​Building healthcare capacity in the Solomon Islands
 
Dr Ayman Shenouda

Unmatched resilience
 
A recent visit to the Solomon Islands provided some new insights into what it really means to be resilient. It is one of the least developed countries in the Pacific Region, the population languishes in poverty yet they make the most out of limited resources.  
 
The community here face significant health challenges and on multiple fronts. They lack even the basic health infrastructure, and universal access seems an almost impossible health policy goal. Despite this, I found the healthcare teams here work with courage and resolve.
 
Health system challenges
 
Persisting social disparities mean they face significant health challenges through what is termed the “triple burden” of disease. The community deals with communicable diseases alongside rising rates of non-communicable diseases combined with the threat of climate change which we know already hits hard too regularly.
 
The Solomon Islands suffer from significant resource deficits and the underdevelopment of infrastructure is driving inequalities. There is no CT scanner in the country – that places new meaning on what it is to be deficient in resources here. This is a country of over 620,000 people spread across more than 900 islands and it is without essential imaging diagnostic tools.
 
Coverage of services is very weak. This is partly because past development efforts have lacked the required multi-level coordination to support any sort of integrated health system. Almost half of all health expenditure comes from donors which is mostly put to disease management with little left for service system development. [i]
 
The Good Samaritan
 
My visit to the Solomon Islands was unexpected and prompted by a local MP who approach me following some donations I made to the hospital in Tetere. They were relatively small contributions in the form of blood pressure and haemoglobin machines. From this visit, I learnt that while small they were vital and are the sorts of supports that help to develop capacity and reliability.
 
The Good Samaritan hospital is on the coast in Tetere in Guadalcanal province which is about 40km from Honiara. The caseload here is overwhelming. The hospital is basic with about 30 beds, that provides mainly chronic disease management, emergency medicine and obstetrics. There is one doctor per 60,000 population, two midwives and two nurses. But with that they perform miracles here - this team provides obstetric care averaging 170 delivers a month.
 
This is a population facing serious health problems yet you would be amazed by how well they cope with very little. The four most common conditions leading to critical illness are malaria, diseases of the respiratory system including pneumonia and influenza, diabetes mellitus and tuberculosis.[ii] Screening programs are grossly underdeveloped which increases critical care demand.
 
Most facilities are short staffed and without basic equipment. From Tetere it is one hour  to Honiara for Xray or just to do bloods.
 
Despite the many challenges, the team use their clinical skills to the highest levels to provide the best care for their patients. It is the practical supports that they need the most and I think as a community of GPs we are well placed to do more.
 
Improving critical care
 
It is clear that the underdevelopment of healthcare infrastructure compounds inequalities.
 
In Pacific Island countries, including the Solomon Islands, there is a high need for basic critical care resources. Equipment such as oximeters and oxygen concentrators are needed as well as greater access to medications and blood products and laboratory services. [iii]  
 
A cross-sectional survey study examining critical care resources in the Solomon Islands found that inadequate resources from primary prevention and healthcare contribute to the high degree of critical illness. This study suggested that the solution lies in simple therapies and context-appropriate resources to mitigate the high burden of morbidity and mortality.[iv]
 
Therefore, the emphasis should be on the development and acquisition of simple and inexpensive tools rather than complicated equipment. This helps to prevent critical care from diverting resources away from other important parts of the health system. [v]
 
This makes perfect sense in these resource-poor contexts and certainly, the healthcare team in Tetere provide a stunning example of making it work with almost nothing at all.
 
Enabling partnerships
 
Empowerment is key to improving health service development in the Solomon Islands. The focus needs to be on strengthening the health system and improving access to services but bringing health care to these areas is no easy task.
 
It needs a partnership which filters right down to the community level. The Ministry of Health and Medical Services (MHMS) is really working hard towards enabling these partnerships to ensure a more planned approach to funding health services.
 
