Endemic Non-Communicable Diseases

**Panelist Ross Donaldson **

I'm the global head of International Medical Corps' emergency and disaster care development programming. I also serve as the director for the emergency medicine global health program at the Harbor-UCLA Medical Center, as well as faculty at the UCLA schools of medicine and public health.

Although I've worked around much of the globe at various times, current ongoing programs in emergency care development include Iraq, Haiti, and Armenia. For example, over the last four years in Iraq we have trained thousands of personnel spanning the full spectrum from community to prehospital to hospital-based emergency care. We have also focused heavily on systems-building on multiple levels, supporting the development of a universal phone number, nation-wide emergency care health information systems, mass casualty response protocols, and many other system improvements, to build a modern emergency care system out of the ashes of conflict.

1. What factors should be considered when selecting and developing an appropriate training curriculum for different audiences or cadres in prehospital care work force?

There are three main keys to developing appropriate prehospital training materials for low- and middle-income countries. First, the curriculum should be for general emergency care training, as opposed to a ...

**Panelist Ross Donaldson **

I'm the global head of International Medical Corps' emergency and disaster care development programming. I also serve as the director for the emergency medicine global health program at the Harbor-UCLA Medical Center, as well as faculty at the UCLA schools of medicine and public health.

Although I've worked around much of the globe at various times, current ongoing programs in emergency care development include Iraq, Haiti, and Armenia. For example, over the last four years in Iraq we have trained thousands of personnel spanning the full spectrum from community to prehospital to hospital-based emergency care. We have also focused heavily on systems-building on multiple levels, supporting the development of a universal phone number, nation-wide emergency care health information systems, mass casualty response protocols, and many other system improvements, to build a modern emergency care system out of the ashes of conflict.

1. What factors should be considered when selecting and developing an appropriate training curriculum for different audiences or cadres in prehospital care work force?

There are three main keys to developing appropriate prehospital training materials for low- and middle-income countries. First, the curriculum should be for general emergency care training, as opposed to a specific vertical focus on trauma or another disease/injury process. Although specific processes are frequently the impetus for such programs, prehospital emergency care is a classic area for synergy; it should ideally address the many divergent illnesses that benefit from rapid treatment and transport.

Second, the curriculum should be evidence-based. Although the exact needs varies by locale, this almost always includes a strong focus on basic emergency care, as demonstrated by the Canadian OPALS Studies and other literature. Developers need to resist the tendency towards thinking that a higher level of prehospital care is always better and rather focus on first providing quality basic care in a rapid, accessible and systematic manner.

Third, the curriculum needs to be adapted to the local environment with local buy-in. Disease processes and emergency systems vary by country; the standard operating procedures of their prehospital personnel, as well as the training programs for these personnel also need be adapted to these differences, normally in partnership with national counterparts.

2. Which stakeholders should be involved in the training and capacity building process?

As the delivery of prehospital emergency care varies widely by country, it is not possible to give universal answers as to the choosing initial stakeholders. However, it is invariably true that the key to the long term success any emergency care development program is the buy-in of national stakeholders. Traditional stakeholders include the general community, medical community, and government, as well as humanitarian groups.

Our standard approach is to establish a local Emergency Medicine Working Group, in the initial stages of any emergency care development program. This can include high-level members of the government (e.g. Ministry of Health, Ministry of Transport, Ministry of Interior, etc., depending on country), national medical leaders, community leaders, representatives from other NGOs, as well as other identified individuals or groups.

3. What program aspects should be measured and over what time frame?

There are a host of possible indicators, depending on the emergency care development program focus and environment. These can include program indicators (e.g. training numbers, test scores), community indicators (e.g. using emergency care KAP studies), operational indicators (e.g. response time, call volume), and hard indicators (e.g. changes in morbidity and mortality).

Preferably, indicators should be measured before program onset, throughout the program, and at its termination. Such indicators should also ideally be incorporated into the capacity building of the prehospital system and continued to be measured in a sustainable manner far after the termination of any specific development project.

4. What factors should be considered throughout the process to promote institutionalization and long-term viability of the training programs and ensure high quality trainees?

Sustainability and institutionalization of program gains are of primary importance for successful prehospital emergency care development programs. To avoid misadventure, programs should have strong buy-in at multiple levels throughout society. Developers also need to give intensive thought to the cost-effectiveness of the program they are implementing, as well as to the long-term financial arrangements that will support the system into the future. Local government and/or community cost-sharing is a good way of establishing this early on in program development. System development and ongoing quality assurance/improvement is as important, or more important, than the initial training program. Experience shows that short-term trainings of prehospital personnel in the absence of local buy-in, financial support, and an overall system, are rarely sustainable or of long-term utility.

**Panelist Manjul Joshipura**

As a trauma care scientist at WHO HQ I provide scientific leadership and technical support in the field of trauma care to WHO departments and Member States. I support trauma system development, capacity building and quality improvement activities across countries. I have over 25 years of experience working as a Trauma Surgeon in both developed and developing countries.

