The “Twinning” Concept: Building Healthcare Capacity in Pediatric Neurosurgery in Ukraine
Laura-Nanna Lohkamp, Myroslava Romach, James T. Rutka Department of Surgery (Neurosurgery), University of Toronto
Global health has gained increased attention over the last decade, and there has been considerable growth in the concept of program “twinning”. This concept of building partnerships between academic institutions in high-income countries (HICs), and hospitals/academic institutions in low- and middle-income countries (LMICs) aims to overcome discrepancies in quality of patient care, workforce education, and surgical capacity building. Such partnerships have been established all over the world in resource-poor LMICs, leading to significant improvement of healthcare delivery.
As a response to the dire need of improving the quality of pediatric health care in Ukraine, we used the “twinning” concept as an academic initiative to establish the Ukraine Pediatric Fellowship Program (UPFP). The program was launched in 2013 as a capacity-building program with Children of Chernobyl Canadian Fund (CCCF), SickKids Hospital, and the Ukrainian Canadian Congress. It is intended to facilitate a bilateral exchange of knowledge, skill, and expertise between healthcare specialists from Ukraine and SickKids in dedicated areas of pediatric medicine.
Ukraine is the second largest country in Europe by territory, with a population of 45 million people. Its healthcare system relies on the former Soviet Semashko model of healthcare, a highly centralized process of training healthcare workers, financing care, and delivering services. Being entirely detached from population health requirements, Ukraine’s healthcare still faces remnants of political and health system corruption, and a sclerotic central bureaucracy having a significant impact on infrastructure, medical education, and quality of care. Clinical protocols, qualification requirements for specialist training, and indicators of health service outcomes are not compatible with European and North American standards, leading to an overall low health profile with continuing high rates of morbidity, disability, and mortality. Unlike some low-income countries, where building capacity begins from the ground up, Ukraine not only struggles constantly with these unique challenges, but also is resourcepoor. Improving the quality of care is a key reform expectation and depends to a large extent on reforming undergraduate and postgraduate medical education as well as training. However, these actions require international assistance through diverse organizations, providing financial, technical and educational support.
Development of the Ukraine Pediatric Fellowship Program (UPFP)
Against this background, we chose to be part of the international assistance and to implement an academic partnership, improving the quality of pediatric healthcare in selected centers of need in Ukraine. We developed the Ukraine Pediatric Fellowship Program (UPFP) in 2012, a postgraduate training program for pediatric physicians in Ukraine, as part of a global health outreach initiative based at SickKids Hospital in Toronto, Canada.
As Canada has the largest Ukrainian diaspora in the world, constituting approximately 1.2 million Canadians who consider themselves of Ukrainian heritage, there was a substantial background for establishing sustained community and financial support for this initiative.
The UPFP was developed based on a capacity-building model focusing on several key features: 1) endowed philanthropic funding for sustainability: 2) bilateral exchange of knowledge; 3) a focus primarily on pediatric brain disorders; and 4) team building. Practically the exchange component would be two-fold: 1) specialists from SickKids would offer biannual advisory visits at several Ukrainian sites for teaching, supervision of clinical consultation; and surgical guidance; and 2) Ukrainian physicians would have the opportunity to receive intensive skill training through month-long observerships at SickKids in Toronto. Centers for partnering are selected on the basis of need, receptivity to change, and participants’ fluency in English as the success of the UPFP would largely depend on these factors.
Implementation of the Ukraine Pediatric Fellowship Program
The first visit to Ukraine in 2012 consisted of meetings with physicians and hospital administrators from several large regional cities where the majority of children’s hospitals are located (e.g. Kyiv, Lviv, Dnipro, Kharkiv). Ultimately three centers were selected for pilot collaborations. Two were children’s hospitals in Lviv: Lviv City Children’s Clinical Hospital and Western Ukraine Specialized Children’s Hospital. A partnership was also established with the Romodanov Neurosurgical Institute, Pediatric Division, in Kyiv, the only center for postgraduate neurosurgical training in Ukraine.
The first project phase focused on pediatric neurosurgery. Dr. Rutka from SickKids, with Ukrainian descent, accepted the role of Project Leader in implementing the program. After a year of correspondence and planning, the first mission to Ukraine took place in June 2013 in neurosurgical centers in Lviv and Kyiv. The mission, which began as a neurosurgery initiative in 2013, has since grown to become a comprehensive brain health program, expanding to other disciplines such as neurology, neonatology, neuropathology, and psychiatry. More recently, several neurosurgical fellows from SickKids have visited Ukraine. There are typically two visits per year, with fellows from SickKids making more than one visit to Ukraine to emphasize continuous engagement and relationship-building.
