Monday, 10 October 2016

BMET training in Zambia: the money

As described in a previous blog, I am supported by THET to work at a Technical College in Zambia to train local students to become hospital equipment maintenance professionals. In this blog I want to share with you some of my experiences on what it means to be in what the ‘International Development’ world calls a ‘low resourced country’.

Training to become a Biomedical Technician is quite an expensive undertaking. The college is over 90% funded by the fees from students. The main fee is about 300 USD per term (900 USD/year).  On top of that come examination fees (100 USD/year) and housing fees (60 USD/term), for which you have a bed in a small room with two-four co-students plus some facilities. Altogether, that is quite a lot of money in a country where 60% of the population lives below the poverty line and 42% are considered to be in extreme poverty.

Chris Mol lecturing to BMET students.

Our BMET students are usually funded by their family. This includes not only parents, but also uncles, aunts and older brothers and sisters. It is very difficult for ‘older brothers’ with a reasonable income to save money or purchase a house while their (many) younger siblings still require education. These contributions are not considered a loan and won’t be paid back. Money is spent in the family where it is needed.

On top of family funding, many of our students have to work to earn money during their school terms as well as in between terms. The work they do is what they call piece work: washing cars, helping in building works, and whatever else they can find. The salary for this, as for gardeners and house maids, is in the order of 40 cents/hour, if you can find the work!

Students take notes during a lecture.

In this context it is not surprising that many students have little money left for anything that is not an absolute must. Most students do not have a computer and if they do, are dependent on the overloaded network at the college to get internet access. However, most of them do have a mobile phone which is frequently used. The cost of talking is about 10 cents per minute, but many schemes give cheaper access under certain conditions. Also, special offers for ongoing Facebook access are popular. 

Coming from a high resource country, it at first appears to be a good idea to help students by offering them loans to finance their studies or a computer, something that is currently not done by the government. But this becomes less attractive considering the near certainty that such loans will not be paid back, simply because students would not feel this as a strong moral obligation.  And a problem of gifts is to define where to begin and where to end and how to do this in a way that appears fair and does enable you to continue to be related to your environment in a ‘normal’ way.  The advice I am currently following is not to interfere in these matters and consider my teaching of the BMET course and the long-term improvements to healthcare graduates will make as the best contribution I can make.

Your comments are welcome at:

Wednesday, 10 August 2016

Contributing to a new movement in anaesthesia care

Laura Macpherson, Grants Officer at THET, shares her impressions following a recent monitoring visit to health partnership projects in Ethiopia, which are funded through the DFID/THET Health Partnership Scheme (HPS).

In June I travelled with my colleague Emily Burn (Evaluation and Learning Coordinator) and two DFID representatives to monitor the progress of seven health partnerships in Ethiopia. We anticipated that a monitoring trip to Ethiopia promised insights into an exciting health context and would allow us to verify some examples of truly successful partnership working.

We were not proved wrong. A highlight for me was our visit to Jimma University Hospital (JUH), which partners with the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the Association of Anaesthetists of Uganda (AAU) to deliver the SAFE Paediatric Anaesthesia in East and Central Africa project. Faced with the reality of extremely basic anaesthetic equipment, very few anaesthetists, a lack of continuing professional development opportunities, only five ICU beds, compounded by a recent increase in road traffic accidents across the country, the senior residents who had received training through this project have been inspired to make a difference and are working against the odds at JUH. As Tirunesh Gemechu, Anaesthesia Resident states:

‘It is very challenging, and it would be much easier for me to go through other departments and specialise in them. There are very few trainers, very limited equipment to practice, and very few consultants with knowledge to pass down.’

Tirunesh Gemechu, Anaesthesia Resident. (Photo: Emily Burn)

They commented that they are noticing a real difference in the way they treat patients on a daily basis, are now much more confident in caring for newborns in particular, and are eager to share their learning with colleagues.

‘The course has filled a major gap I had in paediatric anaesthesia. I am now more confident to practice that. I was able to meet people who can help me get more learning and more experiences and even more rotations outside of Ethiopia. We were trained with international participants so I could learn from them and hopefully learn from them in the future.’ Says Tirunesh.