Australia is the largest provider of Official Development Assistance (ODA) to the Solomon Islands, providing almost two-thirds of overseas aid in 2016-17. We are the lead donor in the Solomon Islands health sector, with Australia’s main bilateral assistance provided through the Health Sector Support Program (HSSP) (equates to AUD 66m over four years to 2020). [vi]
 
Since 2008, the MHMS, with their development partners including Australia, has led a sector-wide approach (SWAp) to the delivery of health services in the Solomon Islands. The overall program goal for HSSP3 is to improve the access and quality of universal health care in the Solomon Islands. The current funding supports the Solomon Islands National Health Strategic Plan 2016-2020 and provides direct budget support, performance-linked funding and technical assistance.[vii]
 
What more can be done?
 
It is clear that Australia is doing its fair share for the Solomon Islands. There is now alignment in terms of ensuring best outcomes from this funding. This will certainly help build health services for this nation. But there is always more to do and GPs, in particular, can make a significant difference.
 
We need strategies to work through how best we can support our disadvantaged pacific neighbours from a community of GPs. Education partnerships being key and the RACGP already contributes in this way particularly in Papua New Guinea.
 
From my recent visit to the Solomon Islands, I have seen how the community there through their own resilience can achieve so much. Those working in Aboriginal Health would be familiar with what it takes to support patients in low-resource, laboratory-free settings. It would be great to share some of these learnings and provide more support for the Solomon Island communities.
 
[Ends]
 
[i] World Health Organisation. Article. Health closer to home: transforming care in the Solomon Islands. March 2017. Available at: http://www.who.int/features/2017/health-solomon-islands/en/
[ii]Westcott M, Martiniuk AL, Fowler RA, Adhikari NK, Dalipanda T. Critical care resources in the Solomon Islands: a cross-sectional survey. BMCInternationalHealthandHumanRights.Mar1,2012.doi:10.1186/1472-698X-12-1.Availableat: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307438/
[iii] ibid.
[iv] ibid.
[v]  ibid.
[vi] Commonwealth of Australia. Independent Performance Assessment. Solomon Islands – Health Sector Support Program. Specialist Health Service. May 29, 2017; revised 24 July 2017.
[vii] ibid.

Australia needs to place a levy on sugary drinks now
 
Dr Ayman Shenouda
 






​ 
A sugar fix anyone?
 
Sugar certainly got some attention this week prompted by some important, corresponding, new research undertaken here in Australia[i] and in France[ii].
 
The first focussed on risks associated with fizzy drinks, while the other a little broader and on ultra-processed foods, but both found similar findings in terms of increased cancer risk. In a third article featured this week, in Meds Obs opinion, Dr Jon Fogarty wrote that we cannot allow another 50-year con job. I couldn’t agree more.
 
Rapid increasing consumption of lower nutritional quality foods is clearly driving an increased disease burden. It is those ultra-processed foods that we need to look at which contain high salt, trans fats and saturated fats along with sugar.
 
Prevention focus
 
It was quite telling that the recent PC Report Shifting the Dial: 5-year Productivity Review, released in August last year fell short of recommending a sugar tax. This is despite a strong obesity emphasis in the report only called for a soft market control solution through voluntary reductions in sugar content (by major manufacturers of SSBs).
 
Many are comparing the current policy complacency in response to sugar, in particular, with the dangerously slow response to tobacco. And, I truly believe that if we were serious around prevention then we would be looking to a sugar tax here in Australia. If we are to shift health outcomes then we need to think less about a system which drives episodic care and more about those broader factors that influence health outcomes. I’ve said that before but it needs restating particularly on this issue.
 
Policy levers
 
Consumers clearly need more help to identify those foods with added sugar.
 
Some of this work has been done through the Federal Government’s Health Stars Rating scheme designed to help consumers make more informed choices. But manipulative marketing seems to be out-tricking the system by making unhealthy products look healthy.
 
Choice put forward some good recommendations in August to make this system better. Making sure foods high in sugar, fat or salt can’t get a high star rating being their number one!
 
A Navigation Paper of the 5-year review of the Health Star Rating System was released in January. It will be interesting to see what changes are made in response to the review.
 
