Twinning partnerships for improvement: recovery partnership preparation package: building capacity to reactivate safe essential health services and sustain health service resilience

MEETING REPORT

WHO Global Initiative for Emergency and Essential Surgical Care Sixth Biennial and Tenth Anniversary Meeting

14-15 December, 2015 WHO Headquarters Geneva, Switzerland

Emergency and Essential Surgical Care Services Organization and Clinical Interventions Unit Service Delivery and Safety Department World Health Organization

© World Health Organization 2016. All rights reserved.

WHO/HIS/SDS/2016.11

Contents Page Number

1. Executive summary 2. Background 3. Objectives 4. Session I - Opening session - Celebration of 2015 4A. Surgery within the context of universal health coverage and quality care 4B. Surgery within the framework of integrated people-centred health services 4C. Global surgical workforce update 4D. Surgery within the context of emergency care 4E. Evolution of EESC at WHO culminating in a WHA resolution 4F. Impact of the resolution at regional and country level 4G. Fifty years of surgery at WHO 4H. Presentation of the First WHO GIEESC Distinguished Service Award 5. Session II - Presentations, Q&A, Working groups 5A. Objectives and overview of the sessions 5B. Advocacy and resource development 5C. Access, governance, integrating systems, quality, partnerships 5D. Working groups and plenary discussions 6. Session III - Presentations, Q&A, Working groups 6A. Data collection, Analysis, Sharing, E&M 6B. Essential medicines: Ketamine and narcotics 6C. Antimicrobial Resistance 6D. Working group and plenary discussions 7. Session IV - Presentations, Q&A, Working groups 7A. GIEESC Next Steps 7B. Global Surgery: A novel and innovative training programme 7C. Training, competence, credentialing, oversight 7D. Working group and plenary discussions 8. Annexes 8.1 List of participants 8.2 Programme agenda

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1. Executive Summary The sixth meeting of the Global Initiative for Emergency and Essential Surgical Care (GIEESC) was convened on December 14-15 at the headquarters of the World Health Organization in Geneva, Switzerland. GIEESC was established in December 2005, and represents the first coordinated effort to address the lack of adequate capacity for emergency and essential surgical care services at the primary referral level in low and middle-income countries (LMICs). The purpose of the meeting was to convene GIEESC members to discuss important current developments and their implications, especially World Health Assembly Resolution 68.15: Strengthening Emergency and Essential Surgical Care as a Component of Universal Health Coverage, as well as the roadmap towards implementation of this resolution.

2. Background Deficiencies in access to emergency and essential surgical and anaesthetic services result in unacceptably high rates of death and disability from a host of surgical conditions, especially at primary health care facilities in LMICs where there are significant gaps in terms of infrastructure, physical resources and supplies, as well as human resources for health. With the goal of strengthening emergency and essential surgical care at the primary referral level, WHO established the Clinical Procedures Unit (CPU) in 2004, which was charged with “ensuring efficacy, safety and equity in the provision of clinical procedures in surgery, anaesthetics, obstetrics, and orthopaedics, particularly at the district hospital level” and “promoting the appropriate effective and safe use of cell, tissue, and organ transplantation”. The Services Organization and Clinical Interventions Unit (SCI) has since replaced CPU, although programmes and goals of the EESC programme have remained constant. The Emergency and Essential Surgical Care Programme (EESC) cuts across a wide variety of vertical initiatives which each include components of surgical care, such as maternal and child health, male circumcision to prevent HIV transmission, Buruli ulcer, violence and injury prevention, and many others. Activities have been focused at the countrylevel, and have encouraged collaboration between WHO, ministries of health, and both local and international partners. Training materials produced include the Integrated Management of Emergency and Essential Surgical Care (IMEESC) toolkit and a reference manual entitled Surgical Care at the District Hospital. The IMEESC toolkit is a flexible template which may be adapted to local needs, to transfer appropriate technology to primary health centres. Core components include 1) Policies (standards, needs assessment (Situational Analysis Tool), essential surgery equipment, anaesthetic infrastructure and supplies), 2) Capacity building (integrated workshops to “train the trainers,” which include Emergency Trauma Care Course and an eLearning platform), and 3) Reference manuals (“Surgical Care at the District Hospital,” as well as slides and other teaching materials), and quality/safety materials (best practices on safety procedures, equipment, disaster situations, monitoring and evaluation of programmes). The Global Initiative for Emergency and Essential Surgical Care (GIEESC) was inaugurated in December 2005 at WHO headquarters in Geneva, and encourages collaboration between a diverse group of individuals, institutions and organizations from various disciplines, all concerned with improving access to safe, timely and quality surgical services, especially at the district level in LMICs. The ultimate goal is to strengthen local and country health care systems by better integrating emergency and essential surgical care and anaesthesia into health system strengthening activities, which will require a multidisciplinary, multisectoral effort. Currently, GIEESC has over 2100 members spread across 140 countries. 3

3. Objectives The specific objectives for this sixth WHO GIEESC meeting were: • • • • to gather input to finalize the roadmap towards implementation of WHA resolution 68.15 that reflect priorities and needs at country level; to develop a final draft of the roadmap; to reach clear understanding of key roles and timelines of Member States and WHO Secretariat in working towards implementation of the resolution; to discuss next-steps forward for WHO GIEESC

4. Session I – Opening Session - Celebration of 2015 • Introduction by the Session Chairman Dr Emmanuel Makasa

Dr Emmanuel Makasa provided an introduction to guide the discussions that would follow for the next two days. He noted that the implementation of WHA resolution 68.15: Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage, would require a commitment from both the World Health Organization and its Member States, including at the national, regional and local levels within countries. National leadership will be of key importance during the implementation phase. There will be the need to bring multiple partners together for a concerted effort, including departments at the World Health Organization and other UN agencies, Member States, non-governmental organizations, professional associations and other organizations and individuals. These entities must work in conjunction as a single unit to engage with Member States to implement this resolution. This must be well organized, as “actualization is the most difficult”. 4A. Surgery within the context of Universal health coverage and quality care Dr Edward Kelley Dr Kelley’s presentation focused on surgery as an essential element of both primary healthcare and universal health coverage. He emphasized that the global public health agenda is “extremely crowded” and that the community of individuals and institutions with an interest in promoting the surgical agenda will need to come together now. While universal health coverage is the over-arching concept, the sustainable development goals will also be important over the upcoming years. We, as a group need to focus on how emergency and essential surgical care will increase access to quality services. Discussions will be most important at the country level. The gradual evolution of surgical care at the World Health Organization has included the early work involving patient safety and quality, for which a World Health Assembly resolution (WHA 55.18) came to fruition in 2002, which recognized “the need to promote patient safety as a fundamental principle of all health systems”. These efforts led to the birth of the World Alliance for Patient Safety in 2004. Recently there has been significant interest in healthcare associated infections, due to the significant accompanying morbidity, mortality and associated costs. Surgical site infection has also been highlighted. We have seen the emergence of checklists in health service delivery, most notably the WHO Surgical Safety Checklist in 2009. Dr. Kelley discussed the “improvement 4

continuum”, beginning with implementation of that checklist, which has resulted in enhanced surgical safety and safer health care delivery, improved quality of care, robust people-centred health service delivery. All of these steps result in stronger health systems. With regard to the implementation of universal health care, and surgery within the context of this, Dr Kelley discussed the modification of a “cube” which graphically describes the three dimensions to consider when moving towards universal health coverage, namely 1) which services are covered, 2) who is covered, and 3) financial risk protection. He also mentioned that there should be explicit consideration of quality and safety within the cube, as both are essential components of service delivery. Universal coverage of essential surgery will require approximately $300 billion above current levels of funding, over the next 15 years but would produce a benefit to cost ratio of more than 10 to 1. He then outlined the complex nature of service delivery, with people at the centre, surrounded by important concepts including health promotion, prevention, treatment, palliation, and rehabilitation. Care should be people-centred, of high quality, and ideally delivered within the context of community-based financing. Coverage should be expanded, with quality parameters embedded in enhancing coverage, and the range of surgical interventions meeting the local population’s needs. A comprehensive package must be offered with quality, timely service delivery, and financial risk protection as preconditions. Components of transformative change will include weaving quality into the fabric of the universal health coverage cube, placing people at the centre of service delivery, integrating monitoring and improvement, applying quality improvement tools, developing strong national health policies and strategies surrounding surgical services, and working together to develop contextually relevant solutions with links to the regional and global architecture. There are also important links to target Goal 3.8 of the Sustainable Development Goals, to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services, medicines and vaccines for all.” 4B. Surgery within the framework of integrated people-centred health services Dr Hernan Montenegro Dr Hernan Montenegro looked at surgery through the lens of the framework on integrated people-centred health services. He noted that the challenges with strengthening health-care delivery with better surgical services are immense, that partnerships will be required, and that we must all work within the context of the roadmap to advance our agenda. The mandates and commitments required in WHA Resolution 68.15 are explicit for both WHO Secretariat and Member States, and the work should be linked with the health system as a whole at the country level. Components include policies and financing; essential services including access and integration; quality; health care workers; infrastructure and medical devices, medicines and supplies; data and information; monitoring and evaluation; networks and partnerships; and advocacy. The development of appropriate policies and of mechanisms for financing surgical services will be critical, and the approach must emphasize quality and safety. Dr Montenegro outlined five general strategic directions, including creating an enabling environment, coordinating services, strengthening governance and accountability, empowering and engaging people, and reorienting the model of care, each of which have their own strategic goals and objectives. It will also be important to harmonize the humanitarian and development health response, through disease surveillance and early

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warning systems, emergency and preparedness response, along with emergency and essential surgical care. 4C. Global surgical workforce update Dr James Campbell Dr Campbell discussed surgical care within the context of the sustainable development goals (SDGs) as well as universal health coverage, and emphasized that improvements can only be captured if we have metrics. These will involve some joint work between the World Health Organization and the World Bank, along with other partners, with tracers for progress which include emergency and essential surgical care. He emphasized the importance of population coverage, people-centred service delivery, and financial protection from catastrophic expenditures. The “cube” of universal health coverage was discussed once again, in relation to the health workforce. The dimensions of the cube included peoplecentred and integrated services, population (including wealth quintiles), and risk protection. In looking at global indicators, there are eight key areas or “tracers,” one of which involves trauma and surgical care in the measurement framework. The others are child health, communicable diseases, non-communicable diseases, public health and global health security, mental health, sexual and reproductive health, and maternal and newborn health. In order to determine the number of health providers required, there are a number of questions to ask, including which interventions, which model, what competencies are required, which educational model for training, and what workforce will be required. The Lancet Commission on Global Surgery has suggested, as a minimum standard, a number of twenty surgical health providers, (defined as Surgeons, Anaesthetists and Obstetricians) per 100 000 population. Our current ability to reach accurate estimates of the surgical workforce is a challenge, as many countries do not have quantitative information on their workforce, and this is difficult to measure. Health workers move within and between countries. In some countries, more than 80% of surgical procedures are performed by non-surgeon health providers. A joint WHO/European Commission project is currently being carried out in five countries (Ireland, India, Nigeria, South Africa and Uganda) and phase I involves measuring stock and flow (entries and exits) of health workers in these countries. Multiple data sources will be utilized for this purpose. For example, in the state of Kerala in India, we know that there are between 2.6 and 6.8 providers per 100 000 population. Migration between countries is a significant issue, for example many graduates from Uganda can be found in other countries within Africa, and 51% of the surgical workforce in Ireland is made up of international medical graduates. There is a global strategy on human resources for health, and one target is that by 2020 all countries will be sharing data on human resources for health through National Health Workforce Accounts (NHWA) and submit core indicators to WHO annually. A number of organizations will contribute to this effort (WHO, OECD, ILO, World Bank, CDC, USAID, Member States, EU joint action on Health Work Force). Goals include a harmonized, integrated approach for an annual and timely collection of health worker information, improving the information architecture and interoperability, defining core workforce indicators, and defining reporting and open access for global public goods.

