Introduction

According to recent estimates, 11 % of the global burden of disease can be treated with surgery [1]. More than 2 billion people lack access to even the most basic surgical care, most of them found in the lowest income countries [2]. Of the estimated 234 million operations performed worldwide every year, only 3.5 % occur among the poorest third, whereas 73.6 % occur among the world’s richest third [3].

Since the Declaration of Alma Ata in 1978 recognized the right of every human being to primary health care [4], efforts have been underway to provide essential, preventive, and curative health measures to every human being worldwide. While the resultant primary health care movement has made some improvements with basic health care [5], basic, emergency, and essential surgical services have been neglected [6]. An epidemiologic shift in disease patterns in develo** communities has transitioned from primarily communicable to noncommunicable diseases. Morbidity and mortality from surgically treatable diseases, including complications of many chronic diseases (e.g., cardiovascular disease, diabetes, and obesity), cancer, and injury, continue to rise epidemically [1, 7].

In 2004, recognizing the need for surgical systems to address this growing unmet burden of disease, the World Health Organization (WHO) established the Emergency and Essential Surgical Care (EESC) program [8], which was designed to strengthen surgical services at the first-referral hospitals in low- and middle-income countries. The EESC program published an Integrated Management of Emergency and Essential Surgical Care (IMEESC) toolkit, which contained the components necessary for establishing essential anesthetic and surgical services, such as emergency, trauma, and obstetric care (Table 1). The program adopted a health systems strengthening approach, from instituting EESC at the policy level to focusing on the education and training of health workers on the most essential surgical procedures, protocols, and equipment. A necessary component of the program is promoting collaboration among the various stakeholders in surgical care.

Table 1 Components of the IMEESC Toolkit
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To date, there are limited data documenting the implementation and scale-up of surgical services in rural, resource-poor environments. Ivers et al. [9] describes increasing access to surgical services for the poor in rural Haiti. Maru et al. [10] recently proposed an 18 month, single-center implementation research protocol to assess the surgical scale-up process in a rural, resource-limited setting. To our knowledge, the nationwide scale-up and implementation of rural surgical services has never been described.

This report will be the first of its kind to document the 6 year experience of a nationwide implementation and scale-up of surgical services. The article highlights the role of the various stakeholders in surgical care (i.e., the Mongolian Ministry of Health (MOH), WHO Emergency and Essential Surgical Care (EESC) program, academe, professional societies, and international partners and nongovernmental organizations (NGO)) and how the efforts of these various groups were coordinated and integrated at the national level. Moreover, we document the impact of the program on process measures such as availability of infrastructure, personnel, and interventions after the institution of the program.

Background

Mongolia is a large, landlocked country situated in Central Asia with 2.8 million inhabitants [11]. Almost 69 % of Mongolians are in the age range of 15–64 years with a median age of 26.2 years and an average life expectancy of 68 years. The country ranks 148 of 227 in the world in terms of GDP, with a per capita GDP of USD 3,600 [12]. Health expenditures account for 4.3 % of the GDP [13] and the per capita health expenditure was USD 74 as of 2009 [14].

As recently as 50 years ago, the majority of Mongolians lived as nomadic herdsmen in the grasslands in the central and eastern parts of the country, and a smaller population lived in the Gobi desert in the south and the mountainous region in the northwest [15]. Prone to natural disasters, the country experiences numerous episodes of flooding and extreme cold weather. Today, 62 % of the population lives in urban areas, half of which are located in the Mongolian capital Ulaanbaatar [12]. This rapid urban shift has had a profound impact on the health care system. Residents crowd into urban areas, living in slums or shantytowns, and create a higher demand for medical services, while the rest of the population remain relatively isolated in the vast rural areas of the country with limited or no access to medical care, especially essential surgical care.

Since the 1990s, Mongolia has undergone an epidemiologic transition. Deaths from cardiovascular disease, cancer, and injuries have increased, whereas deaths from communicable and respiratory diseases have declined. In particular, mortality from injuries and poisoning has sharply increased, overtaking respiratory illnesses during the late 1990s, and now ranking third (after cardiovascular disease and cancer). The injury mortality rate has almost doubled since 2000 [13].

