World J Surg (2011) 35:1183–1193 DOI 10.1007/s00268-011-1097-4

Surgical Care in the : A Road Map for Universal Surgical Care Delivery

Eileen S. Natuzzi • Adam Kushner • Rooney Jagilly • Douglas Pickacha • Kaeni Agiomea • Levi Hou • Patrick Houasia • Phillip L. Hendricks • Dudley Ba’erodo

Published online: 13 April 2011 Ó Socie´te´ Internationale de Chirurgie 2011

Abstract the provincial hospitals were evaluated using the World Background Access to surgical care and emergency Health Organization’s Global Initiative for Emergency and obstetrical care is limited in low-income countries. The Essential Surgical Care Needs Assessment Tool question- Solomon Islands is one of the poorest countries in the naire. Data on infrastructure, workforce, and equipment Pacific region. Access to surgical care in Solomon Islands available for treating surgical disease was collected at each is limited and severely affected by a country made up of provincial hospital visited. islands. Surgical care is centralized to the National Referral Results Surgical services are centralized to the NRH on Hospital (NRH) on , leaving a void of care in Guadalcanal in Solomon Islands. Two provincial hospitals the provinces where more than 80% of the people live. provide surgical care when a surgeon is available. Six of Methods To assess the ability to provide surgical care to the hospitals evaluated provide only very basic surgical the people living on outer islands in the Solomon Islands, procedures. Infrastructure problems exist at every hospital including lack of running water, electricity, adequate diagnostic equipment, and surgical supplies. The number of surgeons and obstetricians employed by the Ministry of E. S. Natuzzi Á P. L. Hendricks Health is currently inadequate for delivering care at the Loloma Foundation, Encinitas, CA, USA outer island hospitals. Conclusions Shortages in the surgical workforce can be E. S. Natuzzi (&) Á A. Kushner Society of International Humanitarian Surgeons, 225 East 6th resolved in Solomon Islands with focused training of new Street, Suite 7F, New York, NY 10003, USA graduates. Training surgeons locally, in the Pacific region, e-mail: [email protected] can minimize the ‘‘brain drain.’’ Redistribution of surgeons and obstetricians to the provincial hospitals can be E. S. Natuzzi William Moore Stack Foundation, Encinitas, CA, USA accomplished by creating supportive connections between these hospitals, the NRH, and international medical R. Jagilly Á D. Pickacha Á D. Ba’erodo institutions. Department of Surgery, National Referral Hospital, Guadalcanal, Solomon Islands