The project is also contributing to a new movement across the country that is seeing more attention being given to the specialty of anaesthesia, which is clearly much-needed.

The visit has reiterated the value of visiting projects in person. This really allows you to appreciate the numerous and varied benefits to health partnership working that are difficult to capture without discussion. I count myself lucky to have seen first-hand the impact that all of the projects are making across the country.

Thursday, 4 August 2016

A New Generation Takes On Chronic Malnutrition

THET’s Communications Officer, Timur Bekir, traveled to Lusaka, Zambia, to document the activity of two ground breaking training courses in nutrition.  

100 acutely malnourished children. That’s how many cases University Teaching Hospital (UTH) in Lusaka has in the severe acute malnutrition ward at any one time during its peak season. It’s a shocking number for a country edging towards middle income status.

It’s a number that becomes more overwhelming when you’re told that the whole hospital only has four Nutritionists. Just four to deal with the multitude of nutrition related cases such as under-nutrition, diabetes, obesity, renal failure, the list goes on.

Mr Zimba, one of UTH’s valuable Nutritionists, is showing me around the children’s ward. He explains that the peak season is from April to September, this is before harvest time when food stores are low:  

‘Malnutrition is about bad nutrition so there is over nutrition and under nutrition, so on this ward we are dealing with under nutrition. Nutrition intervention is not a remedy but it is a supplement to whatever doctors are doing.’

60% of the population lives below the poverty line and 42% are considered to be in extreme poverty, with much of the population surviving on subsistence farming. Chronic malnutrition, or stunting, is a serious concern in Zambia. With a prevalence of 45% among children under five years of age, substantially higher than the average of 38% for sub-Saharan Africa and the eighth highest prevalence among the 123 countries for which data exist.[1]

Mr Zimba takes me to another ward where the role of the Nutritionist is crucial. At the Renal Unit he explains the tests he does on patients to find out if they are deficient in nutrients or electrolytes or minerals like iron, potassium, sodium. Those tests allow him to see where the deficiencies are, do calculations and know the amount of nutrients needed in the fluid. This is a specialised role but the hospital does not have any specialists in the field of nutrition:

‘Right now in Zambia we do not have Nutritionists who are specialised in treating all these outlying cases, and with only four Nutritionists we are struggling in the field of nutrition.’

THET responded to the lack of Nutritionists and the problem of chronic malnutrition by working in partnership with the University of Zambia (UNZA) to develop the first BSc and MSc in Human Nutrition. This level of teaching in Nutrition has never existed in Zambia before and will go a long way to supporting the Zambian government’s commitment to improving the nutritional situation of its population.

The country’s National Food and Nutrition Strategy and the First 1000 Most Critical Days Programme were launched in 2013.  Central to the Government’s strategy are the objectives to significantly reduce chronic malnutrition in young children and increase investment in nutrition and nutrition-sensitive interventions.  The Government of Zambia acknowledges that achievement of their objectives is constrained by the shortfall of adequately qualified nutritionists and dieticians in Zambia.

Five volunteer lecturers from the UK, east and southern Africa are delivering the programme until UNZA has enough qualified lecturers to run the programme themselves.  Lecturers like Tonderai Matsungo from Zimbabwe:

‘The skills that the students are going to get from the programme are very crucial in terms of improving the quality of care that patients receive at the different health institutions, either government or private. An integral part of any nutrition training, besides the clinical part, is an emphasis on preventing and prevention is the one that covers public health and community aspects of nutrition so that is very important and those components are well covered in the BSc and MSc nutrition programme.’

Lecturer Tonderai Matsungo teaching in class at UTH. (Photo: Timur Bekir)

22 students graduated from the BSc on the 8th of December 2015 and there are nine students currently enrolled in the MSc Programme. Adana has one more year left of training, after which she hopes to go back to her local community and carry on her work as a Nutritionist. But, as she states, if the course wasn’t there she may have chosen a different career path altogether due to the lack of career development:

 ‘If this course was not there, probably I would have been doing other courses in other fields and I’m sure by now I would have gone to do another profession or career. But now that there’s this course I will continue as a nutritionist and I will go back to my province to make sure malnutrition levels are low.’