The typical schedule of an advisory visit consisted of SickKids clinicians visiting each site for several days. The first day is typically structured with a series of predetermined lectures, at times with translation, based on the most current knowledge in the field, addressed to physicians and allied health workers from the host hospital and from institutions in the surrounding areas. The following day, consultations take place on complex patients selected in advance by the Ukrainian physicians or surgeons. On this day, 1 or 2 cases are identified and discussed for surgical intervention on subsequent days.
During the surgical procedures, the visiting surgeon assists in and helps to direct the procedure, which is always carried out by a Ukrainian surgeon. The Canadian specialist surgeon intervenes only if necessary to demonstrate a specific skill. This pattern of training and mentoring has persisted to date with gradual expansion to other cities in Ukraine including Lutsk, Uzhhorod, and Odessa.
During their observerships in Toronto, Ukrainian participants take part in and observe a variety of activities they do not often experience in their home country, such as multidisciplinary team rounds, practice in the surgical simulation center, or work in the cadaver lab. Moreover, they get exposed to organization of emergency services, up-to-date diagnostic and treatment protocols (oncology, radiology, epilepsy) and techniques (surgery, genetics), as well as integration of research into clinical activities with subsequent participation in international conferences and publications. A potential shortcoming of these observerships is that participants are not permitted to conduct hands-on patient care, due to stipulations of the hospital and credentialing authorities.
Over 7 years, 14 teaching visits have taken place, and 20 physicians have trained at SickKids Hospital in Toronto. Six Ukrainian children's hospitals are now collaborating with UPFP. New neurosurgical procedures have been introduced, such as endoscopic third ventriculostomy and corpus callosotomy. Subsequently patient referrals have significantly increased at the participating institutions over the years, and most of the promoted sites have now the capacities and potential to perform life-saving pediatric neurosurgery in their own operating rooms after decades of sending children with operable brain tumours more than 700 km away to the capital city of Kyiv. This new capability, which eases the practical and financial burden for families by allowing children with brain tumours to receive treatment close to home, can be attributed directly to the successful translation of the “twinning” concept in this particular context of surgical care.
With regards to education and quality improvement of care, the intent to build “expert multidisciplinary teams” with professionals of interrelated disciplines, such as neurosurgery, neurology, oncology, neonatology, and psychiatry in selected regional children’s hospitals in Ukraine has been equally successful. A major component of this multifaceted success is the continuous and strong connection between the SickKids clinicians and their Ukrainian colleagues. Maintaining regular interactions in order to discuss the treatment of complex patients via internet consultations, and the progress of different projects is one of the benefits that the Ukrainian participants appreciate most beyond the temporary local exchanges. Their perception of the mentoring program provided by the UPFP is extremely positive and reflects their will and endeavor to improve their health care system.
Other beneficial “downstream effects” of the program are additional donations, which have allowed the purchase of much-needed medical equipment for some of the hospitals in Ukraine, including operating microscopes, microsurgical instruments, and operating loupes – all of them contributing to increasing surgical quality standards and performance. Moreover the program has promoted an increased awareness of fetal and infant neurodevelopment deficiencies such as neural tube defects. This has led to secondary programs, e.g. a campaign petitioning the Ukrainian government to make mandatory the fortification of flour with folate. This is an example of policydirected activity occurring concomitantly with the efforts being made by the UPFF to improve quality and effectiveness of care.
The development and implementation of the UPFP is a good example for successful translation of the “twining concept” into practice. It demonstrates how a small group of committed individuals can successfully build capacity in pediatric healthcare in a post-Soviet LMIC. The keys to success have included focusing locally, selecting trustable partners, building incrementally, and creating interspecialty synergies. Nevertheless, the availability of sufficient funding is crucial for ensuring the sustainability of such a program and its financial independence.
Figure 1. Drs. Oles Semenyuk and Yuriy Chomokyak welcomed by Dr. James Rutka.
Figure 2. Drs. Yuriy Kolivoskha, Yuriy Chomokyak, James Rutka, Taras Mykytyn reviewing a case.