Health care system

Mongolia is divided administratively into the capital city, Ulaanbaatar (approximately 1 million people), and 21 aimags (45,000–100,000 people), which is further subdivided into 338 soums (3,000–6,000 people). The health care system is organized into four levels of care (Table 2). The first point of contact between the population and the healthcare system are the bagh feldshers (specialized nurse practitioners) who work in their own gers (tent houses) and follow the nomadic community providing health education and basic primary care. Essential primary care services are provided at soum hospitals, which are fully operational health facilities with a doctor providing emergency services in low-resource settings. Secondary care services are provided by aimag general hospitals and regional diagnostic treatment centers that have better equipment and surgical and obstetric care. Tertiary care services with specialists are available only in the capital city, Ulaanbaatar [16].

Table 2 Health care system of Mongolia
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Currently, rural areas are losing their health personnel as a result of an influx of doctors into urban areas. The lack of adequate infrastructure is one of the difficulties encountered in the provision of health services to the population in remote areas. In a study done in 2002, only 47 % of soum hospitals had equipment that was consistent with standards, half of which were manufactured before 1990 and a quarter of which were not utilized at all. In 2003, only 1.4 % of the patients in soum hospitals received surgical care [16]. Rates of postoperative surgical complications were 0.47 %, and mortality was at 0.31 % in 2004 [17].

A survey of surgical and anesthetic capacity at primary health facilities in Mongolia revealed major deficits in infrastructure, physical resources, and human resources. Of 44 institutions, no fully qualified surgeons or anesthesiologists were available. The majority of surgical procedures were performed by nonphysician providers (i.e., bagh feldshers) (30 %) or general practitioners (16 %) [18].

Materials and methods

Realizing gross deficiencies in surgical services, equipment, and manpower necessary to provide adequate emergency and essential surgical care to the Mongolian people, the Mongolian MOH solicited the aid of the WHO EESC program together with various stakeholders in surgical care to organize and strengthen surgical capacity at the soum (first-referral level) hospitals in the rural areas of Mongolia.

Before this initiative, various international organizations have been operating in the urban and major cities of Mongolia in an independent fashion providing surgical services, training, and infrastructure. The Swiss Surgical Team (SST), a branch of the International College of Surgeons, has conducted annual team visits with 15–20 physicians and nurses in Ulaanbaatar since 1999. Besides offering scholarships to Mongolian surgeons and anesthetists, the group is involved in providing university and district hospitals with surgical equipment and supplies. After the EESC program initiative, the SST provided on-site training of regional doctors in the soum areas for 3 weeks at a time. In 2005, in cooperation with the University of Basel, the Swiss Government Agency for Development and Cooperation (SDC), Health Sciences University of Mongolia (HSUM), and the Mongolian MOH, the SST implemented a Telemedicine Network (MonTelNet) in Mongolia. The goal of the project was to improve surgical services in rural and isolated areas of the country through pre- and postoperative diagnostic and treatment support and to enable access to current medical knowledge. The WC Swanson Family Foundation (SFF) began improving the infrastructure of many hospitals throughout the country in 1999 and still continues through today—providing hospital beds, operating room tables and lights, cautery machines, birthing beds, laparoscopy, autoclaves, ventilators, and monitors. Since 2005, under the direction of the HSUM and the Mongolian MOH, the foundation has combined basic emergency and essential surgical training for the surrounding soums. Other international organizations have provided similar support, which were coordinated and directed by the Mongolian MOH after the start of the EESC program.

WHO EESC program staff conducted a site visit before the first training workshop, followed by a planning meeting with Mongolian health leaders, WHO country staff, and professional societies. The result of the meeting laid the foundation for the systematic nationwide implementation of a program to strengthen surgical care at the first-referral level, beginning with six pilot sites.

The pilot sites, representing a catchment area of six administrative divisions (aimags) covering a total area of 439,471 km2 were selected based on: population size, health quality indicators, availability of emergency and surgical care at the aimag and soum level, linkages/referral networks, accessibility, distance, infrastructure, and morbidity and mortality pattern [19]. Table 3 lists details of each site.

Table 3 Characteristics of the six pilot sites
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A needs assessment evaluation was done at the six pilot sites using a modified form of the WHO Situational Analysis Tool and the Essential Emergency Equipment (EEE) checklist [8] to establish a baseline and to identify key areas for improvement.

In October 2004, a WHO Training of Trainers workshop was held at Ulaanbaatar with 42 participants comprised of policy makers from the Mongolian MOH (i.e., quality assurance, directorate of medical services, nursing) and health providers (i.e., directors, managers, doctors, and nurses) from the six selected aimags (pilot sites). The objective of the workshop was to train the participants to become trainers in building surgical capacity and to enable them to use the tools in the IMEESC package to strengthen emergency and essential surgical services when they return to their respective hospitals. Details of the workshop are published in a separate article [16].