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4D. Surgery within the context of emergency care Dr Teri Reynolds Integrated emergency care is a broad platform for addressing a range of diseases, including injury, communicable and non-communicable diseases, and pregnancy-related complications. Whether the emergency care is framed by disease (injury or NCDs), condition severity (emergent), or an event (disaster or outbreak), surgical and anaesthesia care are critical aspects. Strengthening operative capacity at first-level referral facilities, such as district hospitals, is, therefore, central to implementing WHA resolution 68.15, and many have spoken to this. In addition, increasing capacity at the primary level of the health system for early recognition, resuscitation and transfer for surgical conditions will be key to a more effective utilisation of district-level surgical services. People accessing the system do not know whether their condition will require surgical care—in most parts of the world, adults and children are seen by front-line providers facing a range of undifferentiated conditions. Disseminating the knowledge and protocols to support these primary-level providers at the first point of access, both pre-hospital and at sub-district facilities—protocols to guide initial management and to facilitate direct transfer to facilities with operative services—will be key to effective and efficient utilization of strengthened operative capacity. In addition, developing these services will be essential to meeting the time-dependent surgical indicators currently under consideration. WHO offers an Emergency and Trauma Care System Assessment Tool, as well as a Basic Emergency Care course and a Trauma Care Checklist to support emergency care delivery. And on the other side of surgical services, early access to rehabilitation will be key to maximising the impact of expanded operative capacity. 4E. Evolution of EESC at WHO culminating in a WHO resolution Dr Meena Cherian Dr Meena Cherian described the surgical care programme at the World Health Organization from its inception in 2004 through the World Health Assembly resolution in 2015. Dr Cherian noted that while the case for emergency and essential surgical care was made by Dr Halfdan Mahler in 1980, by 2001 there was still no surgical care programme at WHO. There were challenges in framing surgical care to resonate with the public health agenda, but gradually data emerged from multiple sources. In particular, the public health community was made aware of the links between emergency and essential surgical care via existing public health programmes, including violence and injuries, pregnancy related complications, congenital anomalies, cancer and others. However these remained mainly vertical, so in 2004, WHO established the Emergency and Essential Surgical Care (EESC) Programme with the goal of ensuring the safety and efficacy of clinical procedures in anaesthesia, surgery, orthopaedics and obstetrics. This programme has aligned with a number of WHO strategies. The WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) was inaugurated in December of 2005 in Geneva with the principal goal of providing a convenient, global surgical forum of multi-disciplinary stake holders for expertise, partnerships, and collaboration, to strengthen the delivery of essential surgical services around the world. The GIEESC meetings have been held biennially and it currently counts 2,083 members from 140 countries. WHO has developed tools to meet local needs, including the Integrated Management for Emergency and Essential Surgical Care (IMEESC) toolkit, and the manual entitled Surgical Care at the District Hospital. The Situational 7

Analysis Tool (SAT) for assessing the specific infrastructure and availability of surgical services at facility level was developed in 2007 and has subsequently been utilized in 59 lowand middle-income countries, at a total of 1,700 health facilities. A global surgical workforce database has also been developed, and includes data from 164 countries. Numerous publications concerning the availability of essential surgical and anaesthetic services have been published using the SAT, and have outlined significant deficiencies in infrastructure, physical resources and supplies, and human resources available for essential surgical interventions. This has also identified gross deficiencies in the availability of anaesthetic services; it is clearly recognized that the role of anaesthesia extends well beyond the operating room to services which include pain relief, intensive care, and post-operative management. Data has also emerged concerning large gaps in the surgical workforce, both in terms of absolute numbers and their distribution. In addition to the many publications on emergency and essential surgical care, a number of global health programmes and academia, as well as professional societies are now addressing surgery as a global health issue. The literature has been greatly augmented by the third edition of Disease Control Priorities, with an entire volume devoted to Global Surgery. In addition, the Lancet Commission on Global Surgery has provided a wealth of additional information specific to the overwhelming unmet global need for surgical and anaesthesia services, particularly in LMICs. While a number of previous World Health Assembly resolutions touched on a component of surgical care, such as several disease-specific conditions linked to essential surgical services, no specific resolution had been passed concerned with emergency and essential surgical care alone, until the 68th World Health Assembly in 2015. Zambia made a proposal update at the WHO Executive Board meeting in January 2014, and within the next few months a report was prepared for the 135th WHO Executive Board meeting in May 2014. This report was then reviewed and approved at the 136th WHO Executive Board in January 2015, resulting in WHA Resolution 68.15: Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage, being unanimously adopted by the 68th World Health Assembly on 22 May, 2015. This resolution is now in the implementation phase, where Member State commitments now include integration of surgical services into national health plans, using data to drive health policies and planning, and investing necessary resources into strengthening surgical services. The WHO EESC secretariat has also committed to develop an action plan with a number of Member States through collaborations and partnerships to monitor and evaluate progress, quality and safety and report back to the World Health Assembly in 2017. Now there is a role for all members of WHO GIEESC to participate alongside colleagues, other partnerships, and with countries, to assist in the implementation of this resolution. 4F. Impact of the resolution at the regional and country level Dr Emmanuel Makasa Dr Makasa stressed the need to enhance awareness of the global surgery cause with the respective ministries within each Member State to explain how the new resolution will help to improve health services within their country, and the need for accountability. There will be an impact on health service delivery at multiple levels, including political, on health professionals and organizations, on the population, and even on the economy and sustainable development. Politically, there need to be national and regional commitments to implementation. Economically, it is recognized that enhancing the surgical workforce will 8

create employment opportunities for citizens and increase the tax base. Strengthening the delivery of surgical services may translate into better economic development, and will also strengthen the health system as a whole, thereby increasing service delivery to patients at the primary referral level in a number of ways. There will also be an impact on disaster preparedness and response. Referral systems must be strengthened between different tiers within the system. Ensuring quality and safety will be essential to enhance the utilization of health services. There will need to be an increase in the health workforce and in its distribution. Standards and protocols will have to be developed and training will be an essential component. Task shifting or task sharing will necessarily be embraced in many environments, and regulation of providers will be essential. This can only be fostered by collaboration and partnerships. There must be a consistent message with which to approach governments and funding agencies. Dr Makasa discussed the Sustainable Development Goals, including a detailed analysis of the targets within Goal number three. Strengthening the delivery of surgical services will also have an impact on Goals one and five. The key will be implementation, riding the momentum of the resolution and beginning to make changes at the country level. 4G. Fifty years of surgery at WHO Dr William Gunn Dr William Gunn reflected on fifty years of surgery, or specifically “a lack of surgery” at the World Health Organization. When he began his employment in 1967, there was no surgical department although “there was some interest in emergency and disaster situations.” However, there was no surgical response to deal with mass casualties. In 1977, he expressed the need for “essential surgery” at a meeting in Dallas, Texas. The Alma Ata declaration came about in 1978, and while surgery was not specifically cited, it was implied. WHO Director General, Dr Mahler gave his important address in 1980 to the International College of Surgeons in Mexico City, Mexico, where he emphasized the importance of surgical care within the context of primary care. In 2004, Surgical Care at the District Hospital was published. 4H. Presentation of Award In a surprise presentation, the first WHO GIEESC Distinguished Service Award was presented to Dr Meena Cherian for her many years of dedicated service to the Global Initiative and to her numerous contributions to the field of global surgery.

5. Session II – Presentations, Q&A, Working groups 5A. Objectives and overview of the sessions Dr Walt Johnson 5B. Advocacy and resource development Dr Andres Rubiano Dr Rubiano discussed efficacy and resource development, mainly in relation to trauma and emergency care in Colombia. It is clear that there is enormous global impact from traumatic injuries, which mainly impact economically active people between 10 and 45 years of age. Injuries are a common cause of both mortality and morbidity, especially road traffic 9

crashes. But with regard to the neurosurgical community, the international ratio is approximately one neurosurgeon to 230 000 people. In low-income countries, only 6% of neurosurgeons are available to take care of 34% of the world’s population. Similar disparities are seen in critical care. For example, in Uganda, there is only a single intensive care unit bed for every one-million population. In an audit within Uganda, head injuries were a common reason for ICU admission, and also the most common cause of mortality in this setting. Ideally, a neurosurgeon would be present to care for those with head injuries within the intensive care unit setting. The reality is that in most circumstances either a general physician or a general surgeon would serve in that role. Thus, the most appropriate solution over the short term would be to provide extra training for those responsible for caring for these patients with head injuries. In addition to training individuals, consideration needs to be given to how to better organize the delivery of essential services, and also increase data collection and analysis. Contextual variables are important when setting up a programme of neurotrauma and critical care, as well as advanced training of non-neurosurgeons. Adhering to standardized plans of care will likely improve outcomes as well. 5C. Access, governance, integrating systems, quality and partnerships Dr Villami Tangi This presentation concerned the Kingdom of Tonga’s experience in perioperative mortality, as well as the training of specialists in the Western Pacific Region. Tonga is a small island in the Pacific with a population of just over 103 000 people. Regional stake holder meetings suggested two indicators of post-operative mortality rate (POMR), the POMR 24 in which death occurred on the day of surgery or within 24 hours of surgery, and POMR 30 in which death occurred after the first 24 hours and within 30 days of the date of surgery. Data was collected for the years 2012, 2013 and 2014. With regard to the POMR 24, the rate was 0.03% in 2012, 0.0% in 2013, and 0.059% in 2014. Data for the POMR 30 included 0.43% in 2012, 0.12% in 2013 and 0.059% in 2014. This experience suggested the importance of commitment and leadership of surgeons and anaesthetists with support from the health information system. The minimum requirements for this data collection system included complete theatre and ward registration, comprehensive hospital admission and discharge records, and a national death registration database. Regarding training in Tonga, there are approximately 66 doctors per 100 000 population, and fourteen surgical and anaesthesia providers per 100 000. If all of the islands in the South Pacific are considered together, there are a total of 68 surgical providers and 46 anaesthesia providers. 5D I. Working Group: Advocacy - Summary • • • • • • • Develop a compelling narrative Advocacy point: Surgery improves the quality of the entire system – paediatrics to obstetrics Action items o Seek marketing expertise Need to adopt a multidisciplinary approach Funding for local projects vs. funding for larger initiatives Corporate funding needs to be tapped; many have a clear sense of social responsibility Governments are interested in health systems strengthening

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Need to change the paradigm of funding for surgery from donation to investment – sustainability o Need to convince governments that surgical services can be cost-effective and affordable What can we do? - As individuals: we can represent our various groups, medical schools, surgical colleges, institutions, governments and non-governmental organizations. o As an organization: We need to develop strategies to get the point across to individuals, governments and policy-makers. We can learn from the cancer movement and donor world • Cancer community engaged with private industry through civil society What are our key messages? 1. Encourage all countries and Member States to adopt SDG Target 3.8 on Universal Health Coverage 2. Inclusion of surgical and anaesthesia care indicators as part of the post 2015 SDGs Create a Managed Global Surgical Fund Strengthen collaboration between organizations The strategy in low income countries has to start at the local level and develop to the global arena—not the other way around Engage national health and finance ministries to demonstrate the real socioeconomic benefits of improved access to surgical care Accountability and transparency: where is our money going? o Any opacity at ministry/WHO/G4 level will be hugely counter-productive Concept of internal champions, see what is working in current settings and use their local expertise/ experience to develop enlarged programmes serving larger population cohorts

WHO can coordinate funding requests, validate funding requests • Provide endorsement and coordinate funding requests between different groups • Encourage governments to support bilateral or multilateral organizations • Focus on local WHO offices and representatives o Use the WHA resolution to promote increased activity by the local WHO offices • Multi-level approach: o Engage champions at the local level to enhance their work with the rubber-stamp of “WHO brand” o Global level discussion using WHO’s clout and credibility to lobby the largest funders 5D II. Working Groups: Access, integration, systems and partnerships - Summary Access/UHC: Space, staff, stuff & systems; affordability • One size does not fit all: develop flexible templates important o “Essential” surgeries: build on caesarean sections—if able to do these, system should be mature enough to integrate other surgical services o Country specific tools/metrics to identify outcomes/gaps • Communication essential: cannot assume because there is a resolution, individuals in government/others will understanding or be willing to implement necessary changes • Access o Includes availability, physical accessibility, affordability and acceptability o Even if adequate services are available, they must be better utilized 11

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o Providing excellent care will solve the issue of under-utilization o Must get on the agenda as key aspect of first level hospitals; bellwether procedures to represent functionality Need to fully integrate national surgical care plan (NSCP) into National Health Plan (NHP) Chance of success greater if progressed within a NSCP, rather than by direct engagement with indigenous surgery societies or groupings Address how other cadres, non-surgeon, non-physician surgeons, can be integrated into a comprehensive delivery care model Dedicated person within each ministry

Quality • Subscribe to the quality agenda, but we should look at a quality journey - a process of continuous quality improvement • Need to know the minimum acceptable standard of care (wearing gloves, using sterile equipment, washing hands, having running water, etc.); realistic minimal in LMIC environment • Caution about the validity of many so-called parachute missions o Should use ethical framework

