Public health approach to expanding laparoscopy in mongolia

Nearly half of the population in Mongolia lives a shepherding nomadic lifestyle where vast rural areas and extremes of weather exist and roads are non-existent or very poor presenting serious challenges to appropriate healthcare. In Mongolia, disease patterns have transitioned from primarily infectious etiologies to non-communicable causes including heart disease, cancer, and trauma. Access to quality healthcare has been limited in the rural areas secondary to lack of the necessary infrastructure and inadequate human resource development. Direct attempts to improve basic and essential surgical capability were not readily embraced by the local healthcare providers. Gastrointestinal disease is the second most common cause for inpatient morbidity with liver diseases, appendicitis, and gallbladder diseases as the top three etiologies. Open cholecystectomy requires weeks for recovery and had more frequent open wound complications; laparoscopic cholecystectomy allowed patients to return to work within days and had markedly decreased wound infections and pain. The Health Sciences University of Mongolia requested assistance in expanding laparoscopic cholecystectomy as a concerted countrywide public health priority. From 2006-2012, laparoscopic cholecystectomy was taught and implemented in the four Regional Diagnostic and Treatment Referral Center (RDTRCs) and one regional hospital. Emergency and essential surgical care courses (EESC) were incorporated into the laparoscopic training programs. Healthcare workers from the surrounding rural facilities attended the combined laparoscopic and EESC training at the RDTRCs. Laparoscopy became a surrogate to improve basic healthcare to rural Mongolia, build community trust in their physicians, and increase needed self esteem for rural healthcare providers.