K. Agiomea Introduction Department of Anesthesia, National Referral Hospital, Guadalcanal, Solomon Islands Surgical care is the neglected disease of global health in L. Hou many low-income developing countries. While efforts to Department of Obstetrics and Gynecology, National Referral cure diseases such as malaria, tuberculosis (TB), and Hospital, Guadalcanal, Solomon Islands human immunodeficiency virus infection/acquired immu- nodeficiency syndrome (HIV/AIDS) have grown, surgical P. Houasia Department of Orthopedic Surgery, National Referral Hospital, care and treatment of surgical disease remains a low pri- Guadalcanal, Solomon Islands ority in the ‘‘preventative medicine strategy.’’ International 123 1184 World J Surg (2011) 35:1183–1193 surgery groups such as the Bellagio Conference on funded hospitals and hundreds of small health clinics Increasing Access to Surgical Care in Sub-Saharan Africa, throughout the island chain. The Society for International Humanitarian Surgeons The capital of Solomon Islands is located on the (SIHS), along with the World Health Organization’s northern coast of Guadalcanal. Internal migration has (WHO) Global Initiative on Emergency and Essential resulted in the movement of people from and other Surgical Care (GIEESC) have laid the groundwork for outer islands to Honiara in hopes of finding work. This has quantification and justification for funding the surgical resulted in crowded and dirty squatter camps that facilitate needs of these developing countries [1–3]. the spread of disease. It has also created periods of civil Surgical conditions account for 11–15% of the world’s unrest. Transportation between the countries’ many islands disability adjusted life years (DALYs), with the most is mainly by ferry, outboard motorboat, or canoe. There are common surgical conditions being injuries, infection, limited and expensive interisland flights. malignancies, obstetric complications, congenital anoma- This article’s goal is to provide information on the lies, and cataracts. To influence global health funding infrastructure, workforce, and supplies as they apply to sources, the state of surgical care in developing countries surgical care in Solomon Islands. We also present a road must be quantified. These data need to be reported by map for the development of universal surgical care for the country, by region, and finally by socioeconomic level of country based on standards that have been previously developing countries. Kingham et al. have reported on the published and issues that are unique to the country. availability of surgical treatment in provincial hospitals throughout Sierra Leone using the GIEESC Needs Assessment Tool [4]. This method allows efficient evalu- Materials and methods ation of infrastructure, workforce, and equipment capabil- ities for the delivery of surgical care by a hospital. The WHO’s Tool for Situational Analysis to Assess Located in the Melanesian portion of the South Pacific, Emergency and Essential Surgical Care Survey was used to the Solomon Islands are just northeast of Australia and collect information on the infrastructure, workforce, inter- New Zealand. The country is an archipelago 1450 km (900 ventions provided, and consumable and reusable surgical miles) long, with a total of 999 islands scattered across a equipment during site visits to 9 of the 12 hospitals in 725,197 km2 (450,000 square miles) area of sea. Only Solomon Islands. These site visits were conducted from 3.8% of this area is land. Solomon Islands is one of the June 2009 through September 2010 as a collaborative poorest countries in the South Pacific. It ranks 135th among effort between Loloma Foundation, the Ministry of Health, 177 countries on the United Nations Development Program and the surgeons at the NRH. Site visits lasted for a min- (UNDP) Human Development Index [5]. The World Bank imum of 6 h (Taro, Sassamunga, Kilu’ufi, Atoifi), and classifies Solomon Islands as a low-income country with a some were conducted while providing surgical care for an gross national income per capita of $910 [6]. The popu- extended period of time at that particular provincial hos- lation exceeds 600,000, with 82% of the people living in pital (NRH, Good Samaritan, Gizo, , Helena Goldie rural areas where clean drinking water and proper sanita- Hospital). The hospital site visit data were recorded on tion are lacking. The population is increasing at a rate of individual Needs Assessment Tool data sheets by one 3.5% annually [7]. More than half of the population is evaluator (E.S.N.) based on observations and information under 15 years of age. obtained from the provincial doctors and nursing staff. The Health care in Solomon Islands is publically funded, Needs Assessment Tool, developed by the WHO GIEESC, with 80% of the health care funding from the government consists of a check box questionnaire covering more than and the rest from international development partners 20 items of general information about the hospital capacity (Australia, New Zealand, ROC Taiwan, European Union, as well as infrastructure, human resources available, sur- Japan). In 2006, the total expenditure on health care was gical interventions provided, and availability of emergency 4.7% of the gross domestic product (GDP). The life equipment and supplies for resuscitation. We have col- expectancy in Solomon Islands is 62 years. Infant mortality lected all the data but have selected certain pertinent items is 17 per 1000 births, and maternal mortality is 500 per to publish in the interest of space limitations. The full 100,000 [8]. The incidence of malaria exceeds 30% and Analysis Tool form can be downloaded from the WHO includes infection by Plasmodium falciparum as well as GIEESC website. P. vivax. HIV is underreported because of under-testing for Table 1 lists all of the public and private hospitals the disease [9]. The health care system supports one main located in the Solomon Islands along with each hospital’s hospital, the National Referral Hospital (NRH) located on overall catchment demographics. The hospitals that were Guadalcanal, and seven provincial hospitals located on surveyed are marked with an ‘‘a’’. Operating theaters were outer islands in the provinces. There are four privately inspected and photographs obtained to record supplies and 123 World J Surg (2011) 35:1183–1193 1185

Table 1 Public and private hospitals located throughout the Solomon Islands and the estimated population served Institution Location Population served Status