All components of the IMEESC toolkit were translated into Mongolian in 2005, including the manual Surgical Care at the District Hospital, needs-assessment checklist, and program evaluation form. Curricula and modules for training in EESC were developed for the training program.

From May until June of 2005, a total of 210 health personnel from the six pilot sites simultaneously underwent a 5 day training program on basic emergency and essential surgical skills using lectures, e-learning, video conferences, working group discussions, and hands-on basic skills training, such as suturing, splinting, and casting. After a field visit to selected soums for baseline assessment of emergency care capacity, the participants were trained on surgical safety, waste management, basic surgical skills and principles, principles of trauma, wound management, obstetric emergencies, orthopedic procedures, cardiopulmonary resuscitation, emergency surgery, anesthetic principles, and care of the critically injured. Consultants from HSUM and specialized hospitals in Ulaanbaatar conducted the training sessions. Table 4 lists components of the local training. Fund of knowledge was assessed before and after the training session using a questionnaire developed by the trainers. Participants independently developed working plans to strengthen EESC at their respective hospitals with a set time frame and indicators for achievement. At the end of the training session, each participant received a certificate of completion. Evaluation of the training program led to recommendations to expand the project to the rest of the country.

Table 4 EESC local training
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In June 2006, the EESC project was continued and implemented in two aimags. Three-week training courses were conducted from May to June by the SST at Ulaanbaatar and three regional centers where doctors from the neighboring provinces could participate. The participants were divided into subgroups and rotated for 1 week at a time at each specialized center in the capital (e.g., trauma, maternal, and child health) while other groups simultaneously attended training courses in other regional hospitals. Moreover, multidisciplinary seminars in multiple centers were organized. Pre- and post-test evaluations were conducted to assess fund of knowledge [20]. From 2007 to 2010, six aimags were included in the program (Table 5). Figure 1 details the implementation process.

Table 5 Program scale-up
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Fig. 1
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Implementation of the EESC program

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From March 29 until April 15, 2007, evaluation of 12 soums from 3 aimags took place. Key areas of evaluation were: staff knowledge, infrastructure (i.e., availability of a designated ER), equipment and supplies, and safety and sterility. Retrospective, administrative data were obtained from a nonrandom cohort study conducted by HSUM in conjunction with the Mongolian MOH. Frequencies were compared by using a χ2 test, and means were compared by using a t test to generate corresponding p values. All analyses were performed by using STATA software (version 11; STATA Corporation, College Station, TX).

Results

The program was implemented in 66.67 % of the aimags (14/21) and 52.66 % of the soums (178/338) since 2005, representing a catchment area of 495,946 km2 and serving a total population of 958,819. Figure 2 shows the distribution of selected sites. A total of 657 doctors from primary (soum) to tertiary hospitals, 29 midwife and bagh feldshers from rural provinces, and 50 nurses from rural areas were trained under the EESC program.

Fig. 2
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Distribution of pilot sites. Map of Mongolia divided into 21 aimags. All labeled areas represent training sites, gradient shows implementation from earliest to latest (darkest to lightest)

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Needs assessment done on the 12 selected soum hospitals in the six pilot sites before the program was implemented revealed gross deficiencies in basic and essential emergency surgical care (Fig. 3). All sites evaluated lacked a designated emergency room (ER), ER equipment, and a policy for EESC, whereas >75 % of the sites lacked an emergency and disaster preparedness plan and EESC training materials. Access to electricity and water was available for 83.3 % of the training institutions.

Fig. 3
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Needs assessment of 12 selected soum hospitals at the pilot sites

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Fund of knowledge evaluation showed a universal increase in the scores of the participants after the training program (Fig. 4). The mean correct score at the pilot sites increased from 47.72 % (95 % confidence interval (CI) 40.7–54.7) to 77.9 % (95 % CI 70.1–85.7, p = 0.0001).

Fig. 4
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Pre- and post-test evaluation scores at six pilot sites

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The pilot soum hospitals’ evaluation 1 year post-training showed significant improvements in infrastructure. There was a 57.1 % increase in the availability of emergency rooms, a 59.1 % increase in the supply of emergency kits, a 73.64 % increase in the recording of emergency care cases, and a 46.66 % increase in the provision of facility and instrument usage instructions (Fig. 5).

Fig. 5
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Pilot soum hospitals’ evaluation 2 years post-training

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Twelve soums were evaluated in 2007 by using the WHO Monitoring and Evaluation form—five of them 1 year post-training (Uvurkhangai aimag), and seven of them 2 years post-training (Tuv and Khenthii aimag).