Governance • Recognize challenges faced by states involved in armed conflict or classified as “fragile” • Recognize that the health sector may be governed by federal or provincial authorities • Levels of governance include macro-, meso-, and micro-governance Partnerships • Many models exist o Government-Private +/- industry, o Twinning • Ownership should always be at the country level • No best model—should be developed to best suit the local context • Different components to be implemented; specific roles for each partner • Governments are committed but must decide how to invest • Need to be equal, preferably underpinned by MOU o Universities or institutions, rather than individuals; more sustainable • Need to be structured o Twinning can be a model • Partnership should be holistic; involve all aspects of a training or clinical institution • Professional societies should guide visitors before they initiate any project • In fragile states, linkage with NGO that has championed surgery; if successful, try to scale up services • WHO guidelines for donation must be used o Important to remember local needs • Free services and training are not usually good idea due to disruption of local community’s economy

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WHO’s role: • WHO might, in anticipation of WHA 2017, produce a reporting template for Member States to report on their progress towards achieving the goals of the resolution • Can help support health systems at a local level • Emergency department should be strengthened to improve access • Develop ethical standards and codes of conduct for parachute missions • WHO has responsibilities at the global, regional and country levels; we should not assume that these levels are familiar or sympathetic with EESC

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Day 2 Tuesday 15 December 2015 6. Session III – Presentations, Q&A, Working groups 6A. Data collection, Analysis, Sharing, Evaluation and Monitoring Dr Andy Leather Measurement is the first step leading to control and eventually to improvement. The Lancet Commission on Global Surgery has advocated for six indicators to assess the strength of surgical systems. Under the heading of Preparedness, there is the percentage of the population within two hours of a surgical facility, and the density of surgeon, anaesthetist, and obstetricians per 100 000 population. Regarding service delivery, the indicators include surgical volume (number of cases per 100 000 population per year), as well as the level of perioperative mortality by the time of hospital discharge. The third category is financial impact or reduction in the risk of catastrophic expenditures. The “Bellwether” procedures, namely Caesarean deliveries, treatment of open fracture, and laparotomy, are suggested as a proxy for well-functioning surgical services since hospitals capable of performing these procedures are likely to perform all other essential surgical procedures as well. With regard to access, of being within two hours of a facility able to perform the Bellwether procedures, the target is a minimum 80% coverage by 2030. With regard to the surgical workforce, the target goal is that all countries have at least twenty surgical, anaesthetic, and obstetric physicians per 100 000 population by 2030. The length of surgical volume, or procedures done in an operating theatre per 100 000 population per year, is an indicator of met-need. The target is that 80% of countries will be tracking their surgical volume by 2020, and 100% by 2030, with a goal of 5000 procedures per 100 000 population by 2030. Perioperative mortality is an indicator of surgical safety, and the goal is that 80% of countries will track this statistic by 2020 and 100% by 2030. National targets can be set based on the data in 2020. One critical issue is that of financial risk protection, especially as essential surgical conditions are often critical/life—threatening, they are unpredictable, and families are therefore unable to plan or save up for these, and that user fees are often high and can result in catastrophic financial losses. The metrics include protection against impoverishing expenditure and catastrophic expenditure by 2030. A set of indicators to monitor and evaluate surgical systems have also been proposed by the G4 Alliance, also involving the domains of access, quality and financial risk protection. The G4 list contains fifteen indicators, including the six proposed by the Lancet Commission. Additional indicators suggested include the proportion of seriously injured patients transported by ambulance, the national rate of whole blood donation, the rate of caesarean sections, the proportion of operating theatres with pulse oximetry, the ratio of anaesthetists to surgeons, the inpatient trauma mortality rate, maternal mortality ratio, neonatal mortality, and post-operative mortality on the operative day. It should be noted that several of these surgical indicators as well as the six named by LCoGS were already included in the WHO global reference list of 100 core health indicators. Efforts are now underway to integrate surgical indicators into the list of World Development Indicators published by WHO and the World Bank. There has also recently been a global indicator initiative, with goals including developing relationships with individuals in all 215 countries, communicating 14

with clear data, developing an online data measurement system, training a team of associates to manage relationships and data, and cleaning the data and providing a summary to all contributors and the World Bank. Data is emerging in a large number of countries. Of the six indicators suggested, the two hour access in perioperative mortality had the least amount of data available. 6B. Antimicrobial resistance Dr Benedetta Allegranzi Recent research has shown that surgical site infections (SSI) are the most common type of health care associated infection in low- and middle-income countries, and the rates are significantly higher than in high-income countries. In a systematic review of 57 previous studies, Allegranzi et al, found that the incidence of SSI ranges from 0.4 to 30.9 per 100 surgical patients, and 1.2 to 23.6 per 100 surgical procedures. The pooled cumulative incidence was 11.8 per 100 surgical patients, and 5.6 per 100 surgical procedures. Antimicrobial resistance has become a very important concern especially in recent years, for example methicillin resistant Staphylococcus Aureus is responsible for 44% of SSI in the United States. It has become apparent that the prevention of surgical site infections is complex and requires multiple considerations including control of patient related risk factors, factors relating to preparation of the skin and other details in the operating room, antibiotic prophylaxis, and physiologic variables intraoperatively and postoperatively. The SSI prevention guidelines will become available, with a strong component on implementation strategies and surveillance, and tools as well. Risk factors for SSI include obesity, tobacco abuse, cancer, bacterial and non-bacterial infections, age, previous operations and transfusions. A number of recommendations for the prevention of SSI have been produced, including pre-operative bathing and chlorhexidine cloths, skin antiseptic preparation, mechanical bowel preparation, hair removal, timing of surgical antibiotic prophylaxis, surgical hand preparation, antimicrobial sealants, temperature control, glycaemia control, oxygen therapy, normovolemia, wound protectors, type of suture, use of drains, drapes and dressing of the surgical field, post-operative dressings, nutrition, immunosuppressive agents, wound irrigation, prophylactic negative pressure wound therapy, SAP prolongation in all surgeries, and laminar flow. In order to reduce surgical site infections in Africa, a programme entitled “SUSP” (Surgical Unit-based Safety Programme) has been developed, involving surveillance protocols both perioperatively and postoperatively. A number of technical elements were introduced such as avoiding shaving, using the alcohol-based skin preparation, and antibiotic prophylaxis. This is supplemented by WHO tools and support, such as webinars, fact sheets, and posters. Adaptive elements were also introduced, including executive rounds of premortem study. There are WHO formulations for surgical hand preparation and optimization of surgical skin preparation. These efforts have also been supplemented by safety videos. Overall, there has been a strong effort to change culture of both individuals and institutions to promote safety and reduce surgical site infections. A follow up study documented significant changes in process measures for a number of variables including the use of chlorhexidine, reducing the number of door openings when in the OR, and the administration of antibiotic prophylaxis. It has also been shown in three out of the five districts studied in Africa that these measures significantly reduce the incidence of surgical site infections by 4-

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8%. It is clear that a culture of patient safety including the reduction of SSI will be an extremely important part of implementation of the new resolution on essential surgical care. 6C. Essential medicines: Ketamine and narcotics Dr Gilles Forte International drug control conventions promote better health, and recognize that narcotic drugs should be made available for the relief of pain and suffering as should the use of psychotropic substances. A number of previous resolutions are related, including those related to cancer prevention and control, strengthening palliative care, strengthening of emergency and essential surgical care and anaesthesia as a component of universal health coverage, and also epilepsy. There are enormous imbalances in the availability of opioid analgesics, as 92% of the world’s morphine is consumed by just 17% of the world’s population, mainly in North America, Western Europe, and Oceania. An estimated 5.6 billion people live in countries with low- or non-existent access to opioid analgesics for the treatment of moderate to severe pain. As such, there is an urgent need to improve access to these controlled medications. There are a number of controlled medications of importance to the emergency and essential surgical care in the WHO central medicines list, including the opioid analgesics, long acting opioid agonist, ergometrine and ephedrine (for emergency obstetrics), benzodiazepines, and phenobarbital. Barriers to accessing these controlled medications include insufficient knowledge and training on efficacy and safety profiles which lead to inappropriate use or no use at all, inaccurate quantification of needs and inefficient supply chain leading to shortages, diversion and waste, fear of abuse and dependence, sanctions, and regulations, such as those relating to prescriptions, dispensing outlets and restrictions on imports and exports. The international drug control conventions require WHO to recommend if a substance should be placed under international control or if its level of control should be changed. The WHO Expert Committee on Drug Dependence (ECDD) examines the risk of dependence and harm, as well as the therapeutic usefulness of the substance. There are presently 250 substances used for medical purposes that have been placed under international control through this mechanism. Most recently, it was determined that ketamine should not be brought under international control, considering that reports of dependence are rare, that ketamine has a short duration of action, and that it is of critical public health importance. It is recognized that ketamine is a safe and affordable drug used for many emergency and essential surgical procedures. 6D I. Working Group: Data collection, analysis and sharing, E&M - Summary Data needs • Surgical indicators (Lancet, G4) are excellent for obtaining a high-level, birds-eye view o There are different data needs at national and facility/local levels o Country and local stakeholders should define own data needs; should not be imposed or burdensome, but relevant at multiple levels • Paradigm of research needs to shift towards delivery and implementation science o Hand washing is a prime example o Quality and safety best practices 16

•

•

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• • • • •

More granular information necessary at different levels o Nursing; formally trained/untrained o Anaesthesia: non-physician clinicians WFSA is working on an extensive dataset for this purpose; can contribute to WHO for broader dissemination, availability o Surgeon: non-physician clinicians o Midwives o Operating room maintenance o Bio-medical engineering technicians o Functionality of equipment, sustainability o Pulse oximetry o Outcomes – track morbidity, mortality Can adopt models such as emergency care and injury, including the injury minimum dataset, the Trauma Care Cchecklist, WHO Emergency care and systems framework assessment tool, acute presentation case dataset, WHO Situational Analysis Tool DHIS2 could be used to collect data Need a simple surgical case form- a minimal surgical dataset o Basic volume data, but adaptable to local context/needs o Basic measures of morbidity and surgical site infections Focus first on top procedures and mortality o Demonstrate volumes and trends o Tools require both the creation of tools and teaching on how to use them Train people at local levels to competently collect data Educate local administrators that it will add value Create a culture of data collection starting with a minimum dataset Provide feedback to sites collecting data so they receive a return for their efforts Partnership between WHO, academic, professional society and LMIC institutions

Data repository • WHO Global Burn Registry o Data platform needs to have instant feedback o Local stakeholders need access to data and analysis • Data registry needs to be globally accessible to researchers; MoH always has final say in data use • Open dialogue with MoH in LMICs – create a network of LMIC data sites • Wide stakeholder group meet regularly o surgeons o administrators o policy makers o epidemiologists • Determine what exists that can be leveraged o Digital Health Information Ssystem-2 (DHIS2)—open-source, web-based o WHO Situational Analysis Tool o Top procedures and diagnoses o WHO sign-in module for registration • Plan a pilot of 6-8 countries to test what minimum data set is actually feasible and useful for starters. • Start with a wide dive and in future years dive deeper • WHO sign-in procedure for an operation can be used for initial data 17

• • •

Basic registration procedure for hospitals WHO has included surgical indicators in their top 100 list Many disparate efforts at data collection—could be standardized and coordinated

WHO role: • WHO global data platform o Lead consensus process in collaboration to standardize data requests, collection, visualization; create module addressing surgical data needs • Need a surgical dashboard for WHO o Subgroup that engages with member countries, agree on metrics o Seven principles that metrics need to agree on Goals, targets, indicators Reflect the multidisciplinary nature of surgical service delivery, other health workers who are part of the surgical team Must be feasible Focusing too much on a single metric is a problem, need trade-off between quality and quantity Suggest a small group globally defined which can be expanded locally; needs to be sustainable, rather than large set of globally imposed metrics WHO should take leadership, GIEESC as consulting body Simple metrics for safe surgery for 80% of the world 6D II. Essential Medicines: available in all countries, to all people - Summary Issues • Access (regulatory and importation/manufacture/distribution) • Cost • Preparations o Oral vs. IV o Child-friendly o Stable with temperature variations/transport Drugs • Ketamine o Formal encouragement of NGO and country driven data collection o Strong advocacy—will be ongoing issue with ECDD, etc. o WFSA: partner to advocacy and education Ketamine website for advocacy, data collection, education resource o Develop data driven policies, protocols related to appropriate usage • Analgesics (Opioids, NSAIDs, Paracetamol/acetaminophen, Gabapentin?) o The absence of chronic pain and acute postoperative pain alternatives is a human rights issue and should be presented as such for adults and children o Formal encouragement of NGO and country driven data collection o Country level advocacy to ministry of health regarding the importance of compassionate/palliative care o Promote research into non-narcotic pain relief from alternative medicine to regional anaesthesia nerve blocks o Promote development of regional anaesthesia training courses such as the WFSA 3-month fellowship in regional anaesthesia currently offered in Ghana 18