National Referral Hospitala Guadalcanal [600,000 Public Gizo Provincial Hospitala Gizo Island [60,000 Public Taro Provincial Hospitala 24,000 Public Tulagi Provincial Hospitala Tulagi, Florida Island 30,000 Public Buala Provincial Hospital 26,000 Public Kirakira Provincial Hospital Ulawa 40,000 Public Kilu’ufi Provincial Hospitala Malaita Island [200,000 Public Lata Provincial Hospital Temotu Island 20,000 Public Atoifi Hospitala Malaita Island [40,000b Private Helena Goldie Hospitala Island 40,000b Private Sasamunga Hospitala Choiseul Island 2500 Private Good Samaritan Hospitala Guadalcanal 25,000b Private a Indicates the hospitals that were the site visited and therefore included in the assessment data. Demographic data were obtained from the 2008 Annual Report of the MOH and HSSP [29] b These hospitals are sponsored by and affiliated with church organizations. Their catchment numbers include local residents and members of the church who travel from other regions of the country to be treated equipment. The availability of consumable supplies was Sassamunga and GSH have rooms that can be converted recorded after inspection of supply rooms. Surgical pro- into operating theaters; but during the site visits they were cedures performed at the hospitals were obtained from the being used as an examination room and a delivery room, provincial doctor in charge of the hospital and by respectively. Lighting availability is mainly by portable inspecting the surgical logbooks. operating room (OR) lights and daylight. Oxygen is available at most of the hospitals, with five having partial to full oxygen tanks in the operating theaters (NRH, Gizo, Results Kilu’ufi, Atoifi, Taro). Oxygen concentrators are used at the remaining hospitals and on the wards. At Sassamunga Infrastructure there is no source of oxygen. Altogether, 40% of the hos- pitals have a working anesthesia machine. Two of these The infrastructure of the hospitals in Solomon Islands varies machines had leaks, and all are in need of servicing. widely (Table 2). All of the hospitals, including the NRH in Anesthesia monitoring equipment was found at three hos- Honiara on Guadalcanal, are subject to power outages, but pitals (NRH, GizoKilu’ufi). Most commonly, it was a those most vulnerable to long and frequent power outages portable monitoring machine that records the heart rate, are located in the outer provinces. These hospitals have blood pressure, and pulse oximetry. generators as the only source of power, and the generators There are no critical care beds available throughout the are used sparingly due to limited fuel supply. Two of the Solomon Islands, and there are no ventilators. Medical hospitals, Sassamunga and GSH, have solar panels that diagnostic and surgical equipment at the hospitals tends to supply limited energy for lighting. Access to running water be old and poorly maintained. There are radiography and varies throughout the country and within a given hospital. In ultrasonography (US) machines at all the hospitals except all, 80% of the hospitals have rainwater-collecting tanks. Sassamunga. In Sassamunga the US machine was One hospital collects unfiltered water from a mountain destroyed by floodwaters, and the portable radiography creek located nearby (Atoifi). The plumbing at Gizo Hos- machine was partially buried in the sand after the tsunami. pital and the NRH is in need of repair as breaks in the pipes There are no computed tomography (CT) scanners or have rendered some parts of the hospital wards without mammography capability in the entire country. Most pro- water deliverable by faucet. On these wards, buckets of vincial hospitals and the NRH have a blood bank and basic water are kept in the sink for hand washing. medical laboratory. Cytology and pathology specimens for There is at least one operating room at each of the the entire country are processed at the NRH and referred on hospitals visited. At the NRH, there are four functioning to the Royal Brisbane Women’s Hospital Pathology Lab- operating rooms. At Gizo, Kilu’ufi, and Atoifi, there is a oratory. The test results for these specimens take up to major functioning operating room and a minor one. Both 6 weeks to return.

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Table 2 Hospital infrastructure at site visited hospitals including admission statistics from 2008 Hospital Communication Running Electricity Oxygen Working No. of No. of Total Surgical water sourceb anesthesia operating beds admits/year admits/year machine theatersc

NRH P/I/SWR Yesa Yes Yes Yes 4 305 11,000 1029 Gizo P/I/SWR Yesa Interrupted Yes Yes 2 60 [400 [35 Taro P/I/SWR Yes Interrupted Yes No 1 29 [400 [25 Tulagi P/I/SWR Yes Yes Yes No 1 26 [500 [30 Atoifi P/I/SWR Yes Interrupted Yes Yes 2 80 [1200 [340 HGH P/I/SWR Yes Yes Yes No 1 55 [500 [100 Sasamunga SWR Yesa Interrupted Interrupted No 0 30 [300 [10 Kilu’ufi P/I/SWR Yes Yes Yes Yes 2 140 [1200 [200 GSH P/I/SWR Yes Yes Yes No 0 20 [700 [10 Total 745 2679 (estimated) P phone, I internet, SWR shortwave radio, Admits admissions, NRH National Referral Hospital, HGH Helena Goldie Hospital, GSH Good Samaritan Hospital a Areas of the hospital have had extended disruption of their water supply b Oxygen source can be tanks or oxygen concentrators c Includes both minor and major theaters