Sugar levy
 
Placing a fiscal incentive through increasing the price of these foods would make for an effective solution. But, I really think a sugar tax is warranted here. And, if not a full sugar tax, then perhaps a health levy on sugary drinks is a good start.
 
The UK is leading the way with its plans to introduce a levy on sugar-sweetened beverages this year. Importantly, revenue will fund a prevention focus through expanded programs to reduce obesity and encourage physical activity and balanced diets for school children.[iii] Ireland is following with a levy coming into effect in April.
 
Closer to home, there seems very little appetite to introduce a similar levy in Australia despite calls from various leading health experts and many of the peak bodies.
 
Despite twenty-six countries placing a health levy on sugary drinks, we are not seeing similar leadership from our Government. Federal minister for agriculture and water resources, David Littleproud, said in January that governments “should not dictate the diet of citizens”, much to the delight of those industries that benefit from inaction.[iv]
 
Minister Littleproud heads a portfolio responsible for the investment in the development of Australia’s sugarcane industry. In my view, this is an issue that falls in the food safety category as excess refined sugar has undesirable health consequences. Therefore, despite where the legislation may sit, this is more an issue for the health minister.
 
There’s plenty of evidence
 
In terms of a need to take immediate action, we’re certainly not short on evidence here. And there’s now increased evidence to act on sugary soft drinks.
 
The French research I mentioned earlier looked at the risk between ultra-processed food and cancer. In this prospective study published in the BMJ, found a 10 per cent increase in the proportion of ultra-processed foods in the diet was associated with a significant increase of greater than 10 per cent in the risk of overall and breast cancer. ii
 
Proving that soft drinks elevated risk of cancer, the new research from the University of Melbourne and the Cancer Council Victoria released this week also found people who regularly drink sugary soft drinks were more at risk of cancer. i
 
Interestingly, this Victorian study showed that higher consumption of both sugar-sweetened and artificially sweetened soft drinks is associated with higher waist circumference. However, cancer risk was only higher among those who drink more sugar-sweetened soft drinks. This is an important finding as many opt for the alternative diet option or sugar substitute thinking it better, yet it also may be contributing to our obesity epidemic. i
 
Even more surprising, the key finding from this study that increased cancer risk is not driven completely by obesity. Those who are not overweight have an increased cancer risk if they regularly drink sugary soft drinks. i
 
We need action now
 
It is always those who can least afford it that suffer the most. Poor diet is more a result of poverty than a lack of understanding around the risks. The only food the poor can afford is making them unhealthy.
 
The key findings from these recent studies both in terms of ultra-processed foods and sugary soft drinks now link to increased cancer risk. This issue is a health priority and needs to be a key focus for the health ministry.
Let’s not sugar coat it – sugar and sugar sweetened drinks kill - we need action on this now.
 
[Ends]
 
[i] Hannink, N. Increased cancer risk from fizzy drinks – no matter what size you are. University of Melbourne. 22 February 2018. Available at: https://pursuit.unimelb.edu.au/articles/increased-cancer-risk-from-fizzy-drinks-no-matter-what-size-you-are
[ii] Fiolet, T., Srour, B., Sellem, L., Kesse-Guyot, E., Allès, B., Méjean, C., et al. Consumption of ultra-processed foods and cancer risk: results from NutriNet-Santé prospective cohort BMJ 2018; 360 :k322. Available at: http://www.bmj.com/content/360/bmj.k322
[iii] Gov. UK. Department of Health and Social Care. Guidance: Childhood obesity. A plan for action. 20 January 2017. Available at: https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action/childhood-obesity-a-plan-for-action
[iv] Davey, M. Article. Health experts support sugar tax as coalition calls for personal responsibility. The Guardian. 8 January 2018. Available at:https://www.theguardian.com/australia-news/2018/jan/08/health-experts-support-sugar-tax-as-coalition-calls-for-personal-responsibility

Dr Ayman Shenouda 

Announcing the Collingrove Agreement following the rural and regional health forum in Canberra on Friday 9 February 2018 from L–R: ACRRM’s Dr Michael Beckoff, National Rural Health Commissioner Professor Paul Worley, Minister for Rural Health Bridget McKenzie, RACGP Rural Chair A/Prof Ayman Shenouda.
 