• •

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o Identify barriers to procurement/usage of analgesics o Improve training in Opioid and anaesthetic alternatives through global anaesthesiology colleges Local anaesthetics (Lidocaine, Bupivacaine) General anaesthetics (Halothane, Isoflurane, Sevoflurane, Oxygen) o Oxygen availability Promote adequate oxygen producing and distribution networks Promote development of better oxygen concentrators: display % oxygen output, have battery back-up, designed for low-resource environments Encourage use of oxygen supplies that are more hygienic and designed to be decontaminated and re-used Adjuncts (cardiac drugs, etc.) Antibiotics, antiseptics, sterile equipment (gloves, etc.) o Consider antimicrobial stewardship campaigns in low-resource hospital settings o Data collection regarding use o Antimicrobial usage and antibiotic resistance is a local or regional issue o Formal encouragement of NGO and country driven data collection o Separating SSI issues from Malaria issues o Develop best practice guidelines, defined locally, which advise optimal antibiotics to use

Primary barriers: • Cost — no government coverage for essential medicines in many countries 1. Assure all costs of operation covered by national insurance plans 2. Advocate as a powerful organization to make essential medicines available and affordable in the whole world • Availability (irrespective of cost) 1. Identify barriers to procurement/use of analgesics in the different settings • Ketamine What can WHO do? • Define basic essential drugs package specifically for surgery based on WHO guidelines; recommend this package in all areas to guarantee there are enough medicines to cover surgeries (bellwether procedures?) including antibiotics, anaesthetics, analgesics— probably locally specific o Would allow comparisons between hospitals/regions • Evidence-based guidelines (best practice) for antibiotic and other use o Make this part of surgical metrics and/or certification programme for Safe Surgery practice. • Support consortium or bulk buying — take lessons from ARV programmes • Advocate, recommend, recognize: essential medicines o Distribute collection of compassionate stories re: unavailability of opioid narcotics in low resource countries; posting some examples on the WHO web site

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7. Session IV – Presentations, Q&A, Working groups 7A. GIEESC next steps Dr Walt Johnson Future activities for the GIEESC may include updating and revising the Surgical Care at the District Hospital textbook; developing guidelines for Ebola, clubfoot, and safe anaesthesia; and developing collaborative centres to promote networking, in Mongolia, Canada, Sweden and Zambia. The EZCOLLAB will provide a forum for discussion, and will be more interactive and relative, allowing a two-way dialogue. The biennial GIEESC meetings will continue, and the next meeting will likely be in association with COSECSA in Sub-Saharan Africa. We need also to focus on building bridges within WHO headquarters, as well as outside WHO with the ministries of health, professional societies, and other nonstate actors. GIEESC membership should continue to grow in order to support all of these activities. 7B. Global Surgery: Training, competence, and credentialing Dr Carlos Garberoglio Dr Garberoglio discussed a global surgery project at Loma Linda University (LLU) in California, in which several phases are involved. LLU has a large integrated network of hospitals worldwide, with 627 healthcare institutions and more than 30 000 beds, distributed globally. The deferred mission appointee (DMA programme) allows students to accept a mission appointment in exchange for amortization of their debt over the span of the mission service. These individuals are placed in one of the Seventh-day Adventist Church’s healthcare organization worldwide. A number of specialties are represented. For each year of service, one-tenth of the individual’s debt is paid off. Thus, the entire debt can be repaid in approximately ten years of service. The second phase of the global surgery project is a general surgery residency rotation at Malamulo Hospital in Makwasa, Malawi. This is a standard part of the PGY4 rotation schedule, thus a trainee is constantly present at this hospital. As a specific rotation director, a number of logistic issues are permanently managed by the residency programme manager in collaboration with the LLU Global Health Institute. A logistics manual is available. The cost to the institution is approximately US$15 633 per resident for a two-month rotation, but excluding their general salary and benefits, only approximately US$3225. The university pays for the salary and benefits, while several foundations and/or charitable organizations cover the additional costs. This has proven to be a very unique rotation and excellent learning opportunity for the general surgery residents. At this point, twelve residents have participated in the rotation and 70 cases have been logged per resident. This is a higher volume of cases than the resident would see in their home institution. The surgical output at the hospital has been increased by more than 50% and excellent reviews have been obtained from the residents. There are a number of barriers, including finances, challenges with interacting culturally, as well as for programme requirements. Loma Linda is currently the only US surgical residency programme with an ACGME approved international participating site and an international rotation that is a standard part of the ACGME approved curriculum. The Pan-African Academy of Christian Surgeons (PAACS) has a group of twelve residency programmes in nine countries for training African surgeons in general surgery, and is on track to train one-hundred surgeons by 2020. These surgeons can be certified by 20

COSECSA or WACS. There is one PAACS residency programme at the Malamulo Hospital which started last year. There are two trainees with plans to have one trainee per year. These surgical residents interact seamlessly with the LLU residents. Phase three of the LLU project will include a Global Surgery Fellowship, which will begin in 2017. Course work will include global public health and the fellowship will provide a real-world international experience. The curriculum will include obstetrics and gynaecology, urology, orthopaedics, and then an international rotation at Malamulo Hospital, Malawi for two months. There will also be training in ENT, anaesthesia, paediatric surgery, plastic surgery, ophthalmology, neurosurgery, infectious diseases, and preventive medicine. Phase four will be the Return to America (RTA) programme, focusing on reintegration into the workforce for the DMA surgeons who have been on a mission for five years or more. This will be funded by integration of the returning surgeons into the acute care (trauma) team. 7C. Training, competence, credentialing, oversight Dr Stephen Ogendo The College of Surgeons of East, Central, and Southern Africa (COSECSA), counts ten permanent Member States, as well as seven satellite members (Dr Ogendo is the immediate Past-President of COSECSA). There are three additional countries likely to join in the near future. Membership of the College of Surgeons (MCS) candidates have been trained beginning in 2003, and the number passing their examination has increased from seven in 2003 to 38 in 2015. Candidates come from a number of disciplines, including general surgery and all subspecialties, including orthopaedics, neurosurgery, urology, paediatric surgery and plastic surgery. At this time, there are 383 trainees, 126 Fellowship of the College of Surgeons (FCS) graduates, 169 accredited trainers, and 87 accredited to training health facilities. Training also involves multiple electronic measures such as elearning and e-logbook, and the plan for the future is to scale up the programme. Projections have been made for the total number of MCS required in ten years per country. Dr Ogendo presented a review of surgical training, credentialing, competency and oversight, with emphasis on the ECSA region. There is a large unmet need for surgical services, with inadequate numbers of surgeons, anaesthetists, and obstetricians, as well as non-physician clinicians. Non-physician clinicians perform 84% and 92% of the caesarean sections, hysterectomies, laparotomies, in Tanzania and Mozambique respectively, and 90% in Malawi. Globally, 2420 medical schools produce 380 000 students per year, however in Sub-Saharan Africa there are fewer than two medical schools per ten million population. Africa has approximately 140 medical schools producing about 6000 graduates per year, each of whom costs approximately US$52 000 to produce, versus non-physician clinicians who cost approximately US$19 465. Non-physician clinicians have been used in a number of countries around the world, mostly in Sub-Saharan Africa, but also in China, India, some south-east Asian countries, as well as some central Asian countries. There are a number of challenges to training surgical providers, including the imbalance between education and health systems, with a lack of training centres and trainers, poor distribution of surgical providers and skill mismatches. Four specific challenges include admission criteria, competency, channels, and clear pathways. In Sub-Saharan Africa, twenty-six countries have one or no medical schools, and there are approximately twenty-one regional surgical training universities within the COSECSA Region. Within the region of 21

East, Central and South Africa, it costs between US$2000 and US$3000 to train a surgeon, and the COSECSA membership costs students approximately US$1050 over five years. COSECSA has been actively involved in non-physician clinician training, as half of SubSaharan Africa countries use non-physician clinicians for minor surgeries. There is an Essential Surgical Training Programme, COSECSA Oxford Orthopaedic Link Programme, and the Clinical Officer Surgical Training Programme. There are 88 training centres, with 297 trainees, and 160 trainers. COSECSA is currently training 50% of the surgeon output in their region and 20% of the volume of surgical work is carried out by COSECSA trainees. It is recognized that significant scaling up will be required to meet the projections for number of surgeons presented as the minimum standard by the Lancet Commission on Global Surgery, namely twenty to forty surgical providers per 100 000 population. In order to achieve the goals by 2030, it would require 20 000 new surgeons, or 1250 per year. The current output is 85 per year. This is for Kenya alone, for which the baseline is 2.49 surgeons for 100 000 population. One published data from COSECSA indicates that 94% of trained surgeons have been retained within Africa, and 84% have continued to work in their home country. Migration within Sub-Saharan Africa has therefore been limited. Minimum standards need to be developed for credentialing, and competency-based programmes should be promoted. There is a role for task sharing and task shifting. There is also a role for social accountability and the accreditation process, linking health outcomes to accreditation, professionalism, addressing societal needs including the use of non-physician clinicians, addressing equity, quality, efficiency in disadvantaged communities, as well as ethical issues. WHO estimates that accreditation processes affects only one in three SubSaharan African countries. Other countries have more than one accreditation body. Regional or global standards should be developed within the realm of surgery, including promotion of competency-based training, appropriate guidelines, standardized and appropriate accreditation, the merger of institutional (COSECSA) instruction, and monitoring of surgical outcomes. Strong governance will be required including surgeons from surgical institutions, to decide which procedures are needed, which providers are safe providers, how to enhance quality control, and advocate for a national surgical policy. Oversight is required, including education, numbers and competency of the health workforce, and training that is “fit for purpose”, and then performance needs to be monitored. Systems needs to be strengthened by data gathering and analysis, standardization of practice guidelines, increased training, credentialing including more NPC’s, improvements in infrastructure, collaborations information and skill sharing, and improving governance structures. 7D I. Working Group: Training, competence, credentialing, oversight - Summary General training • LMICs should train more general surgeons (than specialists) • Competency-based training rather than time-based; surgical management more than just operative management • The essential surgical care curriculum should be across multiple surgical specialties o Broad, based on contextually relevant core competencies, developed by local clinicians and educators o Less specialty-specific o Include trauma training o Include basic anaesthesia principles

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o Core procedures to meet basic needs immediately; develop subsequent higher level procedures subsequently Logging cases and peer review should be mandated Bonding of surgeons in rural areas after graduation, need for supervision of these new doctors—they are a strategic resource o Disseminate training as closely as possible to the trainee district/rural location, to preserve connection to the locale and keep it appropriate to the local context o Recent trainees have limited practical skills which need to be further augmented by specialists o Following training, need ongoing mentoring from specialists in centre o Competency assessment clear—who, how, when, criteria Need to have some specialists locally (e.g. full anaesthetist) so no dilution of quality, if RNAs are training non-RNs to provide anaesthesia. Regional training networks to promote teaching exchanges and context specific curricula o Multi sectoral engagement needed - facilities, academic and professional societies M&E difficult in weak states

NPCs Positive (already performing most surgery, examples of quality of training) • o Develop clear qualifications, and training entry requirements o Training equivalent to tasks undertaken o Clear definition of what operations should be performed and what should be referred (this curriculum should be locally written, locally appropriate) o Perform emergency surgery, (this is harder than elective surgery!) o Supervisory environment important, needs to be supportive o Career progression and continued professional development (CPD) needed o “Surgical Providers” a more useful term than “Surgeons” o COST Africa 5-year RCT on surgical vs. non-physician clinician surgeon outcomes o Outcome due April 2016 o Need to bring data/perspective/best practices to inform debate on task-shifting o Utilize history of task shifting in other settings (e.g. US CRNA), other rural/underserved delivery and training models Research/Training • Courses exist to develop local research capacity (i.e. Royal College of Surgeons, ACS) • Basic metrics should be established like access, mortality, morbidity, surgical care workforce density, economic consequences, population and migration, • Research – building local capacity by local and international mentorship with prioritisation of research methodology training Essential surgery list • WHO/DCP3 should be adopted with the caveat that regional/national variations will be needed and should be expected Career progression and continued professional development (CPD) • “Modular training” • Blended / distance learning model can be valuable • JHPIEGO “training pathway” • Essential for all surgical care providers 23

Anaesthesia • Most of what was discussed re: surgical training applicable here • Regional bodies for anaesthesia would be a step forward • Continued professional development is a major lack • On-site experience incredibly valuable, exceed capacity of what HICs can deliver, train • Anaesthetists usually in the capital cities; services mostly provided by NPAs • Create a defined pathway for further learning and advancement: modular programme so that further training as a physician is possible? • Need to use all strategies to optimize retention Role of MoH • Develop health system focusing on patient management with reliable communication, referrals, transport, and protocols--field, clinic, district hospital, tertiary centre • Surgical, Anaesthesia training programmes should be encouraged and supported • Professional societies should be encouraged and supported • Through national surgical care plan, MOH empowered to negotiate task-shifting reform as opposed to being leveraged externally

