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Training of children’s surgical teams at district level in low- and middle-income countries (LMIC): from concept to reality—a south to south initiative

Madhuri, Vrisha MCha; Stewart, Richard J. FRCS(paed)b; Lakhoo, Kokila PhDc,

International Journal of Surgery: Global Health: October 2019 - Volume 2 - Issue 3 - p e08
doi: 10.1097/GH9.0000000000000008

aDepartment of Paediatric Orthopaedics,CMC Vellore, Vellore, India

bRoyal College of Surgeons of England, London

cPaediatric Surgery, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK

This manuscript has been peer reviewed.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 18 October 2019

*Corresponding author. Address: Paediatric Surgery, Nuffield Department of Surgical Sciences, University of Oxford, Level 6, Oxford OX3 9 DA. Tel.: +07979802203. E-mail address: (K. Lakhoo).

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

A recent World Health Assembly meeting in Geneva, May 2019, highlighted the need for surgical care in children living in low- and middle-income countries (LMIC). According to the Bulletin of the World Health Organization1 an estimated 1.7 billion (95% credible interval: 1.6–1.8) children and adolescents worldwide are without access to surgical care. In 2015, the Lancet Commission on Global Surgery reported that <3% of children in low-income countries and <8% in lower middle-income countries have access to surgical care2. In South Asia, children’s surgical services especially for ages under 6 are lacking and centred in mega-cities3. With improved identification of those affected under the Indian government’s flagship scheme “Rashtriya Bal Swasthya Karyakram (RBSK)”3 those identified with surgical conditions are unable to access healthcare locally. Contributing to the lack of inaccessibility of healthcare is the lack of trained workforce and child appropriate equipment in the district level hospitals4.

To address this need it was decided that a south to south (LMIC to LMIC) response would be better suited for providing a local solution to this challenge. In this way the environment, resources, skill mix, and understanding of the center specific need will be familiar. The children’s surgical providers in a tertiary level institution from a LMIC (CMC-Vellore, India), in collaboration with Royal College of Surgeons of England (RCSEng) have initiated training of a core adult team of anaesthetist, general and orthopaedic surgeons and nurses (ward and operating room) from district hospitals. The course was designed following site visits, interviews, and data presentation on children’s surgery by district surgical providers. Emphasis was placed by the end users on team working, training in appropriate emergency and routine surgical management, trauma management, triage, safe transfer of complex cases, and communication between the tertiary centre and the district general hospital.

The course design is as follows:

Day 1: “Training the Trainers” course by qualified Educator.

Day 2: Session A: the first session is structured with airway and physiological differences between adult and child, how to triage a sick child, basic fluid and electrolyte management, common analgesics and sedatives used, and general dosing for children. Session B: hands on training on mannequins and work stations namely airway, vascular access, hip spica/immobilization and intercostal drainage tube insertion and basic life support.

Day 3: The program is specialty based. The pediatric surgeons conduct interactive sessions covering pediatric surgical topics of relevance to district hospital surgeons mainly giving the insight into diagnosis, stabilization, and safe transfer. The orthopedic team has sessions on management of simple infective pathologies in children as well as congenital anomalies that need to be addressed soon after birth rather than send those babies as a delayed referral to tertiary centers. The anesthesia team is in the operating theater where interactive lectures are interspersed with demonstration of patient induction, caudal analgesia, and airway management. The nursing team was exposed to safe practices in operating theater, equipment needed for pediatric cases, bedside care of patients postoperatively and care of stomas.

Day 4 (Half Day) Session A: specialty specific. The pediatric surgeons have life demonstration in the operating room, while the anesthetists also have a practical demonstration of induction. The orthopedic surgeons have a series of lecture demonstrations of surgical techniques while the nurses have a clarification and question/answer session. Session B: (All participants): demonstration of the WHO check list, transporting an infant and neonate, communication setup, pitfall, and ongoing training.

The quantitative assessments of the first pilot consisting of 5 district general hospital teams are shown in Table1. The preliminary 6 months outcomes of the first pilot consisting of 5 district general hospital teams have shown 120 calls via a “WhatsApp” application, 29% reduction in referrals, 87% appropriate referrals, 72% well resuscitated patients, and 27% remote procedures.

Table 1

Table 1

This course has captured the interest of local government in neighboring Indian states to adopt and fund the project with the aim to train more children’s hospitals teams as trainers creating a cascading effect. The Global Initiative for Children’s Surgery5 endorsement has resulted in expressed interest from Africa and South East Asia. A training program for trainers from 2 COSECSA (College of Surgeons of Central, East and Southern Africa) countries, namely Kenya and Ethiopia is in progress. This novel study addresses access to children’s surgery from within LMIC’s by training district hospital teams and creating a hub and spoke training model for local care. Point of contact to a tertiary center is also a major challenge for district hospital and this initiative provides this contact and opportunities for further higher training and mentoring.

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Ethical approval

No ethical approval is required.

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Sources of funding


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Author contribution

All authors contributed equally.

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Conflict of interest disclosures

The authors declare that they have no financial conflict of interest with regard to the content of this report.

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Research registration unique identifying number (UIN)


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University of Oxford.

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The authors acknowledge faculty who lectures on the course.

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1. Mullapudi B, Grabski D, Ameh E, et al. Estimates of number of children and adolescents without access to surgical care. Bull World Health Organ 2019;97:254–8.
2. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health 2015;3:e316–e323.
3. Rashtriya Bal Swasthya Karyakram (RBSK): National Health Mission. Available at:
4. Krishnaswami S, Nwomeh BC, Ameh EA. The pediatric surgery workforce in low- and middle-income countries: problems and priorities. Semin Pediatr Surg 2016;25:32–42.
5. Goodman LF, St-Louis E, Yousef Y, et al. The Global Initiative for Children’s Surgery: optimal resources for improving care. Eur J Pediatr Surg 2018;28:51–59.
Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of IJS Publishing Group Ltd.