A milestone agreement
 
Those who have been part of this journey will understand the significance of the Collingrove Agreement. Although I think on this topic, even the most casual observer will be across the division that has chocked us for so long.
 
It’s been a long and often dusty road but we’re now steered in the right direction and towards developing a national rural generalist pathway together.
 
Finding that common ground was relatively easy in one sense.
 
You see, the one thing I’ve noticed having travelled extensively over the past four years as Chair of the RACGP rural faculty is that patience, passion and persistence is a common trait of rural GPs or any GP for that matter.
 
From Longreach to Carnavon or Katherine to Goolwa and everywhere in-between and regardless of which camp they belonged – ACRRM or RACGP - there lies a great determination and commitment for their patient and rural community. An unbreakable connection which binds us all in addressing rural health disadvantage and securing a healthier future for all.
 
Navigating slightly rougher terrain
 
But in finding that common ground between the two GP colleges - while the destination remained the same - the road itself was indeed rocky. So rocky in fact it required an all-terrain vehicle for all involved and sometimes perhaps a tank may have been a slightly better choice!
 
Still, despite years of division, I think it was that same spirit that made the Collingrove Agreement possible.
 
An easy headline it may have seemed to those filtering the news last Friday, but the “RACGP and ACRRM collaborating on national generalist pathway” was truly momentous. And certainly, for those around the table at Collingrove Homestead in the Barossa Valley, South Australia, collaboration soon became the only solution.
 
Sharing a picture for history’s sake of those present on those momentous couple of days 11-12 January 2018. 

Securing the milestone agreement from L-R: Dr Melanie Considine, RACGP Rural Deputy Chair, RACGP Rural Chair A/Prof Ayman Shenouda, ACRRM Censor in Chief A/Prof David Campbell, our National Rural Health Commissioner Professor Paul Worley, ACRRM President A/Prof Ruth Steward and Dr Rose Ellis from the Rural Doctors Network.
 
A common goal
 
While the agreement itself is only four paragraphs long - the common ground here was significant. We had 7 million reasons to get this right.
 
It is about equity of access in meeting the health care needs of rural and remote Australians through a responsive needs-based solution.
 
Together we were determined to secure a strong, sustainable and skilled national medical workforce to meet the needs of these communities.
 
More than a definition
 
This is, of course, more than a about a definition but it was always a sticking point.
 
On one hand there were those focussed on the name or a tendency to favour a definition over others. On the other, we knew that developing skills around the ongoing care considerations are the areas that best serve the community.
 
And there’s the commonality – supporting doctors to acquire the skills to meet the needs of their communities. A dedicated and clear pathway for rural GPs to acquire those skills and utilise them in a way that is valued and recognised are important workforce factors.
 
This was the cohesion that brought the clarity to the definition.
 
So here is it -
 
“A Rural Generalist (RG) is a medical practitioner who is trained to meet the specific current and future health care needs of Australian rural and remote communities, in a sustainable and cost-effective way, by providing both comprehensive general practice and emergency care, and required components of other medical specialist care in hospital and community settings as part of a rural healthcare team.”
 
Pathway design
 
Beyond the definition, it is the careful design of the pathway itself that will make the most difference. It needs to be a lot of things but at its core it is about ensuring the right skill mix against demand with supportive elements offering flexibility and choice.
 
Key features which include a clear pathway for young doctors with flexibility that allows entry and exit at different stages. Ensuring adequate funding for the pathway itself alongside essential factors in establishing a critical mass of trainees but with enough flexibility for it to work within the varying jurisdictions.
 
It should also allow lateral entry for practising GPs and other rural doctors who want to acquire new skills to address the shifting need in these communities. Ever changing needs like mental health and palliative care and in dealing with the extra problems which depend on the health needs and context of the community.
 
The full range of competencies enabling them to deliver patient care closer to home in the primary and secondary care contexts. Or quite simply, training young doctors with the right skill set that makes them feel safe and supported to do their job which is addressing rural and remote community needs.
 
