China's accelerated economic development has led to an imbalance in the development of medicine and healthcare across China. The impact of this has been felt across rural areas where medical expertise and services are lagging far behind the healthcare available in big cities like Beijing and Shanghai. The scenario is even worse for pediatric medicine, already challenged by a vast shortage of pediatricians in China.

Many parents in rural areas take their children to see doctors in China's major cities because they are concerned about the quality of pediatric care closer to home and believe their children will get better care in Beijing, Shanghai or Guangzhou. The cost of traveling from rural communities to seek medical care in China's larger cosmopolitan cities places a substantial economic burden on rural families. Children's hospitals in China's big cities are constantly packed with patients, most of whom are from under-developed counties or villages.

According to the 2000 statistics, the mortality rate of children under 5 years old in rural areas of China was 45.7 percent, compared to 13.8 percent in major cities across China. This disparity underscored the urgent need for better medical care in rural China. The global NGO, Project HOPE, recognized the problem and sought ways to bridge the gap between the medical care available in big cities and the care available in rural communities.

Sending experienced healthcare professionals from developed areas to rural areas may treat a few children and teach a small number of local health professionals but the impact is very limited. Although donating modern medical equipment seems to improve a local hospital's efficiency, local doctors may not know how to best use advanced technologies. HOPE experts understood that the best solution would be to develop programs that are practical, economical, effective and sustainable.

Thus in 2002 Project HOPE and the Shanghai Children's Medical Center (SCMC) agreed to launch a program to train healthcare professionals from rural areas in SCMC. The professionals who complete the courses return to their hometowns and then train other healthcare workers. The "Train The Trainer" method is like the old Chinese saying: It is always better to teach a person, who is hungry, to fish than to give him fish.

A rural program

In 2002 using the "Train The Trainer" concept Project HOPE initiated a rural training program with SCMC. The program aimed to accelerate healthcare development with a focus on critical care medicine in China's rural areas, and to reduce the mortality rate of children under 5 by improving the skills and capabilities of rural doctors and nurses through training.

Every June, Project HOPE and the Shanghai Children's Medical Center recruit 25 doctors and nurses from rural areas, especially from the western and northeastern parts of China. Considering the needs of these local hospitals, the programs mostly recruit professionals specialized in Pediatric Intensive Care Unit (PICU), Newborn Intensive Care Unit (NICU), Internal Medicine and Hematology.

The rural medical workers are typically interested in learning how to operate a ventilator, how to set a Peripherally Inserted Central Catheter (PICC), and critical care medicine. Their hospitals expect them to return with these skills and implement new clinical systems.

To date this program has trained 249 professionals from 18 provinces, including 20 from Inner Mongolia, 18 from Gansu, eight from Xinjiang and one from Tibet. Project HOPE provides room and board for these health workers for their one-year stay in Shanghai. Project HOPE also provides scholarships to address specific training needs for rural medical professionals.

The professionals who are selected for the program come to the Shanghai Children's Medical Center, a leading pediatric hospital and medical training center in China, for a one-year course. Each participant has a training plan tailored to his or her specialty and needs. Each rural professional is assigned an experienced mentor who shares his or her medical knowledge and teaches clinical skills. The trainees also rotate to different departments at SCMC to widen their experience and expand their knowledge.

During the one-year training period the participants must pass both clinical and theoretical exams after each rotation. For example many will obtain a Basic Life Support (BLS) certificate, a Pediatric Advanced Life Support (PALS) certificate and undertake a teaching skill presentation and a final exam to test their comprehensive understanding of the training for advanced pediatric practice.

The teaching skill presentation is a unique way of evaluating the participants. The participants have to deliver a lecture on a specific disease illustrating this with suitable clinical cases and direct clinical experience using PowerPoint (PPT). It constantly amazes the mentors when they discover these people have never used PPT before - some are not familiar with computers at all. Their SCMC colleagues help them to make the PPT presentations - teaching them how to make slides and their mentors coach them in public speaking.

