World Health Assembly Resolution 72.16: What are the implications for the Australasian College for Emergency Medicine and emergency care development in the Indo‐Pacific?

Australia and New Zealand have two of the best performing healthcare systems in the world. Universal healthcare is an established norm, and the vast majority of citizens have access to timely and effective emergency care (EC).1, 2 This is not the reality for most of the world's population. EC systems are poorly developed in a majority of low- and middle-income countries (LMICs), and there is a significant unmet need for acute care. These challenges are compounded by structural barriers to healthcare access and a limited health workforce.3-6 In May 2019, the World Health Assembly (WHA) acknowledged the value of global EC by adopting Resolution 72.16 (‘Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured’). Proposed by Ethiopia and Eswatini, and co-sponsored by more than 30 countries, the resolution frames EC as an essential tool to achieve universal health coverage. It recognises timeliness as a critical component of quality and endorses organised EC systems as an effective means of ameliorating health inequalities.7 For the EC community of Australia and New Zealand, the resolution presents both exciting opportunities and important challenges. How can we best work with colleagues and partners across the Indo-Pacific region to build capacity for safe, effective and universal EC? There is a growing body of evidence that suggests EC can substantially reduce preventable morbidity and mortality in resource-limited settings.8-10 Recent modelling from the World Bank Disease Control Priorities Project estimates that 54% of annual deaths in LMICs could be addressed with effective EC, and more than 1 billion disability-adjusted life years (DALYs) could be saved each year.11, 12 These figures indicate that the burden of injury and illness requiring emergency interventions is four times greater in LMICs compared with high-income countries.13 To facilitate global EC capacity development, the World Health Organization (WHO) has devised a framework to describe the essential functions of EC systems. This defines an EC system as pre-hospital and facility-based care for urgent illness and injury across the life course, underpinned by essential building blocks such as financing, leadership and governance, human resources and training, infrastructure and equipment, processes and data collection.14 Implicit in the WHO framework is an acknowledgment that EC systems enable time-sensitive interventions and effective service delivery across the continuum of healthcare. They also promote equity and improve health system resilience for disasters, outbreaks and mass casualty events.15 In LMICs, EC might be the only access point to healthcare for vulnerable populations, including migrants, refugees, women, children and people with disabilities. The Indo-Pacific, a conceptual region encompassing the Eastern aspect of the Indian Ocean and the Western Pacific, is of strategic interest to the Australian and New Zealand governments.16-18 As a result of its geographic, socio-cultural and economic diversity, the Indo-Pacific has a unique set of EC challenges. In addition to significant unmet need for ‘routine’ EC, increasing exposure to climate-related events, infectious disease outbreaks, conflict and food insecurity necessitate robust EC systems that can provide surge capacity in times of increased need.19 Publications from the region provide insights into EC needs and demonstrate how effective interventions can be developed and implemented at low cost. In Fiji, trauma management has been improved through enhanced surveillance and team-based care;20, 21 in Papua New Guinea, action research has helped optimise asthma treatment;22 and in the Solomon Islands, inconsistent triage (a challenge in many Pacific Island countries)19, 23 has been addressed by a simple, locally developed triage system.24 Despite experiencing significant disasters, Indonesia and Myanmar have only recently developed specialty training in emergency medicine (EM)25, 26 and have identified that the crucial pre-hospital EC needs can be assisted by simple rural systems and basic protocols.27, 28 Resolution 72.16 is not the first high-level acknowledgement of EC and its potential to positively impact health outcomes in LMICs.29 In 2007, the WHA adopted Resolution 60.22, calling on countries to ‘strengthen provision of trauma and EC so as to ensure timely and effective delivery to those who need it in the context of the overall healthcare system’.30 Although that resolution concentrated the efforts of the global EC community, translating the intention into meaningful improvements in EC access has been a challenge, especially in LMICs. Efforts have been hampered by vertical approaches to global health and development, which prioritise specific disease states and populations rather than broad-based interventions that strengthen the health system as a whole.10, 31 This ‘verticalisation of health programs’ has been acknowledged as a limitation of the Millennium Development Goals.32 The WHA's latest statement on EC is likely to be more impactful. The global health context has changed considerably, with renewed emphasis on health system strengthening and universal health coverage.32 In addition, the post-2015 Sustainable Development Goals (SDGs) provide a more suitable platform for progressing global EC development.9 With explicit references to non-communicable diseases, road trauma and health security, there are opportunities to leverage SDG priorities to promote investment in EC systems.7, 9, 15 Recent work to develop standards and quality metrics for EC systems, including the International Federation for Emergency Medicine (IFEM),33 will enable this process. In the Pacific region, a project to define