Of the four soum hospitals evaluated in Tuv aimag serving a population of 15,547, with an average radius of 66.5 km, 75 % were found to have electricity and transported water supply. A total of 7 physicians, 19 nurses, and 26 maintenance/technician workers were trained. A 25 % increase in the availability of a dedicated emergency room and equipment was noted in the training sites 2 years post-evaluation. The Jargalant soum hospital’s medical team acquired new skills, such as basic wound care, application of splint for fractures, burr hole, abscess drainage, and suturing. Moreover, they appointed a wound nurse and an obstetrician/gynecologist. They also improved some of their equipment (e.g., acquiring a small range radio to improve communication). The Bor Nuur soum hospital acquired basic skills, such as incision and drainage, ligation of hemorrhoids, and management of wounds. However, they still lacked supplies and sterilization equipment. The Bayantsogt soum hospital was well-equipped but lacked preparedness to deliver ER care. The Lun soum hospital treated 30–35 road traffic accidents per year. Although ER equipment was available, it was locked up in a separate room and was generally inaccessible to the staff.

The Berkh soum hospital in Khentii aimag was found to have a new incubator, surgical coagulator, ventilator, and designated training rooms during evaluation. The hospital instituted innovative programs, such as patient advocacy once per month to involve the community. The Murun soum hospital was able to create a new delivery room that services 15 women per month.

Five soum hospitals from Uvurkhanghai aimag were evaluated serving a population of 23,770 with an average radius of 105 km. Average bed size was 11. The Tugrig soum hospital had centralized water and heating. A total of 16 physicians and 37 nurses were trained in 2006. The Tugrig, Bog, Baruun Bayan Ulaan, and Bat-Ulzi soum hospitals each had a physician who trained 8–13 colleagues for a total of 43 colleagues. A 20 % increase in the availability of a dedicated emergency room was noted. New equipment, such as Ambu bags, suctions, sterilization equipment, and autoclaves, were noted in majority of the soum hospitals. The Baruun Bayan Ulaan soum hospital was able to organize its own joint training on emergency preparedness.

Aggregate measures of the 12 soum hospitals evaluated reflect an overall increase in the performance of essential surgical procedures (Fig. 6), significant for wound debridement (p < 0.0001), suturing (p = 0.0002), incision and drainage of abscess (p < 0.0001), resuscitation (p = 0.016), removal of foreign body (p = 0.014), and venous and peripheral cutdown (p = 0.045). There was a decrease in the number of surgical cases that were referred to other facilities for treatment. Essential supplies and equipment were procured and distributed in 112 and 212 soum hospitals in 2006 and 2010, respectively, for a total of 324 soum hospitals (95.8 % of all soum hospitals).

Fig. 6
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Surgical procedures performed 1–2 years post-training (13 soum hospitals evaluated)

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After the institution of the EESC program, several programmatic features were achieved: systematized monitoring and evaluation of soum hospitals using the WHO Monitoring and Evaluation tool, development of standards and guidelines on basic surgical and emergency care using the IMEESC toolkit, adoption of a health systems strengthening approach by the Mongolian MOH (i.e., inclusion of health, sanitation, and surgical safety in subsequent policies), enhanced collaboration with partner NGOs, and allocation of financial resources to support the program (i.e., WHO country budget and increased MOH budget for emergency care).

Discussion

This report documents the systematic nationwide deployment and implementation of surgical services, never before described at this scope and level. The foundation for improving EESC in Mongolia began with an analysis of the gaps in surgical capacity using the WHO Situational Analysis Tool, translation of the IMEESC tool into Mongolian, and by conducting a “training the trainers” workshop designed to empower local leaders. Aimag training by the trainers then commenced at the six pilot sites, concluding with an evaluation at the end of the session. Overwhelming positive response prompted the organizers to expand the program. Evaluation of the program 2 years after its implementation identified areas of weakness as well as documented important short-term programmatic impact. A plan of action was then formulated to increase surgical capacity.

Before the implementation of the EESC program, surgical care in Mongolia consisted of uncoordinated efforts of various stakeholders, which resulted in mismatched resources, unmaintained equipment, and programs that were not adequately evaluated. After implementation of the program, organization of resources and mechanisms for coordination, evaluation, and ongoing support for the program was established.