Credentialing • Role for appropriate health authorities for each country: MoH, MoE o Roles should be clear o Process should be clear and consistent • Academic/university credentialing of busy rural hospitals to have training authority The role of developing country colleges/universities • Generate faculty and training curricula for various levels • Maintenance: enabling, equipping trainees when finished so that they can thrive— mentorship, equipment, continuing professional development (with professional societies) Professional societies: • Produce training material which can be modified locally • Guidelines for training of surgical trainers • Quality mandates • Leadership development • Educational programmes • Maintenance: enabling, equipping trainees when finished so that they can thrive— mentorship, equipment, continuing professional development (with mother programme) The Role of developed country colleges/universities • Develop bilateral partnerships • Look from a broader systems perspective rather than just surgery o Programme development o Leadership o Hospital and financial management o Nursing o Research • This will make it sustainable 24

North-South Cooperation • Short courses helpful and to be increased, coordination of international short course providers needed • Training of trainers important • International organizations must consider how they affect the “surgical economy” • International bodies must beware of bringing competing qualifications to LMICs • An “inventory of values” of what of value is transmitted from North to South Expatriates • Favour more permanent establishments • Expatriates with particular surgical expertise are welcome but in a more organized manner (WHO may play a role) • Credentialing through the country of origin • HIC clinicians are not the experts in LMIC care delivery WHO roles/priorities: • Promote task shifting. Evidence base, best practices statement and endorsement. Countries can adapt as well as adopt. • Encourage MoH at country level: o Develop national surgical care plan for MOH to fully realize adequate surgical care for their people o Develop appropriate credentialing processes; create model? o Develop appropriate support for in-country training programmes o Support finished surgeons in jobs with good working environment, salary, CPD • Develop guidelines for training, perhaps model curricula, model credentialing • Utilize WHO tools to promote training and gap identification • Strengthen and enable regional alliances, training programmes, professional societies • Identify what curricula and what partners can be employed to create competency • Can WHO coordinate and endorse, disseminate research training?

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Annex I: List of Participants

List of participants GIEESC Members Fizan Abdullah Chair, Board of Directors G4 Alliance for Surgical, Obstetric, Trauma & Anaesthesia Care New York USA Mohamed Abukalish Physician Libyan Emergency Medicine Association Tripoli Libya Prince Kwakye Afriyie General Surgeon & Medical Director SDA Hospital Dominase Bekwai, Ashanti Region Ghana Fifonsi Odry Agbessi Medical Doctor CDTUB-ALLADA Allada Benin Jesus Arenos Representative International Federation of Medical Students’ Associations (IMFSA) Susan Brundage Professor of Trauma Education & Director, International Trauma Sciences Master Suite of Programmes Postgraduate Education Lead Queen Mary University of London, Barts & the London School of Medicine London UK Thomas F. Burke Chief, Division of Global Health & Human Rights & MGH Associate Professor, Harvard Medical School Center for African Studies, Harvard University Boston, USA

Phil Carson Associate Professor, Surgery Chair of the RACS Global Health Committee Royal Australasian College of Surgeons (RACS) East Melbourne Australia Laura Cassidy Professor of Epidemiology Medical College of Wisconsin Milwaukee USA Davy Cheng Professor & Chair Dept. of Anesthesia & Perioperative Medicine University of Western Ontario London Canada Meena Nathan Cherian Past Lead, Emergency & Essential Surgical Care Programme WHO Geneva Switzerland

Bayarmaa Chinbaatar Senior Officer, Emergency Medical Services Ministry of Health & Sports Ulaanbaatar Mongolia

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Evans Chinkoyo Family Physician & Medical Officer Chipata 1st Level Hospital under Ministry of Health, Lusaka, Zambia Ashim Chowdhury Tsepong (Pty) Ltd. Queen Mamohato Memorial Hospital Maseru Lesotho Izabela Chudzicka-Strugala Assistant Professor Dept. of Medical Microbiology PUMS Poznan Poland Amelia Contreras Palomino Medical Doctor Gastroenterology Robert Bosch Krankenhaus Stuttgart Germany Dr Shihab Arefin Chowdhury Shihab Arefin Chowdhury Carissa Chu Medical Student Imperial College London London UK James C. Cobey Johns Hopkins University & G4 Alliance Baltimore USA Michael Cotton Chairman International Collaboration on Essential Surgery Zouheir Dabbour Founder of Scientific Committee Roads for Life Beirut Lebanon

Enrico Davoli Aristomed Global Health Consultant Piccarello Italy

Dan Deckelbaum Co-director, Centre for Global Surgery & Assistant Professor Divisions of Trauma and General Surgery Dept. of Critical Care McGill University Health Centre

Quebec Canada Miliard Derbew Associate Professor of Surgery PI, Medical Education Partnership Initiative School of Medicine, College of Health Sciences Addis Ababa University Addis Ababa Ethiopia Laurie Dontigny-Duplain Doctor Université Laval Quebec Canada Max Downham Executive Director International College of Surgeons Chicago USA Jacob Dreyer International Federation of Surgical Colleges Dumfries Scotland, UK Marcel Idi Ehanga Doctor, Emergency & Intensive Care Dept. Hôpital du Cinquantenaire Kinshasa Democratic Republic of the Congo

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Isabella Epiu Anaesthesiologist & Research Fellow Makerere University College of Health Sciences Kampala Uganda Helena Fantaye Assistant Director, Medical Service Directorate Federal Ministry of Health, Ethiopia Addis Ababa Ethiopia Allen Finley Professor, Anesthesia & Psychology Dalhousie University Halifax Canada Richard Fisher Health Volunteers Overseas Washington, DC USA Amr Frieg Moghazy Consultant & Associate Professor of Plastic Surgery & Burns Faculty of Medicine, Suez Canal University Ismaïlia, Egypt Carlos Garberoglio Chairman Dept. of Surgery Loma Linda University Health Loma Linda USA Maria Garberoglio Dept. of Neonatology Loma Linda University Medical Center Loma Linda USA Mr Julian Gore-Booth Chief Executive Officer World Federation of Societies of Anaesthesiologists (WFSA) London, UK

Anita Gupta Vice Chair, Associate Professor Dept. of Anesthesiology & Pain Medicine Philadelphia USA Walid Habre Head, Unit for Anaesthesiological Investigations Senior Consultant, Paediatric Anaesthesia Geneva Switzerland

Piet Haers Past President & Chair of the IAOMS Foundation Rolling Meadows USA Chokri Hamouda Professor, Emergency Medicine & Director, Nursing School Tunis El Manar University & Ministry of Health Tunis Tunisia Lars Hagander Paediatric Surgeon, Lund University & Co-chair, Lancet Commission on Global Surgery Lund Sweden

Kristin Hatcher Associate Vice President of Strategic Initiatives & Metrics Operation Smile Global Headquarters Virginia Beach USA David Hoffman Doctor, Sub Chairman of Committee on Global Surgery International Association of Oral & Maxillofacial Surgery (IAOMS) Rolling Meadows USA

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Hampus Holmer Medical Doctor/PhD Candidate Lund University Lund Sweden Avril Hutch Assistant Programme Director Royal College of Surgeons in Ireland (RCSI)-COSECSA Programme Dublin Ireland Zahra Jaffry Doctor King’s College London London UK Pankaj Jani Professor University of Nairobi Nairobi Kenya Gnanaraj Jesudian Professor Seesha/Karunya University Karunyanagar Coimbatore India Abu Hena Mostafa Kamal Consultant Anaesthesiologist & Intensivist Dept. of Anaesthesiology & ICU Rajshahi Medical College Hospital Rajshahi Bangladesh Neema Kaseje Paul Farmer Global Surgery Clinical Fellow Program in Global Surgery & Social Change Harvard Medical School Boston Children’s Hospital Boston USA Beat Kehrer Prof.Dr.med.

Swiss Surgical Team St Gallen Switzerland Namory Keita Professor & Head of the Gynaecology & Obstetrics Dept. Centre hospital-universitaire de Donka University of Conakry Conakry Guinea Aij-Lie Kwan Professor Dept. of Surgery & Division of Neurosurgery Kaohsiung Medical University Taiwan Raj B. Lal Cardiovascular Thoracic Surgeon (Emeritus) & Volunteer Medical Manager IMERT & IL.USAR TF1 Oakbrook USA Robert Lane President International Federation of Surgical Colleges London UK Andy Leather Director, King's Centre for Global Health & Senior Lecturer in Global Health & Surgery King's College London London UK

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Marc Levivier Vice Chairman of WHO-World Federation of Neurosurgical Societies (WFNS) Liaison Committee & Head of Service of Neurosurgery Centre hospitalier universitaire vaudois Lausanne Switzerland Demetrius Litwin International College of Surgeons, US Section/ UMASS Medical School Worcester USA Suyu Liu Bournemouth University Dementia Institute Poole UK Ganbold Lundeg Assistant Professor & Head of Critical Care Medicine & Anesthesia Dept. Mongolian National University of Medical Sciences Ulaanbaatar Mongolia Martha Lungu Nchanga North General Hospital Surgical society of Zambia Chingola Zambia Declan Magee President Royal College of Surgeons in Ireland Dublin Ireland Emmanuel Makasa Counsellor — Health Permanent Mission of the Republic of Zambia Geneva Switzerland

Luc Malemo K Head of Surgery & Hospital Director HEAL Africa Hospital Goma Democratic Republic of the Congo Movsum Mammadzada Board Member German-Azerbaijani Foreign Trade Chamber Baku Azerbaijan Janet Martin Assistant Professor Dept. of Anesthesia & Perioperative Medicine MEDICI Centre University of Western Ontario London Canada Anne Lou McNeil Representative International Federation of Medical Students’Associations (IMFSA) Emily Measures Country Director Tropical Health & Education Trust (THET) Lusaka Zambia Mira Mehes Global Alliance for Surgical, Obstetric, Trauma & Anaesthesia Care (The G4 Alliance) New York USA Manish Mehrotra VPS Healthcare Abu Dhabi UAE

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Jannicke Mellin-Olsen Deputy Secretary World Federation of Societies of Anaesthesiologists (WFSA)

Baerum Hospital Norway Yuri Millo President Better Place International Chevy Chase USA Katinka Mijnheer Programme Coordinator, Health Care Netherlands Society of International Surgery Nuenen The Netherlands Mohammad Aminu Mohammad Consultant Paediatric Surgeon Aminu Kano Teaching Hospital Associate Professor of Paediatric Surgery Bayero University Kano Kano Nigeria Reginald Moreels Surgeon & Field Volunteer Belgian NGO Médecins Sans Vacances Mechelen Belgium Frederic Morin General Surgery Resident University of Montreal Montreal Canada Emmanuel Moro Associate Professor of Surgery Gulu University Faculty of Medicine Gulu Uganda Mohamed Mosa President Somali Land Hypertension Society Somaliland

Francine Mwania Ministry of Health of Zambia Lukulu Zambia Armstrong Mwepu Ministry of Health of Zambia Lukulu Zambia Mayur Narayan Professor of Surgery & Director, Center for Injury Prevention & Policy R Adams Cowley Shock Trauma Center University of Maryland School of Medicine Baltimore USA Corina Negrescu Johns Hopkins University Baltimore USA Pravin Nepal Norvic International Hospital Kathmandu Nepal Joshua Ng-Kastra Paul Farmer Global Surgery Research Fellow Harvard Medical School Boston USA Elizabeth Ogboli Nwasor Consultant Anaesthetist, Senior Lecturer Ahmadu Bello University Teaching Hospital Zaria Nigeria Stephen Ogendo Professor of Surgery Dept. of Surgery & anesthesiology Maseno University Kisumu Kenya

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Eric O’Flynn Programme Director Royal College of Surgeons in Ireland (RCSI)-COSECSA Programme Dublin Ireland Bisola Onajin-Obembe Consultant Anaesthesiologist & Assistant Professor of Anaesthesia University of Port Harcourt Port Harcourt Nigeria Jean O’Sullivan Medical Director Global Emergency Care Skills Dublin Ireland Karen C. Owen Faculty Instructor/Clinical Coordinator Eastern Virginia Medical School Norfolk USA

Lutfor Rahman Professor University of Maryland, Baltimore County Maryland USA Marjorie Ratel President Korle-Bu Neuroscience Langley Canada Santosh Rath Professorial Fellow, Global Surgery George Institute for Global Health Oxford UK Nakul Raykar Fellow, Program in Global Surgery & Social Change Harvard Medical School Boston Children’s Hospital Boston USA Peter Reemst Surgeon Netherlands Society of International Surgery & International Federation of Rural Surgery Nuenen The Netherlands Matthias Richer-Turtur Professor DTC Deutsche Gesellschaft für Tropenchirurgie Muensing Germany Pascal Rod Executive Director, Nurse Anesthetist International Federation of Nurse Anesthetists (IFNA) Mantes la Jolie France

