Breathing new life into hospital care

Partnerships nurtured by Associate Professor Amy Gray (MBBS 2001, BMedSci 1997, PhD 2013) and her colleagues with health professionals and academics in Laos have enhanced the care of vulnerable children.

Their work has saved many lives by improving hospital treatment for Lao children, providing critical oxygen supplies, improving the quality of care and implementing a program of essential care for newborns.

They have also promoted individual and institutional connections that have transformed health systems and empowered Lao health professionals to embrace new treatments.

From little things, big things grow

Now a consultant paediatrician, Director of Medical Education at the Royal Children’s Hospital and a University of Melbourne Clinician Educator, Associate Professor Gray first visited Laos in 2008. She had found a second home in South East Asia after volunteering in Vietnam during her paediatric training.

“Laos was a country with some of the greatest needs in our region, but we really didn’t have a good understanding of what we could offer or how we could best work with Lao colleagues,” she says.

What began as a loose connection between the University of Melbourne Department of Paediatrics and The University of Health Sciences of Lao PDR (UHS-Laos) led to a lasting collaboration with Lao paediatricians.

“What they really needed was guidelines,” Associate Professor Gray recalls. “They really didn’t have any guidelines at that time for how to care for children in hospital. That became my PhD.”

Better care for children

The PhD developed the first Lao language guide based on the World Health Organisation (WHO) Pocketbook of Hospital Care for Children. It became a core medical resource for medical student training. Around 6000 copies were published and distributed in all 150 Lao district hospitals. 

Associate Professor Gray’s study assessed the case management quality of four conditions in three hospitals and found the guide improved paediatric outcomes for pneumonia, diarrhoea, and low birthweight.

While it worked well in bigger hospitals, district hospitals at the heart of the Lao health system found the translation from training to practice difficult.

Associate Professor Gray and her colleagues adjusted their approach. They dumped PowerPoints, as some hospitals had no electricity, and provided more direct coaching, relevant hands-on training, and feedback.

This important work evolved into the Lao-Melbourne Children’s Program, which supports needs-based education development, educators, local research, clinical skills and capacity building.

The program works closely with the University of Melbourne, Murdoch Children’s Research Institute (MCRI) and the Royal Children’s Hospital, providing a breadth of resources, knowledge and support.

For the past 10 years, the Lao program has seen a fruitful partnership with UHS-Laos to support health professional capacity, curriculum, and communication skills.

Healing with oxygen

While Associate Professor Gray was looking at care in Lao hospitals, the problems of oxygen supply and treatment became clear.

Oxygen therapy is a key treatment for pneumonia, malaria, sepsis, meningitis and now COVID-19. It can be delivered in several ways, including small machines called oxygen concentrators, which produce medical grade oxygen.

Many Lao hospitals did not have oxygen to treat children. In those that did, families could be charged up to US$50 a day at a time when the average income was less than US$2 a day.

In 2011, the team at the University of Melbourne established a collaborative trial that installed concentrators across 10 hospitals and trained staff to use them. The project has continued to scale up, working with the WHO, the Laos Ministry of Health and Lao Paediatric Association.

Hospitals with oxygen concentrators and quality training reduced pneumonia deaths in children aged under five by a third. Mortality remained the same in those without them.

More recently, the Faculty of Medicine, Dentistry and Health Science established a complementary program, the Lao Oxygen Research Project, led by Associate Professor Gray, to amplify this work.   The project has enabled research-led clinical and technical training to be scaled up to more than 100 hospitals and clinics, which continues to save the lives of babies, children and adults with pneumonia and other respiratory diseases. Thanks to the project’s advocacy, the Lao Government determined oxygen treatment from concentrators would be free to patients.

The gift of life

The Lao Oxygen Research Project has recently been bolstered by direct philanthropic support from an anonymous donor and continuing contributions from the DAK Foundation, which has provided concentrators to 120 Lao district hospitals. The combined efforts of experts and supporters ensure that hospitals have the facilities and power to run the concentrators and that staff are trained to  use them.

“It’s been amazing to receive funding and that funding has made a huge difference to what hospitals can access,” Associate Professor Gray says. “A key part of the work is to upskill people on the ground. It’s one thing to have the equipment but hospitals need to be able to use it well.”

The impact of COVID-19

The pandemic has changed the way global health programs are delivered on the ground. This isn’t all bad – Associate Professor Gray’s aim is to make herself and her colleagues redundant. “If we’re doing our job well, we should not be needed in the longer term,” she says.

The Australian team has worked remotely since 2020 while Lao health professionals maintain the activity on the ground. Work has continued with online teaching designed around slow internet speeds, development of a hospital treatment guidelines app, and a remote mentoring model of child health training.

“COVID has shone a light on the need for oxygen that should have been apparent a long time ago,” Associate Professor Gray says. “It has made oxygen supplies much more available, but we know there is still a lot of work to do to ensure that that oxygen gets to the children who need it ... and that the momentum is maintained.”

Maintaining connections

The program has produced wonderful success stories, saved many lives and nurtured around 15 fellows – Australian paediatric trainees who have been deployed for on-the-ground placements.

Researchers continue to collaborate with Lao paediatricians, UNICEF, the WHO and the Laos Ministry of Health on affordable oxygen systems, the WHO Pocketbook and child death review systems. At the same time, efforts continue on building education capacity at UHS-Lao to ensure health professional graduate with the key skills they need.

The work is complex but rewarding. Associate Professor Gray, who still works with individual patients, recalls that one of the poorest hospitals was only connected to electricity the week before two oxygen concentrators arrived. Free treatment has also built community trust. This bond between families, Lao professionals and their international colleagues has been essential to making sure new tools are successfully adopted.

Associate Professor Gray recalls the pride of hospital staff when they told her: “These concentrators have changed lives. Our community trusts us and trusts that we want to care for them”.