Today, the program continues to grow and has established its permanence in the Mongolian MOH’s roster of policies designed to strengthen its primary health care system. EESC has been integrated into Mongolia’s national programs on trauma, disaster preparedness, and maternal health. The Health Sector Strategic Master Plan (2006–2015) of Mongolia defined the Government and MOH policy on EESC for all levels of health services [21]. The National Emergency Network Program, approved in 2010, renewed emergency facilities, equipment, and ambulance vehicles through funding from the Mongolian Ministry of Finance [22]. Further plans are underway to institutionalize surgical capacity building as an essential component of its primary health care strategy. Massive nationwide implementation and scale-up was achieved via several key approaches: integration, coordination, adaptation, and advocacy.

Initiated by the Mongolian MOH, the program was designed to integrate the various components of a surgical system essential to provision of surgical care (i.e., infrastructure, equipment, human resources, and skills). The aim was health systems strengthening, working directly with the soum health leaders and policy makers and ultimately giving them the autonomy to identify and improve aspects of surgical care unique to their environment. Support from the Mongolian MOH enabled progress in infrastructure and provision of equipment.

Involvement of the Mongolian MOH provided a centralized mechanism for coordinating the efforts of various NGOs, the academe, and the WHO. A specialized office located at the Department of Surgery of HSUM was created where all organizations were directed before doing any fieldwork or providing any surgical service. This prevented duplication of efforts as well as helped these organizations focus their work in areas of Mongolia where surgical support was severely lacking. Moreover, designating the IMEESC toolkit as the primary source of material for surgical capacity building in all sites enabled standardization and quality control. In 2009, Mongolia hosted the third Global Initiative for EESC (GIEESC) meeting with more than 100 members, bringing international partners together to review updates in surgical care as a result of the EESC program [23].

Translation and adaptation of the IMEESC toolkit to the local language and context was essential. Although considered the primary source of material for training and policy-making decisions concerning EESC, considerable expertise brought in by the trainers from HSUM and various international organizations also were welcomed. The central approach of the EESC program was to build surgical capacity and engender a sense of ownership and responsibility among the local health leaders. Trained health workers were encouraged to conduct their own training sessions, designate training rooms in their respective district hospitals, and furnish guidelines and protocols in EESC training. The EESC program’s situational analysis and needs assessment tool identified major areas of weakness in the Mongolian health system at the soum level. This served as a valuable aid in the decision-making process involved in the allocation of scarce healthcare resources and facilitated program revisions and training improvements.

A critical component to expanding the EESC program in Mongolia was the presence of “champions.” These were individuals who held key positions at the MOH, WHO country office, and HSUM who advocated for surgical care and continued to follow-up and support the program.

Several limitations deserve to be mentioned. First, this paper presents a descriptive account of the evaluative process done 2 years after the implementation of the program. Although findings show a positive trend in short-term impacts (i.e., improvements in infrastructure after the implementation of the program), impact evaluation was not done to demonstrate the long-term effects of the program on important surgical outcomes, such as postoperative morbidity and mortality. Second, the evaluation that was done on the soum hospitals 2 years postimplementation was not uniformly done. Because each aimag had a different evaluator, certain aspects of the monitoring and evaluation form were emphasized while other parts of the form were not completely filled out. Moreover, some evaluators added descriptive/pertinent details of their visit beyond the scope of the monitoring and evaluation form while others mainly focused on the evaluation. Improved training on the process of evaluation can yield more uniform results. Third, due to cost, regular evaluations were not performed on a sufficient sample size to represent an unbiased estimate of the total population size.

Integrating EESC with primary health care services in Mongolia has improved human resources and basic infrastructure and has led to its incorporation into the countrywide healthcare plan in the Mongolian MOH. This nationwide implementation of a multifaceted and multiorganizational surgical initiative has resulted in short-term process measure improvements. This approach and focus on investments in surgical infrastructure and training reflects the recommendation of a group of leaders in surgery, anesthesia, obstetrics, health policy, and health economics who met at the Bellagio Conference in Italy in 2007 [24].

Strengthening surgical services at the district level facilities using this coordinated effort to expand the EESC program in Mongolia has succeeded in improving access, availability, and possibly the quality of appropriate emergency and essential surgical care in the most rural areas of this remote country. This coordinated approach can serve as a useful model for increasing surgical capacity through health systems strengthening. Further efforts to refine the approach and standardize monitoring and evaluation may further increase its effectiveness. Impact evaluation on the long-term effects of the program on health outcomes, such as postoperative morbidity and mortality, should be the next step to establish the program’s impact on surgical care and further inform public policy. Undoubtedly, the EESC program, through the ambit of the WHO, has succeeded in serving as an arbiter among stakeholders in surgical care to bring these essential services to those who need it the most.