1. Most short training courses will be off shoots of PHTLS or similar programmes. Long term programmes would follow more or less EMT (B) or EMT (A) type of curriculum. However in low and middle income countries the knowledge and skills imparted should match the resources that are going to be available to them. e.g. if there are no resources for advance airway management in the prehospital setting , will there be value in including ventilator management in the curriculum. The skills and knowledge will need to be retained in absence of it s regular use. WHO publication Prehospital trauma care systems (2005) clearly defines what knowledge and skills will be important based on the sophistication of the EMS in a given setting. Creating awareness and imparting basic life saving basic training in the community has a big role.

2. Trainers and EMS leaders will be the key stakeholders. Centres of Excellence in a country can take a lead to start the capacity building process. There are number of examples where university programmes in high income countries have played hand holding role to such institutions in low and middle income countries. Where available, professional associations (Emergency Medicine Physicians) can also play a central role. One important stakeholder in the setting of low and middle income country will be Ministry of Health. They are not easy to engage in the process however they can be encouraged to participate in this process then they can institutionalize the capacity building with a legislation in the country.

3. The training programmes should be measured over medium to long term only. Generally structure and process indicators are easy to measure.

4. Support from the Government is vital for a long term sustainability of such programmes , especially in low and middle income countries. Governments can make legislations, rules and set standards for such training. It can make mandatory such training for all EMS providers. Obviously the quality of such training would be critical too. Another important factor to ensure sustainability would be periodic re-certification of EMS providers which is can be considered only at a next stage development after introducing and then stabilizing the training programme.

**Panelist Paul Bollinger **
I oversee the Emergency Medical Care (EMC) Train the Trainer education and systems development programs for Medical Teams International based in Portland Oregon. These programs focus on the reduction of secondary injury from trauma related incidents and enhancing EMS and trauma systems in developing countries (Cambodia, Moldova, Sri Lanka, Uganda, Uzbekistan and Vietnam). Program focus includes small community driven programming to nationalized system development from point of entry into the EMS system to discharge from hospital setting. I hold a master's degree in public health with a focus in international health. I have worked in the EMS field in both urban and rural settings for more than 25 years and have extensive field experience in Asia.

1. A key factor when introducing training curriculum is to provide curriculum that is in the local language. The curriculum should not just be a translation of an existing curriculum but a contextualization for use in the project area. This should include pictures, video and diagrams depicting the people within the service area actually demonstrating the skills and concepts being taught.

2. The key to a successful training program is to include all members of the first responder community. This includes both the pre-hospital and receiving hospital personnel. Additionally when introducing a “new” pre-hospital training program be sure that the local healthcare policy makers are aware that the training includes the provision of “non-physicians” providing healthcare outside of the hospital setting. The earlier that the key stakeholders are involved the more successful the project will be.

3. Each program is unique. Easy indicators to measure include both direct (# of students taught, curriculum developed, patients treated in a pre-hospital setting etc...) and indirect beneficiaries (# of potential trauma patients, service area catchment, etc...). Most projects will take at least three years to fully develop in areas where there has not been a previous EMS system.

4. Early engagement with key personnel within the medical education system is paramount to establish long term sustainability. Additionally identification of a local “champion” who has a passion and understanding of the program will help promote the project within respective ministries or local agencies.

**Panelist Junaid Razzak **
I am a board certified Emergency Medicine specialist with training in Public Health. I founded the first department of Emergency Medicine in Pakistan at the Aga Khan University and established the first organized residency training program in emergency medicine. I am also director of WHO Collaborating Center on Emergency Medicine and Trauma in Pakistan. I am currently working with a not-for-profit organization to establish prehospital emergency care system in the city of Karachi.

1. What factors should be considered when selecting and developing an appropriate training curriculum for different audiences or cadres in prehospital care work force?

a. Affordability
b. Relevance to the local setting and talent
c. Availability
d. Acceptability in the local licensing milieu
e. Acceptability in the international market in countries where many people are interested in enhancing their skills to make themselves more marketable in international market.

2. Which stakeholders should be involved in the training and capacity building process?

a. Local medical University/teaching institution
b. Local Licensing authorities
c. Government agencies that define medical care standards
d. Nursing societies
e. International partners

3. What program aspects should be measured and over what time frame?

a. Ability to enhance skills and the level of retention of such skills in obviously the key. A program with a good balance of theoretical training and skills enhancement needs to be looked at.
b. The program guidelines and training standards should be based on evidence especially when in countries where resources are scarce and doing interventions with questionable effectiveness, out of research, can take away resources from more pressing issues.
c. Affordability in the low income setting
d. Ability to teach more than medical care which is to enhance skills in patient and scene handling in out-of-hospital environment.
e. Training in soft skills such as communication, team work etc


4.What factors should be considered throughout the process to promote institutionalization and long-term viability?

a.A non-profit mandate helps in areas such as EMS.
b.Creating market for skills and knowledge in EMS by ensuring that jobs are available for trained staff and there is a career track.
c. Developing local or regional training hubs or perhaps centers of excellence in Pakistan context when travel for people have become very difficult
d. Ability to market the courses at a price which ensure local financial viability without making them unaffordable