This presentation means a lot because the participants will eventually bring home not only their new knowledge and clinical skills but also modern methods of teaching which will enable them to pass on precisely their knowledge and skills. Project HOPE and the SCMC continue working together to identify and provide more professional workshops or clinical practice opportunities for these medical professionals. Most of the lecturers at the workshops are prominent experts from China or abroad and the participants cherish these special learning opportunities.

Project HOPE has also recognized that more has to be done to address some of the many other health challenges in China - for example, talking with those involved to address issues like the shortage of pediatricians and the importance of setting standards for pediatric residency training.

Life in Shanghai

Every year the participants are surveyed for satisfaction rates and every year they report high levels of satisfaction with the program. This is not just because of the training they receive, but also because they are living for that year in Shanghai. Their mentors and management teams are concerned about they way they live and, because many are from ethnic minorities, they want to ensure that their diets and customary lifestyles are as familiar as possible. The participants all have to overcome the difficulties of leaving their families and going to live in an unfamiliar city.

Food can be the first problem they encounter as a lot of Shanghai food tastes sweet and not spicy. But at the SCMC canteen, there are always two bottles of chili sauce beside the serving hatch. This little tradition began to show support for the participants from far away and has continued since the first group of rural doctors and nurses arrived in Shanghai.

The trainees have to get used to the fast pace of life in Shanghai. Here professionals take very short lunch breaks and go back to work promptly after lunch. In the rural hospitals where the trainees have been working, they can take a two-hour break after lunch. Every day the trainees in Shanghai work with their mentors learning how to maintain the pace of life and seeing increasing numbers of patients. One of the hardest things for a visiting pediatrician has nothing to do with their professional skill, but has to do with handling angry parents speaking the Shanghai dialect. 

One participant talked about his experience in the emergency room. He said he had had a hard time understanding Shanghainese and had tried hard to understand the parents' requests. It took time and effort for him to respond to their questions but there were misunderstandings. When he felt the parents were disappointed in him, his mentor and colleagues stepped in to advise him on how to better communicate with parents, how to comfort them and their children. He took the advice and discovered that it really worked. The participants learn that communication skills are as important as professional and clinical skills.

Project HOPE and SCMC organize regular sightseeing trips around Shanghai and neighboring provinces for the program participants.

One success story

Dr Yin is now working in the Wuzhou Red Cross Hospital, Guangxi Zhuang Autonomous Region. He won an "Excellent Student" award in his class while he was at SCMC in 2009. After he returned to his hospital, he introduced new methods and techniques and trained many local healthcare professionals.

In 2010 Guangxi was the worst-hit area in the country for hand-foot-mouth disease. More than 10 children died of this disease. Just one week after Dr Yin had returned to his hometown, two 11-month-old twin babies were brought to his hospital and were diagnosed with a severe type of hand-foot-mouth disease with complicating factors including encephalitis, respiratory failure, myocarditis and electrolyte imbalance. The babies had high fevers, seizures, and were breathing with difficulty.

Dr Yin initiated ventilator therapy for the babies to support their breathing. None of the other doctors in Dr Yin's department knew how to operate a ventilator except Dr Yin who had just acquired the skill at SCMC. He successfully treated the twins in ventilators. After 11 days of hard work by Dr Yin and his colleagues, the twins gradually improved and they eventually recovered.

After this Dr Yin was highly regarded by his colleagues and hospital management. His story was reported in the hospital newspaper. Dr Yin wrote a letter of appreciation to SCMC and HOPE staff to report his achievements. It's always inspiring to see staff progress and positive outcomes from the rural training program.

In the e-mail, Dr Yin told several stories about saving critically ill patients. He was very grateful to Project HOPE and this rural training program and encourages many other rural doctors and nurses to apply what they learned at SCMC at their rural hospitals and clinics.