There’s usually some bleeding before healing
 
Despite years of focus, the disparity of health service delivery in rural and remote Australia remains a key policy failure. Much has been left to our overseas trained doctors who have been the backbone in delivering this care over this time. The lack of a solid training or workforce solution meant that the rural health system depended on individual efforts with very mixed results.
 
Sometimes I feel the split between the colleges had to happen for us to be able to reach this agreement. The Collingrove Agreement is the culmination of 20 years of hard work by both Colleges in building capacity to deliver a needs-based solution for rural health.
 
We’ve seen more collaboration over the past year than in the preceding 20 - through Bi-College Accreditation to this historic Collingrove Agreement. So, let’s keep it up!
 
A Rural Generalist Pathway Taskforce is being formed in the coming months to work through the pathway design. There may still be a long road beyond Collingrove Homestead but I think this time it will be the recently resurfaced type! 
​
Ayman Shenouda 

 A significant step in securing a stable rural medical workforce
 
Dr Ayman Shenouda
 
 
A rural renaissance
 
It is great to see the Federal Government delivering on its commitment to increase the number of rural-based doctors in training.What we are experiencing right now in rural health can only be described as a rural renaissance. We have great leadership in our Rural Health Commissioner and now in our new Rural Health Minister making her mark and building on the great work of her predecessor.
 
More intern placements in general practice is great news for rural doctors and their communities. This is an essential step in securing the next generation of rural GPs by ensuring our trainees receive broad exposure through prioritising primary care and general practice.  These programs really work as they provide trainees with that essential insight to community medicine.
 
Intern rotations in general practice
 
The Rural Junior Doctor Training Innovation Fund (RJDTIF) program provides primary care rotations for rurally based first-year interns. It builds on existing state and territory arrangements to provide primary care rotations in addition to hospital rotations.
.
Last week, Rural Health Minister, Senator the Hon Bridget McKenzie, announced a $1,304,967 Federal Government grant for the Murrumbidgee Local Health District to increase intern rotations throughout the region. I’m proud to be contributing with my practice in Wagga selected to participate and we will be rotating five interns a year through this program.
 
It was great to show Minister McKenzie around my practice and have a chance to discuss how to provide that valuable community exposure early. The Minister showed a deep understanding of what is required in placing policy priority on general practice. She shared my vision that every junior doctor should have a rotation in general practice as part of the first two to three years of training.
 
Quality training experience
 
In our practice, we have GP specialists, new fellows, GP registrars, interns and medical students working alongside nurses and allied health professionals. We aim to support the integration of vertical and horizontal teaching enhanced through a multidisciplinary team environment.
 
A strong teaching culture and established education networks also ensure we have the hospital and community partnerships to enhance exposure and demonstrate for our trainees the diversity of general practice. We’ve worked hard to build the required supportive infrastructure and systems to make this work which needless to say is also reliant on a solid business model.
 
Keeping them there
 
Targeted exposure strategies like these ensure trainees can develop the broad range of skills required. It provides essential rural exposure for interns to learn the complexities of delivering services in rural areas while in a supportive general practice setting.
 
My own experience with the PGPPP where I had 12 interns rotated in my practice really yielded results. From that cohort, about 70 per cent of them have chosen general practice as their training speciality. They loved the diversity and complexity general practice offered. It challenged them, kept them engaged and provided that important insight into the doctor-patient relationship.
 
A little on the policy journey
 
Addressing maldistribution has been dominant in the discussion at many Rural Health Stakeholder Roundtables in Canberra over recent years.
 
Certainly, greater exposure to general practice for junior doctors has been central to RACGP Rural advocacy around securing an integrated rural training pathway. Particularly in ensuring more emphasis on primary care and generalism early in medical education.
 
But really making generalism a foundation of junior medical training – a discussion made more difficult on the back of a defunded PGPPP. This was a significant policy obstacle when you consider that what we were pursuing was more of a supercharged PGPPP but specifically for rural areas.
 