Communication systems at nearly all the hospitals of Medicine Surgery program at UPNG and School of consist of a telephone, dial-up Internet, and shortwave Medicine. NRH is an accredited UPNG surgical training radio. There are frequent interruptions in the telephone and site. All of these surgical trainees are from Solomon Internet services. Shortwave radios are the most reliable Islands. The orthopedic surgery trainees receive their means of communicating between provincial hospitals, the training in conjunction with the Australian Orthopedic NRH, and village-based health clinics. Patient transporta- Association. At the time of this study, there were three tion between hospitals is by ferry, outboard motorboat, fully trained anesthesiologists on staff at the NRH. One canoe, or interisland flights. The cost of transportation and was from Cuba and would end her tour at the NRH in repatriation of patients to hospitals for treatment is pro- January 2011. Approximately 80% of the surgeries are vided by the Ministry of Health. This cost is estimated to performed under general anesthesia with halothane as the be more than $250,000 US per year. The average distance a most common inhalation agent. The remaining 20% of patient must travel to get treatment at the NRH is more surgeries are conducted using spinal or regional anesthesia. than 240 km (150 miles) with a range of 40–600 km. The There are no fully trained anesthesiologists, surgeons, or Regional Assistance Mission to Solomon Islands (RAMSI) obstetricians on staff at the provincial hospitals. Periodi- and Aspen Medical Services provide emergency medical cally, there is a surgeon working in residence at Atoifi evacuation by helicopter. The average number of patients Hospital. An Ob-Gyn doctor provides obstetrical as well as evacuated by helicopter from the provinces to the NRH is some surgical care at HGH. Doctors who have completed a approximately 20 per year. broad-based 2-year internship program—medicine, pedi- atrics, some basic surgical and obstetric techniques, basic Workforce anesthesia—staff the provincial hospitals. Provincial doc- tors provide their own anesthesia for the procedures they There is a significant workforce deficit on every level of perform. It consists of local, regional, and spinal anesthe- surgical care in Solomon Islands (Table 3). There are three sia. At Atoifi hospital, there is a nurse-anesthetist who can full-time general surgeons, one full-time orthopedic sur- provide general anesthesia. The most commonly used geon, and one full-time and one part-time obstetrician/ anesthetic agent in the provincial hospitals is ketamine. gynecologist (Ob/Gyn) to provide care for more than With the exception of the nurse-anesthetist at Atoifi, there 600,000 people. All of them are based at the NRH on are no physician extenders (i.e., nurse-practitioners or Guadalcanal. These doctors received their training in the physicians’ assistants) working in Solomon Islands. Master of Medicine program (MMed) at the University of Twice a year, surgical teams consisting of one surgeon Papua New Guinea (UPNG) and some advanced specialty and one anesthesiologist from the NRH travel to some of surgery training in Australia and New Zealand. The general the provincial hospitals (Gizo, Kilu’ufi, Lata) on a surgical surgical trainees working at the NRH are from the Master tour. International surgical teams, such as from Interplast

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Table 3 Surgical workforce Hospital Surgeon Anesthesia OB/gyn MO surgeona MO anesthesiaa Nurse anesthetist Surgical technician

NRH 4b 3c 24 3 0 0 Gizo 0 0 1 4 4 0 0 Taro 0 0 0 1 1 0 0 Tulagi 0 0 0 1 1 0 0 Atoifi 1d 000 0 1 0 HGH 0 0 1 0 0 0 0 Sasamunga 0 0 0 0 0 0 0 Kilu’ufi 0 0 0 3 3 0 0 GSH 0 0 0 0 0 0 0 Total 5 3 4 13 0 0 This table records the number of fully trained surgeons, anesthesiologists, and obstetricians on staff a MO indicates a registrar or trainee as well as provincial doctors who may provide limited surgical and anesthesia care but are not fully trained in surgery, anesthesia, or obstetrics and gynecology. With the exception of Atoifi Hospital’s nurse anesthetist, there are no physician extenders currently working in the Solomon Islands b NRH surgeons include three full-time general surgeons and one orthopedic surgeon c One anesthesiologist is from Cuba and will be returning back to Cuba in early 2011 d Surgeon is available for periods of time; otherwise, there are large periods of time without a surgeon and the Loloma Foundation, conduct surgical tours that are problem for the health care system in Solomon Islands. coordinated with Ministry of Health and the surgeons at the These patients have, on average, hospital stays of more NRH. than 30 days and occupy more than 50% of the general surgery beds at the NRH. Another 8% of the admissions are Surgical interventions for malignancies. At least 50% of the general surgery patients treated at the NRH are referred in from the pro- Of the surveyed major and minor surgical procedures listed vincial hospitals. The mortality rate on the surgical service in Tables 4 and 5, all are provided at the NRH and at Atoifi was a mere 1.7% [9]. This number does not take into Hospital when there is a surgeon in residence. Surgical account the potential surgical patients who die in the services provided at the provincial hospitals are predomi- emergency room and out in the provinces, nor does it nantly minor procedures, with some exceptions. At Gizo, include patients whose families chose to take them home to HGH, and Kilu’ufi hospitals, a provincial doctor provides die. Nonetheless, this low mortality rate is a remarkable emergency obstetric procedures such as cesarean section. feat considering that just three general surgeons provide all As a general rule, however, the provincial hospitals diag- the surgical care for the entire country. nose, resuscitate, and refer surgical patients on to the NRH. More than 50% of the orthopedic surgeries performed at The most common reason given for referring patients is the the NRH are to treat trauma-related injuries. The most provincial doctor’s lack of skills. common forms of trauma are pedestrian and motor vehicle Of the total number of admissions to the NRH, surgical accidents, falls from palm trees, blast injuries, penetrating admissions accounted for just over 10%. This is surpassed trauma, and burns. Obstetric emergencies comprise 15% of only by postnatal admissions at 36%. The total number of the surgical cases at the NRH. The obstetrics care unit all surgeries performed at the NRH in 2009, including admitted 5600 patients in 2009, with 10% of deliveries at general surgery, orthopedics, ophthalmology, and obstet- the NRH done by cesarean section. Only a limited number rics and gynecology, was approximately 8000. This of cesarean sections are done in the provinces. includes the surgical care provided by visiting specialty The NRH has a program that refers adult patients with surgical teams from Australia and the United States. In advanced surgical problems to St. Vincent Hospital in 2009, there were 1332 general surgical admissions and Sydney, Australia for pro bono treatment. It is known as 1980 general surgery operations performed at the NRH. In ‘‘the 10-bed arrangement.’’ Patients with curable but all, 80% of these operations were emergency cases that advanced diseases such as brain tumors, cardiac valve resulted in cancelation or delay of scheduled elective sur- disease, and complex head and neck tumors who are geries. More than 8% of general surgical admissions are for approved by the Overseas Referral Committee go to St. diabetic foot infections, which are a rapidly escalating Vincent’s for treatment. The Rotary Club in Honiara assists 123 1188 World J Surg (2011) 35:1183–1193