regional standards and priority interventions for EC has helped create a shared understanding and vision for regional EC development. This work utilised the WHO EC Systems Framework and has established a clear benchmark for EC capacity across the Pacific.19 Projects facilitated by the African Federation for Emergency Medicine have similarly resulted in a suite of performance indicators and signal functions that will be useful for measuring the impact of EC interventions over time.34, 35 In concert with these developments, the WHO's capacity to provide EC technical assistance has increased. The organisation has developed a suite of tools to assist with needs assessment, training and essential EC system functions and has a section dedicated to progressing emergency and trauma care.36 Through a partnership with the AO Foundation, there is now a funding mechanism for facilitating national-level needs assessments and the roll-out of WHO tools focussed on trauma care, triage, registry development and provider training.37 In this context, Resolution 72.16 is a timely contribution to the global EC development agenda. It urges governments to create policies that ensure all citizens have access to effective EC; conduct an EC system assessment to identify gaps and priorities for action within each building block category; develop clinical protocols aligned with the WHO EC Systems Framework; and provide EC training for all relevant health providers. It specifically emphasises the need for standards and processes at each level of the health system and the importance of data collection to drive quality improvement.7 Critically, the resolution embeds EC with other priority areas for global health development, such as violence prevention, road safety, health systems strengthening, disaster response and resilience, mental health, surgical and anaesthetic care and public health. A key recommendation is for the better integration of EC with surgical, obstetric and disaster and outbreak response plans. There is a request to foster multi-sectoral networks, increase collaboration and strengthen the evidence base for EC, with a 2-year timeline for action and a reporting deadline in 2021.7 In essence, the resolution provides a roadmap for addressing unmet global EC needs. In highlighting gaps in EC knowledge and service delivery, it has created a platform for governments, donors, non-governmental organisations and practitioners to work collaboratively to achieve universal emergency healthcare coverage. The EC community of Australia and New Zealand is well placed to contribute to this effort. The Australasian College for Emergency Medicine (ACEM) has a committee and network for progressing global EC activities, and international EM is a pillar of the ACEM Foundation.34 The organised involvement of ACEM in global EC activities dates back at least 15 years, spearheaded by pioneering Fellows with a vision for global EM development.38-40 In more recent history, ACEM has signed Memoranda of Understanding with several regional education providers (such as Fiji National University)41 and established partnerships with key development organisations (such as AVI, formerly Australian Volunteers International).42 In concert with these structural advances, ACEM has employed a Global EM Manager to further professionalise its international activities. In keeping with this history of global engagement, a large number of ACEM Fellows and trainees are currently involved in EC development projects across the Indo-Pacific.39 Examples include triage implementation in Papua New Guinea,43 specialty training assistance in Myanmar,26 trauma systems development in India44 and broad-based EC support in the Solomon Islands.42 The establishment of a global EC ‘desk’ within ACEM will help bring greater cohesion to these activities and enhance access to donor funding. Building on these existing partnerships and networks, ACEM and its members have a key role to play in providing strategic advice and facilitating greater collaboration in regional EC development. This is particularly relevant to the priority areas of pre-hospital care and disaster response. Substantial resources, experience and expertise in these fields have been accumulated, but integration with ‘routine’ service delivery and broader EC development across the Indo-Pacific has been limited. Deeper engagement between the ACEM global EC network and major disaster and health security organisations such as the National Critical Care and Trauma Response Centre,45 Indo-Pacific Centre for Health Security46 and WHO Humanitarian Health Action and Health Emergencies Programme47 will help ensure greater alignment of priorities and projects. The WHA's adoption of Resolution 72.16 is indicative of the growing global demand for EC systems improvement. The challenge for the Australian and New Zealand EC community will be to scale-up our capacity to engage in regional EC development and ensure that our contributions are collaborative, sustainable and impactful. Colleagues and partners across the Indo-Pacific will be leading the advocacy, infrastructure, process and academic developments required to meet the WHA call, but expert advice and strategic support from ACEM and Australasian EC practitioners will be crucial to their success. Although the adoption of Resolution 72.16 is a milestone worth celebrating, it is a stark reminder of the enormous unmet demand for timely and effective EC across the globe. Converting a well-intentioned statement into meaningful action will not be easy, but the potential for universal emergency healthcare access makes it worthy of pursuit. The Australian and New Zealand EC community stands ready to assist. GOR is an NHMRC Research Fellow at the National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia. GP, GOR and PC are section editors for Emergency Medicine Australasia.