Adana, BSc Nutrition student. (Photo: Timur Bekir)

Back in the acute ward at UTH a mother is feeding her child, who was brought in with severe malnutrition. Talking to the mother was a stark reminder of how important the role of Nutritionist is, not only to cure nutrition related problems but to improve public knowledge of what good nutrition is. By training a new generation of Nutritionists THET is ensuring that the causes of malnutrition are addressed. Education and training is not a quick fix to health problems, it’s a long-term approach, but one that means a health service, with skilled health workers on the frontline, can offer quality care to patients not just in the short-term but well into the future. 

Mother with under nourished child receiving treatment at UTH. (Photo: Timur Bekir)

[1] UNICEF (2014) State of the World’s Children

Tuesday, 26 July 2016

Now more than ever: in defence of aid

Ben Simms, THET CEO, reflects on the challenges we face as individuals engaging in the health partnership approach as we live through this tumultuous period in UK political history.
UK Volunteer in South Sudan with the Winchester-Yei Partnership
We are living in profoundly troubled and even toxic times, an age when our optimism and idealism is being tested to the hilt.
There is no escaping the fact that the vote to leave the European Union and the appointment of a new Secretary of State for International Development piles on new degrees of uncertainty about the future of the UK’s commitment to spend 0.7% of our Gross National Income on overseas development aid.

Britain is now one of just six wealthier countries to meet this long-standing UN target. In 2015, the UK donated £13.21 billion in overseas aid. It is a profound and impressive contribution, and I believe we are in a fight to ensure this commitment is kept.

Under this government I believe our chances are good. It is, after all, a 2015 Manifesto pledge. But there are others, joined by The Daily Mail, who would wish it away.

And what level of funding will 0.7% deliver if our economy contracts and the value of sterling falls? THET, a medium-sized charity, and our partners, are already feeling the effects of unfavourable exchange rates. It is deeply troubling.

The EU referendum and cabinet reshuffle has also delayed decision-making in DFID. 14 months in to the life of the current UK government we are still unclear about their intentions in relation to most aspects of their development expenditure – multilateral, bilateral and in relation to civil society.

One way of defending the aid commitment is to seize the opportunity provided with the adoption of the Sustainable Development Goals.

The SDGs are a useful communication tool. They are universal. It is just as important to address poverty in Caerphilly as we do in Mbale. It is not one or the other, either/or, over there or over here, it is simply, unequivocally, a fight to end poverty and improve health everywhere.

The SDGs point to the inter-connectedness of our world. As does the health partnership approach, with its emphasis on reciprocity and mutual benefit: the idea that all who engage in training health workers overseas benefit from the kind of professional growth that brings great benefits to our working lives back in the U.K.

However, a new rhetoric is emerging around ‘mutual benefit’ which risks distorting the purpose of aid. I am thinking in particular about the November 2015 publication 'UK aid: tackling global challenges in the national interest'. Here, poverty alleviation is listed as the fourth goal.

I am an enthusiast for the idea of recognising mutual benefit. THET’s new strategy places the concept of co-development at its heart. However, there is a risk, that in embracing the universality of the SDGs and defending the benefit we derive here in the UK from working overseas, aid priorities will be defined too much in terms of our own national interest, and not enough in favour of the governments and people of lower and middle-income countries.

A risk, in other words, that in defending aid from the attacks by the Daily Mail we’ll begin to think and sound too much like the Daily Mail.

It is therefore vital that those involved in health partnerships must be expert in striking the right balance. Alongside our clinical expertise we must be applying good international development practice. 

That is why THET has embarked on a journey of producing a policy paper which will articulate what the appropriate balance between UK national interest and benefit to aid-recipient countries should look like. This paper is being put together in collaboration with leading thinkers from the north and south, such as Lord Crisp, Professor Myles Wickstead, Jim Campbell at the World Health Organisation, and Dr Mliga from Tanzania.