Table 4 Major surgical procedures performed at each site Hospital Laparotomy Appendectomy Hernia repair Prostatectomy, urethral dilation Cesarean section Closed fracture treatment

NRH Yes Yes Yes Yes Yes Yes Gizo No No No No Yes Yes Taro No No No No No Yes Tulagi No No No No No Yes Atoifi Yesa Yesa Yesa Yesa Yesa Yesa HGH Yes Yes No No Yes Yes Sasamunga No No No No No No Kilu’ufi No No No No Yes Yes GSH No No No No No Yesb Yes procedure is provided at that hospital with regularity, No procedure is referred on to the NRH due to the lack of skills or equipment a Surgery provided if a surgeon is visiting the hospital b Referred to NRH for final treatment and follow-up

Table 5 Minor surgical procedures performed Hospital Cricothyroidotomy, Removal of foreign Wound Circumcision Vasectomy Suture closure tracheostomy bodya debridement wounds

NRH Yes Yes Yes Yes Yes Yes Gizo No Yes Yes Yes Yes Yes Taro No Yes Yes No Yes Yes Tulagi No Yes Yes Yes Yes Yes Atoifi Yesb Yesb Yesb Yesb Yesb Yesb HGH No No Yes Yes Yes Yes Sasamunga No No No No No No Kilu’ufi No Yes Yes Yes Yes Yes GSH No No Yes No No Yes Yes procedure is provided at that hospital with regularity, No procedure is referred on to the NRH due to the lack of skills or equipment a Removal of foreign bodies from throat, eyes, ears, and nose b Surgery provided if a surgeon is visiting at the hospital in locating pediatric specialists and hospitals throughout Medical equipment such as endoscopes, US machines, Australia. Unfortunately, the need in these referral pro- and anesthesia machines break down because they are old, grams exceeds the positions available for patients. or they do not undergo regular maintenance. There are long delays in obtaining new equipment and replacement parts Equipment for broken equipment, as they must be shipped in from Australia. The Ministry of Health services must approve all Consumable essential surgical equipment is available costly medical equipment orders, such as endoscopes or US throughout the hospitals visited but in limited amounts machines as hospitals do not have budgets for purchasing (Table 6). Many items found in supply rooms had expired. equipment. The hospitals that provide the most surgical care—NRH, Atoifi, HGH—tended to be the best stocked with con- sumable supplies. Only two hospitals failed to have ade- Discussion quate stores or access to all of the essential surgical supplies (Sassamunga, GSH), which might be because they The problem of delivering surgical care in developing provide no surgical care there. Medical and surgical sup- countries is not a new one. During the past 6 years dis- plies are ordered through the National Medical Store, cussions on how to address this problem have increased as located in Honiara on Guadalcanal. Irregular shipping to interest in global health has increased. A number of well provinces and delays in ordering have adversely affected recognized global health and development organizations the availability of supplies. have set priorities for strengthening the delivery of surgical

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Table 6 Available consumable essential surgical supplies Hospital Resuscitation Oropharyngeal Sterile Basic surgical Sterilizer Nasogastric IV fluids and Suction bag airwaya gloves instrumentsb tubes infusion sets pump