Kee Park Volunteer Foundation for International Education in Neurological Surgery Marrero USA Tom Potokar Consultant Plastic Surgeon & Director, Interburns Swansea Wales, UK Ray Price Director, Center for Global Surgery & Clinical Professor of Surgery Assoc. Clinical Professor Family & Preventive Medicine University of Utah School of Medicine Utah USA Pierre Quinodoz Director, 2nd Chance Association Meyrin Switzerland

32

Lauri J Romanzi Project Director, Fistula Care Plus EngenderHealth New York USA

Gail Rosseau Inova Neuroscience & Spine Institute Falls Church USA Jackie Rowles President, International Federation of Nurse Anesthetists (IFNA) Sursee Switzerland Andrés Rubiano Medical & Research Director Meditech Foundation Neiva Colombia Joseph Sakran Assistant Professor of Surgery & Director, Global Health & Disaster Preparedness Medical University of South Carolina Charleston USA John Sampson Assistant Professor Neuroanesthesia Anesthesiology & Critical Care Medicine Dept. Johns Hopkins University Baltimore USA Frank Peter Schulze Surgeon-in-chief St Marien-Hospital Muelheim Germany Merry E. Sebelik Associate Professor University of Tennessee Health Science Center Memphis, USA

Samuel Seisay General Surgeon & Acting Lead Accident & Emergency Dept. Ministry of Health & Sanitation of Sierra Leone Freetown Sierra Leone Haadi Tarek Shalabi Doctor National Health Service Derby UK Shirwa Sheik Ali St Richard’s Hospital Chichester UK Lawrence M. Sherman CEO & Medical Director Jackson Fiah Doe Memorial Hospital & Assistant Professor of Surgery A. M. Dogliotti College of Medicine University of Liberia Monrovia Liberia Mark Shrime Research Director Program in Global Surgery & Social Change Harvard Medical School Boston USA Chabwela D. Sumba Deputy Director of Mobile Health Services Ministry of Health P.O. Box 30205 Lusaka Zambia David Spiegel Pediatric Orthopaedic Surgeon Children’s Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia USA 33

Barclay Stewart Surgeon & Researcher Operation Smile Kumasi Ghana Richard Sullivan Director, Institute of Cancer Policy Co-Director, Conflict & Health Research Program King’s College London London UK Jordan Swanson Plastic Surgeon, Tsao Fellow in Global Surgery University of Southern California LA Shriners Hospital & Operation Smile Managua Nicaragua Villami Tangi Chief Surgeon Specialist Vaiola Hospital Nuku’alofa Kingdom of Tonga Girma Tefera Professor of Surgery University of Wisconsin School of Medicine & Public Health Vice Chair Division of Vascular Surgery & Chief of Vascular at W.S Middleton VA Hospital Medical Director, Operation Giving Back American College of Surgeons Madison USA

Miguel Trelles Coordinator SAGE Unit (Surgery, Anaesthesia, Gynaecology, Emergency Medicine, Intensive Care) Anaesthesia Advisor, Medical Dept. Médecins Sans Frontières (MSF), Operational Centre of Brussels (OCB) Brussels Belgium Richard Vander Burg Chief Program Strategist Operation Smile Global Headquarters Virginia Beach USA John E. Varallo Technical Advisor, Cervical Cancer Prevention, Maternal Health Jhpiego — an affiliate of Johns Hopkins University Baltimore USA Julie Varughese Medical Officer AmeriCares Stamford USA Julius Vitowanu Doctor Lagos State University Teaching Hospital Lagos Nigeria Rebecca Walker Assistant Professor, Emergency Medicine Stanford University School of Medicine Palo Alto USA Neil Wetzig Consultant & Advisor of Surgical Training Programs HEAL Africa Hospital, Goma DR Congo Goma Democratic Republic of the Congo 34

Penias Tembo Head of Surgery University Teaching Hospital Lusaka Zambia Aissatou Sow Touré President Guinée Humanitaire Annemasse France

Alasdair Williamson Medical Student University College London London UK Getachew Worku General Manager EAA, HRH Project Addis Ababa Ethiopia

Kenan Yusif-zade Head of Military Hospital State Border Service Baku Azerbaijan Anne Zeidan Director of Operations 2nd Chance Association Reconstructive Surgery for Life Reconstruction

35

World Health Organization Headquarters, Geneva, Switzerland

Benedetta Allegranzi Coordinator a.i., Infection Prevention & Control (IPC) Global Unit & IPC team for the Ebola Response

Service Delivery & Safety (SDS) Health Systems & Innovation (HIS) Jim Campbell Director, Health Workforce (HWF) Health Systems & Innovation (HIS) Gilles Forte Coordinator, Policy, Access & Use (PAU) Essential Medicines & Health Products (EMP) Health Systems & Innovation (HIS) Sophie Genay-Diliautas Technical Officer, Office of the Assistant Director-General (ODGO) Noncommunicable Diseases & Mental Health (NMH) Ophira Ginsburg Technical Officer, Management of Noncommunicable Diseases (MND) Noncommunicable Diseases & Mental Health (NMH) Laragh Gollogly Coordinator, WHO Press (WHP) Health Systems & Innovation (HIS) William Gunn WHO Expert Advisory Panel on Clinical Surgical Procedures Past President, International Federation of Surgical Colleges

André Ilbawi Technical Officer, Management of Noncommunicable Diseases (MND) Noncommunicable Diseases & Mental Health (NMH) Gabriella Jimenez-Moyao Technical Officer, Policy, Access & Use (PAU) Essential Medicines & Health Products (EMP) Health Systems & Innovation (HIS) Walter Johnson Lead, Emergency & Essential Surgical Care Programme (EESC) Services Organization & Clinical Interventions (SCI) Service Delivery & Safety (SDS) Health Systems & Innovation (HIS) Edward Kelley Director, Service Delivery & Safety (SDS) Health Systems & Innovation (HIS) Teena Kunjumen Technical Officer, Health Workforce (HWF) Health Systems & Innovation (HIS) Jeremy Lauer Economist, Costs, Effectiveness, Expenditure & Priority Setting (CEP) Health Systems Governance & Financing (HGF) Health Systems & Innovation (HIS)

© World Health Organization 2016. All rights reserved.

WHO/HIS/SDS/2016.11

Alexandra Metherell Project Officer, Policy, Access & Use (PAU) Essential Medicines & Health Products (EMP) Health Systems & Innovation (HIS) Hernan Montenegro Coordinator, Services Organization & Clinical Interventions (SCI) Service Delivery & Safety (SDS) Health Systems & Innovation (HIS) Susan Norris Technical Officer, WHO Press (WHP) Health Systems & Innovation (HIS) Ian Norton Technical Officer, Policy, Practice & Evaluation (PPE) Emergency Risk Management & Humanitarian Response (ERM) Denis Porignon Technical Officer, Health Systems Governance, Policy & Aid Effectiveness (HGS) Health Systems Governance & Financing (HGF) Health Systems & Innovation (HIS) Dheepa Rajan Technical Officer, Health Systems Governance, Policy & Aid Effectiveness (HGS) Health Systems Governance & Financing (HGF) Health Systems & Innovation (HIS) Teri Reynolds Management of NCDs, Disability, Violence & Injury Prevention (NVI) Noncommunicable Diseases & Mental Health (NMH)

Florence Rusciano Results Monitoring & Evaluation (RME) Health Statistics & Information Systems (HSI) Health Systems & Innovation (HIS) Gerard Schmets Coordinator, Health Systems Governance, Policy & Aid Effectiveness (HGS) Health Systems Governance & Financing (HGF) Health Systems & Innovation (HIS) Karin Stenberg Technical Officer, Costs, Effectiveness, Expenditure & Priority Setting (CEP) Health Systems Governance & Financing (HGF) Health Systems & Innovation (HIS) Adriana Velazquez-Berumen Senior Adviser, Policy, Access & Use (PAU) Essential Medicines & Health Products (EMP) Health Systems & Innovation (HIS) Diana Zandi Technical Officer, eHealth (EHL) Service Delivery & Safety (SDS) Health Systems & Innovation (HIS)

Regional Office for Africa (AFRO) Peter Songolo Disease Prevention & Control Officer WHO Representative’s Office Lusaka Zambia

37

Annex II: Programme Agenda

WORLD HEALTH ORGANIZATION Emergency & Essential Surgical Care Programme Service Organization & Clinical Interventions Unit Service Delivery and Safety Department

WHO Global Initiative for Emergency and Essential Surgical Care 6th Biennial and 10th Anniversary Meeting WHO HQ, Geneva, Switzerland 14-15 December 2015

Day 1: 14 December 2015 08h00 Registration: (Badge office opens at 7 AM) Session 1: Celebration of 2015 Chair: Dr Emmanuel Makasa Opening of the Meeting, Surgery within the context of universal health coverage and quality care Surgery within the framework of integrated peoplecentred health services Global Surgical Workforce Update Surgery within the context of emergency care Evolution of EESC at WHO culminating in the WHA resolution COFFEE BREAK Impact of the resolution at region and country level 50 years of Surgery at WHO LUNCH BREAK Session 2: Presentations; Q&A A. Objectives and Overview of Sessions B. Advocacy and Resource Development C. Access, Governance, Integrating Systems, Quality, Partnerships Working Group Discussions COFFEE BREAK Group Reports (5-10 mins); Plenary Discussions Day 1 Close Dr Walt Johnson Dr Walt Johnson Dr Andres Rubiano Dr Villami Tangi Participants

09h00

Dr Edward Kelley

09h20 09h35 09h50 10h05 10h30 11h00 11h30 12h00 13h00 13h10 13h35 14h00 15h30 16h00 17h00

Dr Hernan Montenegro Dr James Campbell Dr Teri Reynolds Dr Meena Cherian

Dr Emmanuel Makasa Dr William Gunn

38

DAY 2: 15 DECEMBER 2015 08h00 08h05 08h30 08h50 09h00 10h30 11h00 12h00 13h00 13h30 14h00 15h30 16h00 17h00 Announcements and Introductions Session 3: Presentations; Q&A A. Data Collection, Analysis, Sharing; E&M B. Antimicrobial Resistance C. Essential Medicines—Ketamine and narcotics Working Group Discussion COFFEE BREAK Group Reports (5-10 mins); Plenary Discussions LUNCH BREAK Session 4: Presentations; Q&A A. GIEESC: Next Steps B. International Rotation and Fellowship C. Training, Competence, Credentialing, Oversight Working Group Discussion COFFEE BREAK Group Reports (5-10 mins); Plenary Discussions Closing Remarks Dr Edward Kelley Dr Walt Johnson Dr C Garberoglio Dr S Ogendo Participants Dr Walt Johnson Dr Andy Leather Dr B Allegranzi Dr Gilles Forte Participants

Speakers: Dr Emmanuel MAKASA, Counselor – Health, Permanent Mission of the Republic of Zambia Dr Ed KELLEY, Director, Service Delivery and Safety Department (SDS) Dr Hernan MONTENEGRO, Coordinator, Services Org. and Clinical Interventions Unit, SDS Dr Meena CHERIAN, Prior Lead, Emergency and Essential Surgical Care Programme Dr William GUNN, WHO Expert Advisory Panel on Clinical Surgical Procedures, Past President, International Federation of Surgical Colleges Dr Andres RUBIANO, Professor of Neuroscience & Neurosurgery, El Bosque University, Bogotá (COL) and President, Colombian Trauma Association Dr Villami T TANGI, Chief Surgeon Specialist, Vaiola Hospital, Nuku'alofa, Kingdom of Tonga Dr James CAMPBELL, Director, Health Workforce Department (HWF) Dr Teri REYNOLDS, Emergency, Trauma and Acute Care Lead, NVI Dr Andy LEATHER, Director, King's Centre for Global Health Senior Lecturer in Global Health and Surgery, King's College London Dr Gilles FORTE, Essential Medicines Programme, Policy, Access and Use Dr Benedetta ALLEGRANZI, Infection Prevention and Control, SDS Dr Stephen OGENDO, Past President, College of Surgeons of East, Central and South Africa (COSECSA), Department of Surgery and Anaesthesia, Maseno University, Kenya

39



Twinning Partnerships for Improvement Recovery Partnership Preparation Package Building capacity to reactivate safe essential health services and sustain health service resilience

Twinning Partnerships for Improvement Recovery Partnership Preparation Package

Building capacity to reactivate safe essential health services and sustain health service resilience