The paper will be launched at our conference this October which will also throw light on striking the right balance through a series of peer-reviewed presentations.

The world is at a crossroads.

As individuals and institutions involved in the health partnership approach, we must:
  • Defend our historic 0.7% commitment to aid.
  • Promote the universality of the Sustainable Development Goals.
  • Strike the right balance between what we expect to give and what we hope to receive; I am unashamed in applying a mutual benefit lens to our work in global health, recognising the enormous benefit we derive as individuals and as UK institutions, but our work must be grounded in an analysis of what our host countries ask of us.

Now more than ever we must work with idealism to promote the value of aid, and to articulate a vision through health partnerships of how we all benefit from being part of a world bent on ending poverty.

This blog is based on a speech given at the Wales for Africa conference, which you can read on the THET website.

Tuesday, 12 July 2016

Sending our professionals overseas is one of the best things the NHS can do

Sending NHS staff overseas is as vital to the NHS as 0.7 per cent aid contribution is to UK plc.

Pulling up the drawbridge and looking after one’s own is a debate that’s gaining pace within the certain media, spurred on by calls that the straitened NHS needs every last penny.

Such reporters would thirst for the story that along with our hard earned cash, the Department for International Development invests in programmes that send our much needed and short on supply doctors, midwives and nurses overseas, too. Fuel on theDaily Mail’s pyre that directly instigated a parliamentary debate on the UK’s spend of 0.7 per cent on overseas aid last Monday.

But sending our UK trained health professionals overseas is one of the best thing the NHS can do right now. There’s no amount of efficiency awareness training that quite cuts through as a stint in an impoverished sub-Saharan hospital.

Comfort zone
Speaking of his time as chair of the first hospital in the country to be rated “Outstanding” by the Care Quality Commission, Mike Aaranson attests that sending his doctors to Zambia encouraged a more innovative and imaginative approach from those used to working in a more comfortable environment.

Speaking on the foreign aid expenditure debate, Conservative MP Steve Double said: “The truth is that this country gets great value for money from the aid”.
There are strong parallels with this argument to why more NHS trusts should send their staff abroad.

Independently audited data and feedback we have from NHS leaders, who invest their resources in our overseas clinician exchange programs, show improvements in skills, leadership and motivation that would be harder won elsewhere.

With the aim of creating a cadre of skilled leaders who will apply their skills on return the UK, one of our programs has led 150 NHS healthcare professionals to swap their UK role for six months of the working in Cambodia, Kenya, Nairobi or South Africa.

Since 2008, a steady stream of NHS professionals on this programe have worked on system-strengthening projects in partnership with local health care workers, contributing to improving healthcare in the local area in a sustainable way rather than providing direct clinical care.

Independently audited data and feedback we have from NHS leaders, who invest their resources in our overseas clinician exchange programs, show improvements in skills, leadership and motivation that would be harder won elsewhere

NHS Thames Valley and Wessex Leadership Academy has carried out an independent longitudinal analysis of the impact of this overseas experience on NHS professionals careers. The findings of which show an impact as long lasting and deep routed as the personal story MP Pauline Latham shared in the House on Monday, living with two abandoned Rwandan girls sharing one bowl between four in a mud floored hut for several days.

Desire for change
From retaining clinicians to stay in the NHS, to continuing to improve their clinical and leadership skills, the results attest to a seismic shift in how clinicians view their place in the healthcare system. When interviewed prior to taking their overseas placement 33 per cent said they ‘felt they were leaders’. On returning, this increased to 82 per cent.

In a questionnaire responded to by 107 of the 150 attendees, 91 per cent of respondents said the programme changed how they approached their current role. One detailed “[I am] less frustrated by system inefficiencies and [have] more desire to change them”, another “My self-awareness of my leadership and management skills has greatly increased and I am much more effective as a doctor on the ward.”