NRH Yesa Yes Yes Yes Yes Yes Yes Yes Gizo Yesa Yes Yes Yes Yes Few Yes Yes Taro Yes Yes Yes Yes Yes Few Yes Few Tulagi Few Yes Yes Yes Yes Yes Yes Few Atoifi Yes Yes Yes Yes Yes Yes Yes Yes HGH Few Yes Yes Yes Yes Few Few Few Sasamunga Few Few Few Few No Few Few No Kilu’ufi Yesa Yes Yes Yes Yes Yes Yes Yes GSH Few Few Yes Yes No Few Yes No These data were put together after interviewing hospital staff and inspecting their supply rooms. It does not denote whether consumable supplies are expired or old Few a limited supply or items run out before being replenished, Yes item is available at all times a Both adult and pediatric cases b Includes scalpel, forceps, clamps, scissors, retractors, needle driver, steel kidney basin, and vaginal speculum care in developing countries. This is evidenced by the curriculum of training programs that includes general creation of the WHO GIEESC [3], and the World Bank’s surgery, urology, orthopedics, obstetrics/gynecology, inclusion of a chapter on surgery in the second edition of emergency care, and anesthesiology to make surgeons as Disease Control Priorities in Developing Countries [10]. self-sufficient as possible [24]. In formulating the present In the United States, universities, organizations, and indi- article’s discussion on how to strengthen the surgical viduals have created global surgery partnerships, such as capacity of Solomon Islands, we outlined the initial steps the American College of Surgeons’ Operation Giving that would be taken to meet the baseline surgical capacity Back, the Society of International Humanitarian Surgeons standards as suggested by Gosselin et al. [24] and by the (SIHS), Global Partners in Anesthesia and Surgery WHO GIEESC [25]. (GPAS), and the Alliance for Surgical and Anesthesia This survey article is the first to report in detail on the Presence (ASAP). These partnerships advocate for an availability of surgical services throughout the Solomon increasing role of surgical care in global health planning. Islands. Several papers have described surgical care needs Paul Farmer, an infectious disease specialist and well in Papua New Guinea and the surgical training program known humanitarian with Partners in Health, and his that was developed to increase surgical care delivery in that coauthor Kim referred to surgical care as ‘‘the neglected country [26–28]. The results that the Health Service in stepchild’’ of global health [11]. There has been a perfusion Papua New Guinea have achieved with their Master of of articles that attempt to define the burden of surgical Medicine program is a potential model for improving diseases in low-income developing countries [12–16]. A surgical care in developing countries and specifically in number of authors have published articles describing the their neighboring country, Solomon Islands. Through their state of surgical care in specific developing countries comprehensive, local surgical training program, the UPNG [4, 17–23]. Although these countries are from different has graduated 51 surgeons, 18 anesthesiologists, and 19 regions of the world, they have a consistency of problems obstetricians and gynecologists since 1978. Some of these with infrastructure, workforce and training, procedures graduates are working in Solomon Islands today. The performed, and availability of equipment. program’s strengths include: training based on local needs, Standards for providing safe surgical care have been training that is controlled and certified by the local Ministry described by Debas et al. [10]. Table 7, which originally of Health, judicious use of expatriate surgeons for training appeared in their publication, lists the requirements for until self-sufficient, and finally careful consideration of the providing adequate surgical services at community clinics, mix of in-country and overseas surgical training to improve district or provincial hospitals, and tertiary care centers or standards without incurring workforce losses due to brain referral hospitals. They include recommendations on drain. infrastructure, equipment and supplies, human resource, The WHO’s GIEESC Needs Assessment Tool is a user- and services that should be available at each site. In a more friendly method to collect data efficiently on the state of recent publication, Gosselin et al. recommended a surgical surgical care. It has the ability to standardize information

