainer teams visiting rural areas for evaluation of the anesthesia care and conditions and provision of hands-on training designed for local conditions. It was decided to enhance postgraduate training by holding each year, a combined MSA/ASA scientific congress with pre- or post-workshops—supported by the financial assistance of Interplast Australia and New Zealand (Interplast) and the ASA. The year 2008, 9 annual congresses have been held, and the continued financial assistance have enabled >40% of participants to come from rural hospitals.

During 2009, the first group commenced the new training program. Since then, 8 groups of 28–30 trainees have passed through the program. All have graduated and remained in Mongolia with 30 graduates undertaking further short-term subspecialty training abroad. In June 2014, Interplast assessed the achievements, challenges, and sustainability of the educational program. The review included a set of qualitative interview questions for the MSA steering committee. During these interviews, MSA steering committee members stated that there has been a “major” and “huge” positive difference when asked about changes experienced since the collaboration with the ASA and Interplast. Interviewees saw positive change in the key areas of organization and output of the MSA. While other professional societies had difficulty in attracting colleagues to their association, “now all anesthesiologists are waiting and wanting to be involved with the MSA.” Furthermore, the Mongolian government was showing increasing respect for the MSA; interviewees felt that this had been little more than superficial in the past, whereas the government now acknowledged the society as an official organization, sought its members’ opinions and granted it anesthesia examination and licensing rights. Participants in the survey stated that the knowledge and expertise of anesthesiologists had flourished with the quality and duration of anesthesia training increasing from 6 to 18 months (an MSA achievement through its advocacy with the government of Mongolia). In turn, the quality of medical care had “dramatically improved”; they spoke of the benefits flowing through to the patients from this improved training: increased provision of safe anesthesia, greater comfort, and enhanced respect and confidence in the profession. Crucially, while in previous decades anesthesiologists were not perceived to be essential and were often not even present in rural hospitals, they were now regarded as essential and “no operations were undertaken without an anesthetist.”

As a result of these sustainable programs running with the collaboration of the MSA, ASA, WFSA, and other partners, patient safety has dramatically improved with surgical mortality decreasing from 0.53% in 2000 to 0.2% in 2015.6 Anesthesia complexity has expanded with anesthesiologists safely providing anesthesia for open heart and transplant surgery. As of 2017, Mongolia had 200 physician anesthesia providers or 6.76 per 100,000 population,7 although there are still significant shortages in rural areas with most primary health facilities without trained anesthesiologists.8

During the 50th anniversary of Mongolia anesthesia celebrations in 2011, the Mongolian Government recognized the achievements of the anesthesia community by awarding the Medal of Honor, to the Australian coordinator of the project, with the citation “in appreciation of your contribution and dedication for the protection and promotion of health and well-being for people of Mongolia.”

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THE FUTURE

First-referral health care for the sparsely populated and vast country of Mongolia is provided by 274 soum hospitals and 37 intersoum hospitals, yet the capacity to manage life-threatening emergencies is highly limited. A prospective, observational multicenter study, of 74 primary-level hospitals of Mongolia over 6 months, revealed that 10% of potentially life-threatening emergencies required emergency surgery; however, only one-third of primary hospitals had operating rooms, and none had trained emergency/critical care physicians or nurses available.9 The study also revealed that <3 life-threatening emergencies present to first-referral hospitals each month, which will present a challenge for maintaining clinical skills.

Currently 83.6% of Mongolia has achieved the Lancet Commission on Global Surgery goal of access to emergency surgery and anesthesia within 2 hours.10 The National Surgical plan for Mongolia aims to reach 90% coverage by 2030. To achieve this, 30 intersoum hospitals will require advancement to provide emergency surgery and anesthesia. In agreement with the pragmatic solution suggested by the Lancet Commission on Global Surgery of “transcending contextually irrelevant professional constructs,”11 the MSA plans to develop, in collaboration with the ASA, a diploma of anesthesia for doctors who will task share in the intersoum hospitals. This will require Mongolian Government legislative change.

To further strengthen anesthesia delivery throughout Mongolia, the MSA plans to develop pediatric, obstetric, and trauma anesthesia subspecialization at secondary aimag hospitals.

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CONCLUSIONS

The scope and quality of the MSA’s activities, and the community regard for its achievements, have significantly grown since commencing its partnership with the ASA and the support of Interplast Australia and New Zealand. From this base, with its program of enhanced training and professional education and the Mongolian government acceptance of its current and potential contribution, the MSA is well placed to continue and develop its critical work. Several challenges face the MSA including achieving self-sufficiency and meeting the Lancet Commission on Global Surgery goals. In the least densely populated country in the world, several barriers remain, including the provision of safe anesthesia care to remote communities and ensuring a clear professional pathway for those offering these services. Such ambitious goals can be tackled by a strong anesthesia profession in Mongolia led by the MSA, and the invaluable support by organizations such as ASA, WFSA, BARTC, Royal College of Anesthesiologists of Thailand, and Interplast Australia and New Zealand. The plan developed and implemented in Mongolia could provide a template for other countries wishing to improve their anesthesia services. It takes cooperation, planning, coordination, support, and time to make progress along the path to the Lancet Commission goals for 2030.

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DISCLOSURES

Name: Ganbold Lundeg, MD, PhD.

Contribution: This author helped with substantial contributions to the conception and design of the work, revising it critically for important intellectual content, and final approval of the version to be published.

Name: Amanda Baric, FANZCA.

Contribution: This author helped with substantial contributions to the conception and design of the work, revising it critically for important intellectual content, and final approval of the version to be published.

Name: David C. Pescod, FANZCA.

Contribution: This author helped with substantial contributions to the conception and design of the work, revising it critically for important intellectual content, and final approval of the version to be published.

Name: Keith Pescod, BA(Hons), PhD.

Contribution: This author helped with substantial contributions to the design of the work, revising it critically for important intellectual content, and final approval of the version to be published.

This manuscript was handled by: Angela Enright, MB, FRCPC.

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