We needed a solution that would boost the number of GPs as well as address the gap in the rural pathway by providing intern rotations in general practice and primary care. We knew there was a strong learner preference for rurally based internships. We also knew that potentially we had lost a cohort of potential rural GPs as the gap from the PGPPP hit hard and narrowed our opportunities.
 
A win for general practice
 
It certainly was a long policy process getting here. This is the why this program, which was the result of a long period of sustained advocacy, is such a significant win for general practice. It is clear much of the hard work over many years is starting to pay off particularly in rural health. This is a significant step forward in securing a stable medical workforce to address maldistribution. 

​Health Advocacy in 2018
 
Dr Ayman Shenouda
 
 
Where are we now?
 
I’m not the first to say that the 24-hour media cycle has taken a toll on our democracy. Some even say it killed journalism. I think the true damage lies in a loss of thoroughness and depth of thought. More specifically, the effects of the demise of principled advocacy and what it now takes to shape and change policy.
 
Twitter now seems to set the policy agenda. But we’ve been in this chaotic and unpredictable world for some time now and we’re never going back to the pre-digital era of journalism. In mobilising support, is there the time and patience left to build a policy dialogue? Without it, we are just left with a policy vacuum and random tweets that lead us nowhere.
 
Inclusive policy
 
Considered policy development takes time. Good public policy relies on effective community involvement and consultation.
 
Good implementation is also important. The process of implementation seems to be skipped entirely from the process these days, which makes the type of incremental change required in healthcare almost impossible.
 
There seems neither the time nor the inclination for the inclusive process required for good policymaking. Even when good policy process does occur, it can all fall over in an instant as was the case recently for constitution recognition which went down without the noise it deserved.
 
The doctor as advocate would be familiar with similar policy disappointment. It’s been a long road to reform and there has been plenty of blocks along the way. It’s clear that it is harder to get attention in such a cluttered space.
 
Healthcare advocacy
 
What does it take to shape and change policy in our own policy space?
 
We advocate at different levels from individual patient advocacy through to more public advocacy or policy leadership roles on the national and sometimes international level.
 
In a world ruled by Twitter, there’s not a lot of time for considered well design policy solutions. The type you need to communicate the evidence base or get the required policy reasoning across. But we still need to build that policy dialogue. This is why it is so important for us – as a community of healthcare professionals – to get it right.
 
By getting it right I mean following good policy process. But how can we avoid the pitfalls of advocacy? Media can certainly help to set the agenda but I think a focus on inclusion is the best place to start.
 
Right place, right time
 
Magic happens when the right people are at the right place at the right time.
 
When things are politically aligned and people at the table are smart and genuine in their intent -  the moment when they recognise what leadership is all about - then Magic follows.
 
When there is no personal or financial gain, leaders start to have a sense of what can be gained through collective advocacy for the benefit of their community. When the vision is clear and simple to understand by all involved implementation becomes a lot easier.
 
Integrity always shines through
 
Some people believe that politics is about being smart enough to make a lie look convincing. Sometimes this falls somewhere between a lie and a falsehood or the new “alternative facts” and post-truth era we now find ourselves in.
 
Some politicians think they know better. They might even get away with some temporary gain but believe me, the power of truth has a longer and more effective success. People can smell dishonesty no matter how enticing a master deceiver may be. It is integrity that always shines through the brightest here.
 
Making collective impact work
 
When there is a genuine and clear goal that addresses the common agenda, people get together to make what look like impossible change feel like a walk in the park. This requires a collaborative approach to creating change to facilitate mutual support and collective impact.
 
When you win the hearts and souls of people, what seemed impossible becomes not only possible but a lot easier to achieve. When everyone in the room feels safe and heard by others, suddenly they will be able to see and value others contributions.
 
In my opinion, you should leave your personal views and judgment of others outside the room. After all, we need to be clear about one thing - it is not about you, it is about others and the trust they’ve placed in you to present their opinion. Some may not agree with me but at the end of the day, everyone is entitled to have their own views.
 
Let’s hope health advocacy in 2018 is a place of inclusive reform. That we work together towards collective impact and a common agenda that will see sector-wide improvements.