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Table 7 Surgical capacity strengthening recommendations machines need to be serviced on a regular basis by a bio- 1. Strengthen skills of current surgeons medical engineering team. Solomon Islands is a country located in a seismically 2. Strengthen services available at the NRHs by surgical academic twinning programs active area, which makes the islands vulnerable to earth- 3. Establish a surgical training program locally quakes and ensuing tsunamis. In 2007, a tsunami in the 4. Extend surgical services to the provincial hospitals western province damaged Gizo Hospital, one of the busier 5. Establish regular CME programs in the country or region provincial hospitals in Solomon Islands. The same tsunami 6. Connect all hospitals via electronic records, database, and devastated Sassamunga Hospital, located on the south- teleconferences western coast of Choiseul Island. The main building and 7. Improve infrastructure at the NRHs and provincial hospitals nearly all the medical equipment were seriously compro- 8. Improve salaries for surgeons and reward further training mised by water damage. Under these conditions, disaster relief planning must be included in any hospital policy. NRHs national referring hospitals, CME continuing medical education The lack of a surgical workforce is one of the greatest From Debas et al. [10] problems developing countries face when establishing surgical care in their communities. At present, Solomon Islands is no different, although it has real potential to across many countries. It does need some modification of change in the near future. Currently, 74 Solomon Island information gathered, especially in reference to transpor- students are studying medicine in Cuba. The first wave of tation and communication. We thought that this informa- these students will graduate in 2013 and will return to tion was pertinent to the delivery of surgical care in a Solomon Islands for internship training. The first work- country made up of many widely scattered islands, and we force challenge the Solomon Islands Ministry of Health took the liberty to include information about patient will have to face is how to establish quality training for this transportation and the availability of telephone, Internet influx of new graduates. Every effort should be made to and shortwave radio communication. keep their training in Solomon Islands or at the very least in Despite the presence of an operating theater in nearly the western Pacific. every provincial hospital, surgical services in Solomon At present, new graduates complete their internship Islands remains centralized to the NRH on Guadalcanal. training at UPNG School of Medicine or Fiji School of This creates a problem of access for the 82% of people Medicine. After an internship they spend 2 years working living in the outer provinces, and it results in delays in as an unsupervised provincial doctor. This experience diagnosis of surgically curable diseases. Although infec- allows new graduates to build their confidence and to tious diseases are still the major causes of morbidity and experience the holistic approach from public health to mortality in Solomon Islands, there has been a steady curative medicine before deciding on their future career increase in the incidence of noncommunicable diseases path. A broad ‘‘provincial doctor’’ curriculum for intern- such as cancers of the cervix, breast, thyroid, lung, and oral ship that includes 6 months of medicine, obstetrics and cavity [29]. Patients with breast cancer present with gynecology, pediatrics, and surgery can easily be estab- advanced-stage disease owing to the lack of a breast cancer lished in Solomon Islands, as the curriculum already exists screening program. Diseases associated with affluence, at the UPNG School of Medicine. A Masters of Medicine such as diabetes mellitus and hypertension, are increasing (MMed) program for specialization in surgery, anesthesia, as well. These increases in noncommunicable diseases and obstetrics and gynecology should also be established in have put additional demands on the surgical services as conjunction with the UPNG School of Medicine or the Fiji evidenced by the number of patients with diabetic foot School of Medicine. To expedite an increase in the number infections occupying the surgical beds at the NRH. of fully trained surgeons in the country, some of the All of the hospitals in Solomon Islands have infrastruc- members of the first class of interns who demonstrate ture deficiencies of water supply, power, oxygen, and strong skills in obstetrics and gynecology, anesthesia, and functioning anesthesia machines. The lack of running water surgery should go directly into the MMed program, on some of the wards at the NRH and other provincial bypassing the 2 years of provincial service. The Solomon hospitals poses an infection hazard. Water, oxygen, and Islands Ministry of Health should certify both the intern- electricity (whether supplied by solar power, grid, or a ship program and the MMed program. At the inception of generator) must be reliable in the provinces to establish this program, recruitment of fully trained expatriate sur- emergency and essential surgical care there. The surgical gical specialists may be needed to assist the current sur- equipment needed to accomplish this should be stocked and gical, anesthesia, and obstetrics and gynecology staff with replaced on a regular basis. Anesthesia machines, blood teaching and training. As the number of Solomon Island banks, medical laboratory equipment, and radiography specialists increases, the Ministry of Health and the 123 World J Surg (2011) 35:1183–1193 1191