WHO/HIS/SDS/2016.3 © World Health Organization 2016. All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Designed by CommonSense, Greece Printed by the WHO Document Production Services, Geneva, Switzerland

Twinning Partnerships for Improvement

4

CONTENTS

Introduction ........................................................................................................................................ 6 Objectives ........................................................................................................................................... 7 A 6-step improvement cycle .................................................................................................................. 9 How to use the Preparation Package .................................................................................................... 10 Step 1: Partnership development.......................................................................................................... 11 Step 2: Needs assessment.................................................................................................................... 12 Step 3: Gap analysis............................................................................................................................ 13 Step 4: Action planning....................................................................................................................... 14 Step 5: Action .................................................................................................................................... 15 Step 6: Evaluation and review.............................................................................................................. 16 Annex 1: Twinning Partnerships Planning Template ............................................................................... 17 Annex 2: Twinning Partnerships Visit Proposal Template ....................................................................... 19 Annex 3: Twinning Partnerships Action Report Template ....................................................................... 20

5

Recovery Partnership Preparation Package

INTRODUCTION

Twinning Partnerships for Improvement (TPI) builds on a widely tested and evaluated model of working that contributes to sustainable improvement in service delivery and safety. Building on the work of the WHO African Partnerships for Patient Safety (APPS) programme - a hospital-to-hospital partnership programme to improve patient safety the approach has particular utility in the context of the recovery period following an outbreak or other shock to the delivery of essential health services (EHS). The approach supports capacitybuilding and the re-establishment of safe essential health services, in addition to supporting longer term efforts on service delivery strengthening. Twinning partnerships can act as a catalyst for change at the frontline in the wider effort towards achieving quality universal health coverage. FOUNDATION OF PARTNERSHIP Partnership can be defined as a collaborative relationship between two or more parties based on trust, equality and mutual understanding, for the achievement of a specified goal. Partnerships involve risks as well as benefits, making shared accountability critical. Definition of Partnership co-developed by the WHO African Partnerships for Patient Safety (APPS), 2009.

health facilities needing to recover from an outbreak or other shock to their system. In line with the national response under way and alongside other recovery frameworks, these tools can contribute to building or strengthening capacity towards the improvement of service delivery, through close partnership working. The package will be useful to any new or existing twinning health institutions, to work through a partnershipbased approach to re-establish safe essential health services and embed the effort within long-term service improvement and resilience. Institutional health partnerships have the potential not only to work as individual partnerships, but also to work collaboratively with other partnerships to support similar national frameworks. This can support national efforts through joint problem-solving, and shared experience, developing a body of evidence which can be used with national, regional and district authorities to encourage further use and development of the partnership model. Ensuring buy-in from facility management and government structures is critical to the success of twinning partnership efforts. Undertaking initial discussions and allowing time for briefings and information sharing is important, for placing the partnership work within the context of the surrounding national policy and strategic direction. The package presents a simple, step-by-step framework to help organizations, facilities and individuals understand and systematically develop the processes associated with twinning and working in partnership, with a focus on four interdependent technical areas, namely: ñ infection prevention and control and patient safety; ñ health workforce; ñ surveillance and systems; ñ essential health services.

Health partnerships continue to expand within and between countries and continents. Building on an initial model of north-south partnerships between hospitals in the WHO Region of Africa and hospitals in Europe and North America, twinning partnerships between health organizations, hospitals, primary care facilities or health authorities can support the re-establishment of safe, effective health service delivery in the aftermath of a shock to health services, such as the Ebola outbreak. The main target audience for this partnership preparation package are those institutions and

Twinning Partnerships for Improvement

6

This partnership preparation package describes: 1. Three main objectives on which to build twinning partnerships for health service improvement; 2. The 6-step partnership improvement cycle; 3. The main partnership activities conducted within each of the 6 steps; 4. The expected outputs associated with each step of the partnership cycle; 5. The tools and resources available to assist partnerships to undertake the activities and deliver results, both in the immediate and longer term. This resource is focused on hospitals working together in a twinning partnership, but can also be used by any institutional health partnership, either for the immediate re-establishment of services or long-term service improvement. This resource can also be of significant use to health bodies and institutions unaffected by an outbreak or shock, but which want to undertake preparation activities to build stronger systems for service delivery and safety or learn from partnerships with other institutions.

7

Recovery Partnership Preparation Package

OBJECTIVES

TPI - Immediate Focus Objective 1: Partnership

TPI - Long-term impact Health Institution

Health Institution

Health Institution

Objective 3: Spread of Improvement

Health Institution

Objective 2: Technical Improvement

Health Institution

IPC and Patient Safety

Workforce

Surveillance

Essential Health Services

Health Institution

1. Partnership development: Ensuring strong institutional partnership working. 2. Technical improvement: Implementing effective technical improvement. 3. Spread: Share learning and spread the twinning partnership improvement experiences within the national health system.

Twinning Partnerships for Improvement

8

A 6-STEP PARTNERSHIP IMPROVEMENT CYCLE The partnership approach is based on a 6-step cycle. The approach facilitates the development of partnerships, the systematic identification of gaps and the development of an action plan and evaluation cycle. Evaluation and review enables twinning partnerships to assess, against their baseline, the impact of both their technical improvement work and the strength and functioning of their twinning relations. A variety of tools and resources are available to support each step. Use of a Situational Analysis template, developed as part of the WHO African Partnerships for Patient Safety (APPS) programme, can support the IPC and patient safety technical action area, for example. Use of the Recovery toolkit and national health assessments in the post outbreak context can also help to assess current levels of service delivery in the key technical action areas. The overall aim of the approach is to strengthen health service delivery, safety and resilience. The approach is applicable in a post-outbreak context and can spread improvement beyond local level activity to national health systems.

Step 1: Partnership Development

Step 6: Evaluation and Review

6-Step Partnership Improvement Cycle

Step 2: Needs Assessment

Step 5: Action

Step 3: Gap Analysis

Step 4: Action Planning

Partnership development supports the establishment of fully functioning, communicative twinning relations between two health institutions. Needs assessment allows the baseline situation to be captured, so priority technical areas can be identified, and forms the basis for an evaluation of the implemented activities. Gap analysis allows identification of key priority areas for focused improvement efforts. Action planning provides twinning partnerships with the opportunity to jointly agree and develop targeted action plans. Action is the stage of implementation of the agreed plan of activity with focused action on both arms of the twinning partnership to help deliver effective health services.

9

Recovery Partnership Preparation Package

HOW TO USE THE PREPARATION PACKAGE This Preparation Package supports the development of effective twinning partnerships for the re-establishment and/or improvement of health services. It describes a step-wise approach for bringing about improvement through twinning. As outlined in the previous section, the first step in the 6-step cycle concerns partnership development. Each of the steps includes a list of suggested activities to help assess baseline, identify gaps, develop, implement and evaluate action plans, all within the context of a twinning partnership for improvement. Each step ends with one or more tangible outputs or deliverables to work towards. To assist partners in working through each step, a list of supportive tools, where available, is provided. When seeking appropriate tools for any given technical action area of focus, it is important to consider how they can support planning partnership activity, technical implementation, and in addition important cross-cutting themes, such as community engagement, knowledge management and communication/advocacy. It is also critical to consider the broader national context, policies, frameworks and national strategic priorities in planning twinning activities. This will be particularly important in achieving objective 3 and spreading the experience from the twinning partnership improvement processes both in the short and long term.

Twinning Partnerships for Improvement

10

Step 1: Partnership Development

Step 6: Evaluation and Review

6-Step Partnership Improvement Cycle

Step 2: Needs Assessment

Step 5: Action Step 4: Action Planning

Step 3: Gap Analysis

Step 1: Partnership development Main activities during step 1 1. Build a strong foundation for partnership, ensuring buy-in and commitment from, not only key institutions, but also government and ministry of health officials. Scoping visits may be useful. 2. Secure management and leadership agreement on both sides of the twinning partnership to take joint action. 3. Identify a twinning lead and deputy at each twinning institution. 4. Consider the APPS definition of Partnership, refine and agree on it across the twinning partners, as a foundation for moving forward. 5. Negotiate with managers to secure protected time to work on the identified technical action areas. 6. Establish a twinning technical committee in each arm of the partnership. 7. Join a global network of those working in partnership focussing on patient safety by registering through the WHO website at: http://www.who.int/patientsafety/implementati on/apps/getting_involved_with_APPS/en/. 8. Identify a lead person in each institution to work on evaluation including data collection and feedback. 9. Develop a written statement of understanding across the institutions (if not already in existence). See the Tropical Health Education Trust sample Memorandum of Understanding. http://www.thet.org/wp-content/uploads/2009/ 11/Links-Manual-Section-2-Chapter-2.3.pdf 10. Download and review resources on partnerships from WHO website. 11. Twinning partnership lead and deputy (as a minimum) work through the Introductory webinar. 12. Establish a schedule of regular communication (minimum of once a month is recommended) using a variety of methods (telephone, SMS text messaging, email, Skype, Fax).

Outputs or deliverables 1. Exchange of letters between institutional management as required. 2. Agreement on a definition of twinning partnership. 3. A lead and deputy trained in the approach using the outline provided in this preparation pack and webinar. 4. Written statement of understanding between twinning institutions.

Core resources for Step 1 ñ WHO APPS Website – www.who.int/patientsafety/implementation/apps - APPS Definition of Partnership - APPS Principles of Partnership - Briefing: Institutional Partnerships in the context of Ebola response and recovery ñ Tropical Health and Education Trust (THET) Partnership Handbook – www.thet.org ñ French Hospital Federation - La Cooperation Internationale Hospitaliere – Guide de bonnes pratiques professionnelles - www.fhf.fr/Europe-International/La-cooperation-internationale/Guide-cooperationinternationale-hospitaliere/Guide-de-la-cooperation-internationale-hospitaliere.

11

Recovery Partnership Preparation Package

Step 1: Partnership Development

Step 6: Evaluation and Review

6-Step Partnership Improvement Cycle

Step 2: Needs Assessment

Step 5: Action Step 4: Action Planning

Step 3: Gap Analysis

Step 2: Needs assessment Establishing a baseline is critical.

Main activities during step 2 1. Agree area of particular focus across twinning institutions. 2. Undertake a specific needs assessment using appropriate assessment/checklist tools for technical area of focus, working together to establish a baseline. 3. Consult appropriate technical resources for the re-establishment of essential health services, IPC and patient safety, surveillance and health workforce.

4. Consult the National Strategic Health Plans and other national frameworks to ensure alignment with national priorities. 5. Consult wider UN assessment reports for broader context.

Outputs or deliverables 1. Completed baseline and situational analysis report appropriate to technical area of focus.

Core tools and resources for Step 2 RESOURCES - ASSESSMENT IPC and Patient Safety APPS Patient Safety Situational Analysis Hand Hygiene Self-Assessment Framework Workforce Workload Indicators of Staffing Needs (WISN) www.who.int/hrh/resources/wisn_user_manual/en/ Surveillance Technical Guidelines for Integrated Disease Surveillance and response in African Region (IDSR) (NB: each country should also have their own national IDSR plan in place) WHO Laboratory assessment Tool 2012 Essential Health Services WHO Recovery Toolkit Hospital Preparedness for Epidemics http://www.who.int/csr/resources/publications/ebola/recoverytoolkit/en/ http://apps.who.int/iris/bitstream/10665/151281/1/ 9789241548939_eng.pdf?ua=1&ua=1 http://www.afro.who.int/en/clusters-a-programmes/dpc/ integrated-disease-surveillance/features/2775-technical-guidelines-for-integrated-disease-surveillance-and-response-in-theafrican-region.html http://www.who.int/ihr/publications/laboratory_tool/en/ www.who.int/patientsafety/implementation/apps/resources www.who.int/gpsc/country_work/hhsa_framework_October_ 2010.pdf LOCATION

Twinning Partnerships for Improvement

12

Step 1: Partnership Development

Step 6: Evaluation and Review

6-Step Partnership Improvement Cycle

Step 2: Needs Assessment

Step 5: Action Step 4: Action Planning

Step 3: Gap Analysis

Step 3: Gap analysis Partners review the baseline and situational analysis findings, identify gaps and agree on priorities.

Main activities during step 3 1. Using the findings of the baseline and situational analysis, work across the partnership to develop a list of gaps that require improvement action. 2. Prioritize technical action area with focused activities. 3. Focus on small-scale simple actions.

Outputs or deliverables 1. List of priorities based on the capacities of both sides to contribute to addressing the gaps identified.

