Taking Paediatrics Abroad: Working with low- and middle-income countries in a global pandemic

Children and young people around the world face challenges to their health and wellbeing. In particular, in low- and middle-income countries they experience a higher burden of disease, exacerbated by global inequity limiting access to quality health care. According to the inverse care law, the availability of quality health care varies inversely to the need of the population, and hardworking health-care professionals in under-resourced countries may face impediments to continued education or subspecialty training. In line with the Sustainable Development Goals, collaborations have been developed between high-income and low- and-middle-income countries to address global disparities in health. These collaborations face challenges of high financial costs, difficulties creating long-term sustainable change, and with the emergence of the COVID-19 pandemic, border closures preventing fly-in volunteers. In this paper, we describe the development of an innovative, paediatric-specific model of care for training and support between high- and low-income countries – Taking Paediatrics Abroad Ltd. Taking Paediatrics Abroad supports the development of mutually beneficial relationships between Australian paediatric health-care professionals and paediatric health-care professionals in developing countries and remote, underserved Australian Aboriginal communities. Since May 2020, there have been over 100 sessions covering a vast array of paediatric specialties. This article explores Taking Paediatrics Abroad’s model of care, its implementation and challenges, and opportunities for the future.

Background

All children have the right to survive and thrive, but children and adolescents around the world face challenges to their health and wellbeing. In 2019, 6.2 million children world-wide died under the age of 15, including 5.2 million children younger than 5.¹ Deficits in health care disproportionately affect low- and middle-income countries (LMICs), where this burden of disease is highest.^2, 3 In order to have a truly equitable response to improve the health of the world’s children so that they both survive and thrive in line with the WHO-UNICEF-Lancet Commission and the Sustainable Development Goals,^4, 5 it is vital to continuously improve efforts to deliver appropriate and necessary health care around the world. However, hardworking health-care professionals in under-resourced LMICs face barriers to their opportunities for continued professional education or subspecialty training.⁶

To address this global inequity, there is a long history of collaboration between high-income countries (HICs) and LMICs. From Australia and New Zealand, some of the earliest efforts to improve paediatric health internationally were from the Royal Australasian College of Surgeons, providing surgical aid, training, and support.⁷ These programmes were very effective as they adapted to local circumstances and worked closely with local specialists. Similarly, Radiology Across Borders has been offering radiology teaching face-to-face and online.⁸ Although medical aid has been historically less involved in supporting clinical care in the Asia-Pacific region, there are emerging medical organisations that offer practical support. For example, oncology collaborations between Australia and New Zealand and LMICs provide training, observerships and twinning partnerships, although there is still room for improvement and formalisation of training opportunities.⁹ Paediatric-specific medical organisations are even more scarce, although links do exist between some Australian children’s hospitals and overseas paediatric hospitals, including the University of Melbourne’s Centre for International Child Health.¹⁰

Many of the existing models of collaboration involve Australian and New Zealand volunteers flying in and providing support or education in country. However, there are ongoing challenges with this fly-in-fly-out model of care. Firstly, it often comes at a high financial cost. The global cost of short-term medical missions was estimated to exceed US$3.7 billion in 2016.¹¹ In addition, the carbon footprint of even short flights is significant. Each passenger on a return flight from London to Rome generates 234 kg of carbon; this is higher than the yearly emissions produced by the average person in 17 countries.¹² To avoid contributing to global health inequity, charitable medical organisations need to create effective, affordable and sustainable strategies that aim to improve health care in LMICs by sharing expert support and education with paediatric health-care teams in those countries, with a focus on local health-care providers delivering the care.⁶

The biggest immediate and short-term barrier to the traditional model of charitable aid work is the emergence of the COVID-19 pandemic travel restrictions and border closures. As a result, the fly-in-fly-out aid model has been challenged to shift towards new, innovative methods of volunteering, including the integration of telehealth. Telehealth has been defined as medical information that is exchanged from one site to another via electronic communication to improve a patient’s health.¹³ The use of telehealth has increased within many HICs to address access barriers; in Australia, the Medicare Benefits Schedule was adapted in 2020 to introduce new funding for the provision of telehealth to support the mental health and wellbeing of those adversely affected by bushfires.¹⁴ There are also instances of telehealth being used to provide support to LMICs; for example, Médecins Sans Frontières has used a telehealth service since 2010 to provide direct specialist expertise to field physicians.¹⁵ Telehealth has provided medical aid models with a method of connecting medical teams across oceans and borders in place of, and in potentially future to complement, face-to-face visits.

In this paper, we describe an innovative, paediatric-specific model of care for training and support between high- and low-income countries – Taking Paediatrics Abroad (TPA) – that has used telehealth to address the global inverse care law. We will describe the development of TPA, its implementation and challenges, and opportunities for the future.