Proud achievements

This year is the 10th anniversary of this rural training program. Looking back over the 10 years, Project HOPE and SCMC are extremely proud of the achievements made.

During the project implementation phases, Project HOPE monitors and evaluates the program to better understand the impact of training. For example, in 2010, Project HOPE conducted a survey of the classes of 2002-2009 on their performances after they returned to their local hospitals.

Over 88 percent of the respondents' had been promoted and assumed more responsibilities, 47.2 percent had introduced new policies or standards for the Intensive Care Units in their hospitals and 52.7 percent had improved their pediatric care basic policies or standards. Some 57.5 percent had begun to use ventilators for critically ill children or improved current practices, while 29.6 percent shared improvements in the use of Peripherally Inserted Central Catheters (PICC). Some 69.5 percent initiated Pediatric Advanced Life Support (PALS) practice and 50 percent had been able to save preterm or newborn babies independently after training. 

This year, Project HOPE surveyed the class of 2010 which graduated in June, 2011. According to the 18 respondents, since returning home they have conducted 36 workshops, and 1,641 local professionals attended training sessions conducted by class graduates. The results back the effectiveness of the "Train The Trainer" method, showing how training one person can benefit many more. This result is exciting. 

After the Rural Training program, many graduates have become an important pediatric workforce in their hometowns. In 2008 during the Wenchuan Earthquake, the Chengdu Children's Hospital did a fine job. All of the local program graduates joined the rescue operations for injured children and families.

All of them put aside concerns for their own health and safety and spent endless days and nights trying to save children from the earthquake's hardest-hit areas. They rescued many seriously-injured people and saved the lives of many children.

The local government praised the hospital for its excellent performance. The hospital's chief medical officer credited the rural training program for making success of the medical response. This was a fine and reassuring example of the potential of the rural training program. Many rural hospitals do not have PICUs or NICUs. The standardized ICUs at SCMC really impress the rural training graduates.

It is a point of pride for the hospitals and for Project HOPE that several hospitals in rural areas have established their own PICUs or NICUs after their doctors and nurses finished training at SCMC. For example, the Qinghai Maternal and Children's Hospital set up the same infection control standard as SCMC in their PICU in 2003 and promoted the standard in other local hospitals.

The Sichuan Ya'an People's Hospital built an NICU in 2005 and a PICU in 2008. The local newborn mortality rate was reduced from 26 percent in 2005 to 6.7 percent in 2009.

This also happened in many other hospitals including the Kunming Children's Hospital, the Inner Mongolia Maternal and Child Care Center and the Chengdu Children's Hospital.

More solutions

Project HOPE has realized that many more efforts must be made to develop healthcare in China. When the media began discussing the shortage of pediatricians in China, Project HOPE began to consider other solutions.

On June 9 a high-level symposium organized by Project HOPE and SCMC discussed how to improve pediatrics on the Chinese mainland.

Noted figures from the Shanghai Jiao Tong University's School of Medicine and 12 leading children's hospitals from Shanghai and other parts and regions of China, including Hong Kong and Taiwan, were invited to share their residents' training experiences. The chairman of the Chinese Pediatric Association, Zhu Zonghan attended. The symposium discussed future trends for pediatric training and ways to encourage more young clinicians to select pediatric medicine as a specialty. It recommended that teaching hospitals train more pediatricians to meet the growing demands.

Zhu Zonghan said it was important for medical schools and hospitals to cultivate young pediatricians for the benefit of all of society not just third-tier hospitals. Primary and secondary hospitals in less developed areas also needed pediatricians. The symposium summarized many important points for medical educators, government agencies and health authorities working to develop pediatric medicine in China.

The focus on children's well-being and building systems for excellent clinical care is one of Project HOPE's missions in China. The "Train The Trainer" program has produced many positive outcomes and it is Project HOPE's commitment to children's health in China that will train more fine clinicians who will safeguard the health of children in China's less developed areas.