Core tools and resources for Step 3

ON I T AC APPS Patient Safety Situational Analysis www.who.int/patientsafety/implementation/apps/resources R FO Hand Hygiene Self-Assessment Framework www.who.int/gpsc/country_work/hhsa_framework_October_ S A 2010.pdf RE A Workforce ITY R Workload Indicators of Staffing Needs (WISN) www.who.int/hrh/resources/wisn_user_manual/en/ RIO P Surveillance IFY T N Technical Guidelines for Integrated Disease http://www.afro.who.int/en/clusters-a-programmes/dpc/ E D I Surveillance and response in African Region integrated-disease-surveillance/features/2775-technical-guideTO (IDSR) (NB: each country should also lines-for-integrated-disease-surveillance-and-response-in-theS T have their own national IDSR plan in place) EN african-region.html M S WHO Laboratory assessment SES http://www.who.int/ihr/publications/laboratory_tool/en/ S A Tool 2012 OF Essential Health Services E M O WHO Recovery Toolkit http://www.who.int/csr/resources/publications/ebola/recoveryC T U toolkit/en/ O E S Hospital http://apps.who.int/iris/bitstream/10665/151281/1/ U Preparedness IPC and Patient Safety for Epidemics 9789241548939_eng.pdf?ua=1&ua=1

RESOURCES - ASSESSMENT

LOCATION

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Recovery Partnership Preparation Package

Step 1: Partnership Development

Step 6: Evaluation and Review

6-Step Partnership Improvement Cycle

Step 2: Needs Assessment

Step 5: Action Step 4: Action Planning

Step 3: Gap Analysis

The priorities are translated into a written plan of action over a 2-year period using the Partnership Planning Template (See Annex 1). Extracting an immediate 6-month plan of action from the 2-year plan provides an effective starting point for long-term sustainable partnership activity.

Step 4: Action planning Main activities during step 4 1. Develop Partnership Action Plans. The Partnership Planning Template (annex 1) can be used to provide direction but modified and simplified accordingly. 2. An immediate 6-month plan of activity may provide necessary rapid response support. This should be developed in the context of the wider 2-year plan. 3. Include an estimate of expected expenditure. 4. Focus on a plan that is simple, realistic and easy to understand and covers preparatory, implementation and monitoring and evaluation activities. 5. Schedule a series of twinning partnership exchanges including visits with clear objectives relating to the agreed plan. See annex 2 for visiting planning guidance. 6. Consider how activities and lessons can be shared beyond the partnership, encouraging national spread.

Outputs or deliverables 1. A 6-month initial short-term activity plan agreed by both twinning partners 2. A 2-year Partnership Plan agreed by both twinning partners.

Core tools and resources for Step 4 RESOURCES IPC and Patient Safety APPS Resource Map Workforce See Early Recovery Toolkit below Surveillance Technical Guidelines for Integrated Disease Surveillance and Response in African Region (IDSR) (NB: each country should also have their own national IDSR plan in place which should be referred to here) WHO Laboratory assessment Tool 2012 Essential Health Services WHO Recovery Toolkit http://www.afro.who.int/en/clusters-a-programmes/dpc/ integrated-disease-surveillance/features/2775-technicalguidelines-for-integrated-disease-surveillance-and-responsein-the-african-region.html http://www.who.int/ihr/publications/laboratory_tool/en/ LOCATION http://www.who.int/patientsafety/implementation/apps/ resources/APPS_resource_map.pdf?ua=1

http://www.who.int/csr/resources/publications/ebola/recoverytoolkit/en/ WHO Strategy on Integrated Peoplehttp://www.who.int/servicedeliverysafety/areas/peoplecentred Care centred-care/global-strategy/en/ See Annex 1 and 2 for partnership planning templates

The High 5s Project Interim Report

14

Step 1: Partnership Development

Step 6: Evaluation and Review

6-Step Partnership Improvement Cycle

Step 2: Needs Assessment

Step 5: Action Step 4: Action Planning

Step 3: Gap Analysis

On completion of the Partnership Plan – partners start action/ activities to support capacity development for essential health services over a 2-year period, with 6-monthly review.

Step 5: Action Main activities during step 5 1. Put the Partnership Plan into action. 2. Use all possible remote exchange mechanisms. 3. Align partnership action with national efforts for strengthening service delivery. 4. Agree a schedule for regular reports on progress across the twinning partnership. 5. Agree a process for reporting on twinning visits to ensure actions and impact are logged in relation to achieving the project goals described in the Partnership Plan. 6. Disseminate progress reports to appropriate bodies at national, regional and district level to maintain dialogue and connection to overall national plans in the post-outbreak context. 7. Take opportunities to use partnership activities to bring about change in other institutions, encouraging national spread.

Outputs or deliverables 1. Series of reports outlining action and progress towards the Partnership Plan (see template in Annex 3).

Core tools and resources for Step 5 RESOURCES IPC and Patient Safety APPS Resource Map Workforce See recovery toolkit below Surveillance Technical Guidelines for Integrated Disease http://www.afro.who.int/en/clusters-a-programmes/dpc/ Surveillance and Response in African Region integrated-disease-surveillance/features/2775-technicalguidelines-for-integrated-disease-surveillance-and-response(IDSR) in-the-african-region.html WHO Laboratory Assessment Tool 2012 Essential Health Services WHO Recovery Toolkit Hospital Preparedness for Epidemics http://www.who.int/csr/resources/publications/ebola/recoverytoolkit/en/ http://apps.who.int/iris/bitstream/10665/151281/1/ 9789241548939_eng.pdf?ua=1&ua=1 http://www.who.int/ihr/publications/laboratory_tool/en/ http://www.who.int/patientsafety/implementation/apps/ resources/APPS_resource_map.pdf?ua=1 LOCATION

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Recovery Partnership Preparation Package

Step 1: Partnership Development

Step 6: Evaluation and Review

6-Step Partnership Improvement Cycle

Step 2: Needs Assessment

Step 5: Action Step 4: Action Planning

Step 3: Gap Analysis

In addition to local review meetings and partnership discussions, each twinning partnership provides routine reports on progress and as a minimum the following are recommended: ñ 6 months – report on activity together ñ 1 year – repeat baseline assessment ñ 2 years – review and write new plan of action

Step 6: Evaluation and review Main activities during step 6 1. Evaluate actions as outlined in the Partnership Plan (informed by appropriate evaluation tools). 2. Keep a written record of evaluation to demonstrate impact and to advocate for financial support. The reports will focus on the achievement of project outputs and outcomes. 3. Repeat the baseline assessment/Situational Analysis annually.

Outputs or deliverables 1. A series of reports shared across the partnership and with hospital leaders outlining action and progress towards achieving the Partnership Plan. 2. Repeated baseline assessment/Situational Analysis.

Core tools and resources for Step 6 RESOURCES IPC and Patient Safety APPS APPS Evaluation Handbook Hand Hygiene Self-Assessment Framework Workforce Workload Indicators of Staffing Needs (WISN) Surveillance Technical Guidelines for Integrated Disease http://www.afro.who.int/en/clusters-a-programmes/dpc/ Surveillance and Response in African Region integrated-disease-surveillance/features/2775-technicalguidelines-for-integrated-disease-surveillance-and-response(IDSR) in-the-african-region.html WHO Laboratory assessment Tool 2012 Essential Health Services WHO Recovery Toolkit Hospital Preparedness for Epidemics http://www.who.int/csr/resources/publications/ebola/recoverytoolkit/en/ http://apps.who.int/iris/bitstream/10665/151281/1/ 9789241548939_eng.pdf?ua=1&ua=1 http://www.who.int/ihr/publications/laboratory_tool/en/ www.who.int/hrh/resources/wisn_user_manual/en/ LOCATION http://www.who.int/patientsafety/implementation/apps/ Evaluation-Handbook_EN.pdf?ua=1 www.who.int/gpsc/country_work/hhsa_framework_ October_2010.pdf

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ANNEX 1 Twinning Partnerships Planning Template SUMMARY INFORMATION Name of twinning institution 1: Name of twinning institution 2: Name and date of situational analysis/base line assessments used: Technical Action Areas for Focus: e.g. IPC or Workforce

Name of lead: Name of lead: Names of individuals completing the plan:

ñ Project 1: Health care-associated infections ñ Project 2: Re-activate malaria treatment services

For each action area complete the template below. Use as many forms as required depending on the additional technical action areas addressed. Project Number and action area: Brief description of project Project goals ñ E.g. Project 1: Health Care-Associated Infection ñ Provide a 1-2 sentence outline of the project ñ List the change the project will contribute to in 1- 2 sentences. ñ Where possible, link to national and/or local policies and plans including the National Health Strategic Plans and early recovery planning. ñ Try to emphasize how the goals of the project respond to the needs identified in the baseline assessment. ñ Describe the improvement that will result from the project. ñ Outcomes often relate to changes in practice or health outcomes. ñ The outcomes should contribute to the achievement of the goal. ñ The direct results of the project e.g. 20 people trained in infection control. The outputs should lead to the achievement of the outcomes. ñ List all planned activities. For each activity, briefly outline what will be done; where and who will be involved on each side of the twinning partnership; how long it will take; methods that will be used; and associated costs. ñ List technical exchange schedule ie. Fortnightly skype connection, Weekly leads 1to1, 6 monthly visits, ... ñ Is a visit planned in conjunction with this project? (if yes, list likely human and financial costs.) ñ Twinning visit plans for year 1 should be thought through in detail. Plans for year 2 may be more general. Include a draft timeline. ñ What mechanisms are planned to allow receipt of just-in-time input to technical issues? ñ How will you connect with WHO efforts to support service delivery and safety?

Project outcome(s)

Project output(s) Main activities

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Beneficiaries

ñ Include information about the people who will benefit (directly and indirectly) from the project e.g. lab technicians; hospital managers; nurses and different groups of patient and community members. ñ Describe how they will benefit and provide realistic estimates of how many people in each group will benefit. ñ Will benefits span both sides of the twinning partnership? ñ Identify the key stakeholders and their interest in the project (e.g. other department, district and national health offices) i.e. any individual or group that may exert influence over the project activities and outcomes (across both arms of the partnership). ñ Consider the local community and key stakeholders, including patients and families who could contribute and add value to the planned efforts, providing a fresh perspective to the re-establishment of safe services. ñ Outline which stakeholders the twinning partnership will report to and how often. ñ Define key indicators to be used to monitor whether the outcomes of your project have been achieved. ñ Provide an overview of your monitoring and evaluation plans, providing an outline of methods, who will be involved, how the process will be managed, and how partners will learn together. ñ Describe how long the activities will continue and what the plans are for long- term funding. ñ What benefits will continue after the initial 2 year project ends and how? ñ List your plans for building on project achievements. ñ Describe how you will actively disseminate new information gathered and consider activities to support vertical, horizontal and spontaneous spread opportunities. ñ Identify potential risks associated with the plan e.g. key personnel moving on, changing institutional priorities, conflict between twinning partners and how you will manage each of these risks. ñ List external risks and how you will manage them (e.g. ICT breakdown, problems with visas, political uncertainty).

Stakeholders

Monitoring and evaluation

Sustainability and spread

Risks

Project management and support ñ Outline project responsibilities including division of responsibilities across the twinning partnership. ñ Provide details of the key personnel involved in each arm of the partnership. ñ Consider key management questions: What systems will be used to manage finances in both locations? Who will have the main responsibility for budgets? How will you ensure that communication is effective and that all partners know what is happening? Approved by Date of approval

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ANNEX 2 Twinning Partnerships Visit Proposal Template Twinning Partnership (list both institutions within the partnership): Name of person completing the Visit Proposal Form: Purpose of visit - describe which Partnership project(s) the visit relates to: What are the start and end dates of the proposed visit? Is the visit aligned with existing in-country activity with no duplication of training or policy development work? Does the visit clearly meet the needs of the host twinning partner institution? Briefly describe the expected outcomes of the planned visit (outcomes are clear, realistic and logical):

Start date: End date: Yes Yes No No Not applicable Not applicable

Briefly describe the outputs of the planned visit (outputs are clear, realistic and logical):

Briefly describe any risks you think might be associated with the visit:

List the estimated cost of the visit:

Briefly describe how the proposed visit will contribute to monitoring and evaluation of the Partnership Plan:

List the number of people involved in the proposed visit and their role in achieving the visit objectives: Has the visit been jointly planned and agreed across the partnership? Will the visit offer potential benefits to both twinning partners (if yes, describe briefly)?

Yes Yes

No No Not applicable

Briefly describe how the visit will help achieve sustainability and spread of effective essential health service delivery.

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ANNEX 3 Twinning Partnerships Action Report Template Twinning Partnership (list both institutions within the partnership): Name of person completing the Action Report: Time period covered by the progress report? Key actions undertaken

Report Number: Dates covered in this progress report:

Key achievements resulting from action taken

Key challenges faced

Date of next expected progress report

Date:

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