Newly qualified GP Charlie Gardiner shared with us directly about the programme that “I’ve learnt more in five months about leadership and service development, and all these really key skills, than I’ve learnt in five years in the UK.”

Health Partnership Scheme
In a detailed analysis of the skill sets improved by taking health professionals overseas, leadership is reported to be most strengthened. On questioning a representative sample of the 2,072 UK health workers who volunteered in a different exchange programme, the Health Partnership Scheme, 76 per cent reported improvements in developing leadership skills.

By opening up our minds, hearts and practice to our health professional peers overseas we are improving outcomes for patients at home

In this current global health climate, we are moving away from traditional forms of development and leaving behind old paternalistic models. To support this move, DfID has turbo charged a new model called health partnership.

These are a model for improving health and health services based on ideas of co-development between actors and institutions from different countries. The partnerships are long-term but not permanent and are based on ideas of reciprocal learning and mutual benefits

Working in this partnership-style has huge and varied impacts on the NHS back home. From the surprising finding shown by preliminary research conducted by Imperial that the imperative of need and dearth of procedures in middle to low income health economies is creating test beds of tech innovative.

To perhaps the more expected, that professionals saying time and time again, that the parred back environment brings about a crystalline focus on the power of their core clinical skills. By opening up our minds, hearts and practice to our health professional peers overseas we are improving outcomes for patients at home.

Ben Simms is CEO of Tropical Health and Education Trust.
Originally appeared on Health Service Journal. 

Friday, 8 July 2016

Collaborating to change behaviour in Mozambique

In this blog, Eleanor Bull, Health Psychologist, and Corina Mason, Trainee Health Psychologist, reflect on their recent experience working in partnership to change health worker practice at Beira Central Hospital, Mozambique. 

In 2016, as part of a new THET funded programme called the Change Exchange, health psychologists joined existing partnerships to help understand and change healthcare staff practice, helping to strengthen THET partnerships. As health psychology practitioners employed in NHS Grampian, we are fortunate to have broad roles in offering expertise in the complex task of changing health behaviour. Our practice includes patient interventions and research and training of professionals across prevention and self-management initiatives in public health and the acute sector.

Both of us had previously volunteered in Uganda, and were inspired by this fascinating programme. The cultural and personal learning opportunities from previous experience in Uganda had influenced our professional development. Following an article in ‘The Psychologist’ (the British Psychological Society monthly publication), we rushed to register our interest in working with a network of multi-disciplined professionals to improve the local health needs in a low income country.  The partnership approach particularly appealed to us as we observe in our daily practice the benefits of working in collaboration with our multi-disciplined colleagues.

From the outset, we were warmly welcomed into the partnership with great enthusiasm and interest from the fantastic team of health professionals at Ipswich Hospital and Beira Central hospital.  The partnership’s current aim is to improve patient safety through projects related to two key strands of work: medical equipment maintenance and medication safety. The Medical Director at Beira Central Hospital states, ‘this is important for us because hospital changes start in the mind of staff.’

Our role predominantly focuses on the complex strand of medication safety because the ideas being implemented by Beira Hospital professionals depend on changes in staff practice. Some initiatives include:

· adaptations to in-patient medication charts
· development and delivery of drug dosage calculation training
· availability of emergency drug boxes on each ward
During our visit to Beira Central hospital in June this year, we collected information from health professionals by conducting interviews, discussion groups and questionnaires with staff involved in implementing the new medication safety procedures. We observed drug dosage calculation training to understand its active ingredients, presented to Beira healthcare staff on the role of Health Psychology and the importance of behaviour in healthcare, and worked with our Ipswich partners to deliver training on antibiotic resistance.

Following data collection, we presented findings and recommendations based on health psychology to help the partners implement their excellent work. We were really pleased that health professionals in the partnership suggested our input to date has been valuable, as the Head of Nursing states,  ‘this is very good for all situations here (at the hospital) and is good that you made these observations as we are too busy to do this.’

