Transforming Health for Children Globally
A testament of perseverance and building relationships on the ground and empowering healthcare workers to deliver sustainable quality patient care.
When an Australian child is sick, their parents seek medical treatment from a local hospital where there is an established standard of care delivered to ensure the best health outcome.
In Lao People’s Democratic Republic (PDR), a low resource country with one of the highest mortality rates for children in South East Asia, it’s not as simple to receive the right care in the right place at the right time.
Dr Amy Gray, Department of Paediatrics, Melbourne Medical School, has been working since 2009 on global health initiatives for improving the quality of care for children in Lao PDR.
A paediatrician and Director of Medical Education, Royal Children’s Hospital, she has been researching the best methods to improve patient outcomes, designing and delivering interventions, and transforming education of healthcare workers to support practice and policy change.
“One of the mechanisms we needed to put in place was guidelines, and there was a need to educate the workforce on these guidelines to enable adherence, feedback and ultimately change,” Dr Gray said.
“It is well known practice change is really challenging as we all have habits which are hard to break,” she said.
“In Laos, the quality of care was lacking; children were dying because they were not receiving treatment at the right time, right place, in the right way or the hospital and family didn’t have the capacity to cover the full duration of their treatment.”
“I worked with Lao paediatricians, in collaboration with the WHO and the Ministry of Health to translate the WHO Pocketbook of Hospital Care for Children – a 400-page guidebook essentially on how you could care for children in hospitals.”
There was no Lao language textbooks available at the time, therefore, Dr Gray worked with a team of local collaborators to design the best way to translate the pocket book guide, educate healthcare workers and measure the outcomes post-implementation.
“We found the quality of care improved, it became much more standardised, and the improvement was greatest for pneumonia which follows an algorithmic treatment approach, when compared to more complicated illnesses where healthcare teams or multiple treatments are needed,” Dr Gray said.
“The intervention improved the way doctors and medical students were being taught and it created consistencies between the hospitals,” she said.
“When we started this research, everyone assumed no one would read a book because they have never had books before.”
“By the end of my PhD, we changed that culture and there were medical students sitting in cafes reading the book spontaneously and it was constantly being referred to in the wards.”
“We have now disseminated more than 6000 books to cover 150 hospitals and it’s in its third reprint.”
Dr Gray said the research uncovered many other needs which had informed new projects including the first which identified a problem in the supply of oxygen in hospitals.
This small concurrent research project gained momentum when the World Health Organization (WHO) became similarly aware of this critical need during the Avian influenza outbreak in the region.
“Oxygen was an essential medicine which was missing from the healthcare system and families had to pay between 20 to 50 US dollars a day for oxygen which was placing them into poverty,” Dr Gray said.
“Our intervention changed the way hospitals engaged with the community,” she said.
“They could now give the treatment for free and families perceived the hospital as a place that delivered care rather than costing them money.”
Dr Gray’s intervention involved 20 hospitals, 10 which carried out business as usual and 10 which received oxygen concentrators, engineering support and clinical training.
The Lao Ministry of Health selected the 10 hospitals based on criteria including remoteness, cost to deliver oxygen, and electricity access.
“We found children with pneumonia aged under five years experienced a 30% reduction in mortality in those hospitals that had oxygen concentrators and training compared to those who received nothing,” Dr Gray said.
“On the strength of these results, the Ministry of Health made it policy to get oxygen concentrators into District hospitals,” she said.
Dr Gray said the team have worked with donors to install oxygen concentrators in 80 out of the 150 hospitals and they have just received funding for an additional 40 sites.
“In global health research, we make decisions based on needs, resources and outcomes and in this case, the research phase ended, and the implementation arm began,” Dr Gray said.
“We obtained the evidence from our project, informed a national policy and our efforts became focused on making it sustainable, to support the system and enable Lao engineers to collect better data for routine monitoring,” she said.
Dr Gray’s research has since extended to designing better education programs to ensure health professionals assimilate the key learnings to deliver sustainable practice change.
“At the time, all training programs were the same whether it was for a large Central, medium Provincial or a small District hospital, yet the healthcare workers and their capacity were quite different,” Dr Gray said.
“The prevailing format of PowerPoints in workshops didn’t work as they stifled interaction and drew the priority away from hands on practice,” she said.
“From a practical perspective many hospitals also did not have projectors or a reliable power supply.”
The team designed a new way of training, which included a two-day visit, with up to five repeat visits, to iteratively provide training for healthcare workers through a coaching approach where they were given the opportunity to learn based on their priorities.
“Most healthcare workers know their priorities well, but they sometimes don’t know what is possible and we help them identify and overcome these gaps,” Dr Gray said.
“By providing skills around feeding a small baby, for example, they are now able to take care of these patients by themselves with a very simple low-cost intervention, rather than referring families to another hospital which could be six hours away,” she said.
Dr Gray said her team is also working with UNICEF in Laos to redesign a global health training program, Integrated Management of Neonatal and Childhood Illness (IMNCI), to improve the effectiveness and broad applicability of the education resource.
“Going forward we are looking at how we can use technology to add value and extend reach when there is a language barrier or other barriers such as person capacity or access,” Dr Gray said.
“Our research in Laos has found Facebook and WhatsApp are where medical students access information, and these platforms could present an opportunity to share information and provide education which is scalable,” she said.