Solomon Island doctors will assume the responsibility of shared. It will also make work in the provinces seem less training new graduates, making the program a sustainable isolated. Medical textbooks and an electronic medical one. library should be established at each hospital. Continuing The NRH should be the main hub of education and medical education and membership in professional socie- training, and it should be strengthened as a tertiary referral ties should be encouraged and supported. Surgical, critical patient care center. Surgical services should be expanded to care, and obstetric nursing training must be included in this include laparoscopic and arthroscopic procedures as the type of training scheme and can be overseen by Atoifi infrastructure at NRH allows. Critical care services and an Nursing School or Solomon Islands College of Higher intensive care unit should be established at NRH as well as Education. at the new Gizo Hospital, which will become Solomon The use of electronic medical records and clinical data Islands second largest hospital once completed in 2011. based on the International Statistical Classification of Mammography, breast screening, and surgical treatment Diseases and Health-related Problems, 10th Revision programs should be established. With the rise in the inci- (ICD 10) is currently being established in Solomon Islands. dence of cancer, the need for interpretation of biopsies will Progress is slow in its development owing to infrastructure increase. The pathology service at NRH will need to be and training constraints, but it is being set up initially at the strengthened. Tissue should be processed on site at the NRH where the surgical capacity and workload is the NRH, with the availability of a TelePathology program to greatest. This type of biometric tool will allow the hospi- aid in the reading and interpretation of specimens [30]. tals, Ministry of Health, and Public Health Division to This will allow timely biopsy results and the development track improvements in surgical care as well as outcomes of advanced histopathology training. and volume. Specialty surgical, obstetrical, and anesthesia educa- To prevent brain drain, the Ministry of Health must tional exchange visits can provide intensive short-duration commit to improving salaries, work conditions, and access training at the NRH as well as at the provincial hospitals. to professional development. They must also provide well The Scripps-Fiji Alliance, the academic arm of the Loloma stocked hospitals and clinics. In return for better support, Foundation (E.S.N., P.L.H.), has had a great deal of success the surgical staff must maintain adequate skills to provide using this type of ‘‘twinning’’ partnership to strengthen most surgical procedures locally, thereby saving the Min- surgical and critical care at the Colonial War Memorial istry of Health the cost of transporting patients from the Hospital in Suva, Fiji. The program is currently underway provinces to the NRH for treatment [7, 32]. Advanced and/ in Solomon Islands through one-on-one teaching of Solo- or specialized training should be made available to the mon Island surgical and anesthesia trainees as well as surgeons on staff with a balance between in country and surgical skills training for provincial doctors. ‘‘Twinnings’’ overseas training. or academic partnership programs such as the Scripps-Fiji Nongovernment hospitals can play a role in the training Alliance have been successful in Sub-Saharan Africa and enhancement of surgical care in Solomon Islands. [22, 31]. There is one limitation to this type of program: Atoifi and HGH are excellent hospitals with good surgical The training and partnership is only at the main teaching provisions and should be included as training sites. The hospital and does not extend out into the areas of the added workforce and financial support from the Ministry of country where most people live. Provincial hospital sur- Health would be welcomed by these church-supported gical care must be strengthened as well. Loloma Founda- hospitals. Unfortunately, GSH and Sassamunga hospitals tion and the surgeons at the NRH have found that working fall short of any potential to provide meaningful surgical with surgical trainees and provincial doctors at the pro- care owing to severe deficits in all of the areas evaluated. vincial hospitals shows these doctors and the Ministry of Therefore development as a high-level specialty clinic, Health that with a modest investment surgical care can be rather than a surgical care center, should be encouraged. extended to these outer island hospitals. A ‘‘twinning’’ Fortunately, both of these hospitals are located close to program with a nursing school that supports advanced other, more functional hospitals. The use of cluster sam- nursing training should be established as well. pling in villages may help determine the potential, but In a formal training program, trainees should rotate untreated, surgical disease as well. The Solomon Island between the NRH and the provinces to improve surgical Department of Public Health has demonstrated that cluster care in the provinces and provide a wide variety of expe- sampling to determine burden of disease can be accom- rience in the number of cases for surgical trainees. Each plished, as demonstrated in a recent report on risk factors provincial hospital must be connected with the NRH and a associated with noncommunicable diseases [29]. postgraduate training institution (e.g., UPNG or the Fiji Solomon Islands is a country with serious deficiencies in School of Medicine) by advanced and reliable telecom- surgical and emergency obstetric care and anesthesia munications so educational and clinical information can be delivery at its provincial hospitals. These deficiencies are 123 1192 World J Surg (2011) 35:1183–1193 no different from those reported in Sierra Leone, Uganda, Finally, the WHO’s commitment to strengthening surgi- Mozambique, and other low- and medium-income devel- cal capacity in resource-poor countries should be mentioned, oping countries (LMICs). What sets Solomon Islands apart especially in light of the recent withdrawal of funding for from these other countries, however, is the country’s small GIEESC. The GIEESC has given international surgeons and size, its infrastructure potential, and the fact that it is poised ministries of health a set of guidelines that allow evaluation to increase significantly the number of physicians working of their current surgical capacity using a highly intuitive in the country within the next 5–10 years. Recruitment and system: the Situational Analysis Assessment Tool. Armed the education of doctors in developing countries is one of with these data, health delivery systems in these resource- the most difficult aspects of improving care. Workforce poor countries have begun to initiate changes in surgical care shortages in Sub-Saharan Africa and Haiti have been and based on the minimum standards put forth by WHO GIEESC are being addressed by training nonphysicians to provide on anesthesia infrastructure, surgical equipment, and best surgical and anesthesia care [33–36]. Physician extenders practice protocols in surgical delivery [25]. have been shown to be good short-term solutions to a shortage of surgical workforce, but a real long-standing Acknowledgment The authors funded this work personally. solution that improves overall surgical care in Solomon Islands is an injection of fully trained surgeons, obstetri- cians, and anesthesiologists working at key strengthened References hospitals in the provinces. With at least 75 new doctors on the verge of entering the Solomon Islands’ medical system, 1. Anonymous (2007) Bellagio Essential Surgical Group Report. http://globalhealthsciences.ucsf.edu/bellagio/docs/bellagio_report. ‘‘surgical extenders’’ may not be necessary, although they pdf. Accessed 26 Oct 2010 should be considered as a cost-effective workforce 2. 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