This was an amazing and inspiring opportunity to develop our health psychology skills within a brilliant UK-African partnership. We are both incredibly grateful for this opportunity and particularly the invaluable help of our UK and Mozambican translators, as unfortunately our Portuguese still doesn’t stretch far beyond ‘Obrigado!’ We are now engaged in meetings on Skype and producing a report outlining our recommendations before a second planned visit in November to offer further help in changing staff practice. 

Friday, 3 June 2016

Zambia: training health workers to make a difference

Sophie Pinder, Evaluation and Learning Officer at THET in London, shares her impressions following a recent monitoring visit to health partnership projects in Zambia which are funded through the DFID/THET Health Partnership Scheme (HPS).

In May 2016, my colleagues Pippa, Viki and I visited five health partnership projects in Zambia working on different health themes in major hospitals across the country. The week-long monitoring visit involved meeting local leads and stakeholders at the sites where these projects are being implemented.

Beyond the monitoring purpose of the trip, this was an excellent opportunity for me to gain a deeper understanding of the local context these partnerships are working in, of the perspectives of local stakeholders and which direction they want to take their projects – aspects that can often be difficult to grasp just by reading project reports when sitting at my desk in London.

One of these projects is being implemented by the Zambian Union of Nurses Organisation (ZUNO) and the Royal College of Nursing in the UK. They established their partnership in 2012. Their project aims to build ZUNO’s capacity to influence nursing policy and improve nursing practice in Zambia. 
At the ZUNO offices in Lusaka, Jennifer Munsaka, Director of Programmes and Professional Affairs and lead for this project along with Rita Mutale, Programmes Officer, explained to us how the partnership has trained twelve staff members at the University Teaching Hospital (UTH) in Lusaka in advocacy skills and supported them to become champions for the implementation of the WHO safe surgery checklist, enabling them to build their advocacy skills in practice. Not only did the champions go on to train 164 members of theatre staff to implement the checklist, they now form a strong collective voice to bring issues and needs, backed by evidence, to the attention of hospital management and advocate for improvements. Their work has also improved interdisciplinary team work and raised the profile of ZUNO at the University Teaching Hospital, the largest hospital in the country. 
The partnership now plans to train the regional directors of ZUNO in advocacy so that they can influence national policy. This expansion has the full support of ZUNO’s new General Secretary, Michelo Fray, who stressed how this project is in line with ZUNO’s strategy of empowering nurses and midwives and protecting and promoting their interests.

In the Eastern Province, Chipata General Hospital has been working in partnership with NHS Highlands since early 2014. The objective of their current HPS project is to empower communities to address mental issues through an improved understanding of mental ill health and how to provide a safe and supportive environment. Communications lead, Pearson Moyo and professional lead, Marron Mugala, introduced us to the hospital staff who are volunteering to deliver messages on mental health in 20 communities around Chipata. We participated in one of the mental health education sessions organised by the volunteers and I found that the community members were very active in the discussion and their answers reflected their awareness of how to deal with mental health issues. At the end of the session, they even told us that they hope this project would be extended to other communities in the region so that volunteers could continue to raise awareness on mental health. The volunteers come from different specialities and wards across the hospital and some of them live nearby or in the communities themselves. As such, I had the feeling that the entire hospital was mobilizing itself for this project and that this could raise the profile of psychiatry and mental health as a speciality with the hospital.

After every project we visited, I felt a real sense of commitment of those engaged, from the UK volunteers delivering training to hospital staff to health workers volunteering their time to drive the projects forward. All have the ambition to expand their work at regional or national level, despite the challenging environment and obstacles they face along the way. On a number of occasions, projects mentioned the lack of resources and workload, hospital budget cuts that are putting a clear strain on already over-stretched services and health workforce.

On a personal level, this visit has broadened my understanding of health partnership work on the ground. It has also inspired me and my colleagues to think more deeply about how THET can support health partnerships working in the same geographical area to collaborate with each other and how this can enable them to become stronger catalysts for change at national level. In light of this visit and others to come, my team and I are discussing how we can support partnerships to connect with each other and deepen their influence and impact.