Tuesday, 17 January 2017

Digital tools building the future of global health?

Digital tools building the future of global health?

In December, Marta our Senior Partnerships Manager, travelled to Maryland to attend the third annual Global Digital Health Forum, a platform focusing on digital and connected health in low and middle income countries, sharing lessons on what works and what doesn’t in technology for development. Here follows an account of her time there.

The potential of digital tools are proving not only crucial to the provision of health services but also to the wider health system, allowing strong systems to be built before crisis occurs. Digital data, for example, helped bring an end to Ebola in West Africa. The global usage of digital tools has also led to a surge in popularity for supporting the growth of digital health globally, it has become trendy. It is coming to be seen as a key part of a complete health package, which needs to be fully integrated into the health system, with countries such as Tanzania and Nigeria having developed national health data strategies.

Over 400 people beat the cold, in Maryland, to attend the third annual Global Digital Health Forum, a platform focusing on digital and connected health in LMICs, sharing lessons on what works and what doesn’t in technology for development. Over two days in December, it seemed that everyone that mattered in the global digital health field, including newcomers such as myself, came together to discuss the future of digital health. A number of shiny, new solutions to global health challenges were shared. From Facebook to Google new innovations such as the use of drones and balloons to bring Wi-Fi to those in remote and rural areas were debated, while others spoke of using apps to ensure healthier babies and mothers. Most discussions, however, revolved around sustainability and collaboration. How can one ensure that technology solutions live beyond the funding period? Digital tools are after all useless if citizens themselves do not use them.

Most of the tools developed for gathering data are, however, disease specific. The donor community are partly to blame for this as most funding mechanisms tend to favour linear health responses.  Partnerships between government, private and civil society actors offer a solution to health information challenges. Yet, collaboration may suffer in the current country-focused political environment. In these times, it is important to remember the nine principles for digital development, which were written by and for international development donors and their implementing partners. These principles emphasise the importance of human-centred design, context-specific solutions, re-use and improve existing technology and tools and being inclusive and collaborative. If we can get these principles right, we’ve come a long way in ensuring sustainable health information systems and better health responses as a result in the future.

With so many new digital avenues and innovations forming in the global health arena, there is certainly much to think over. For THET, we must now ask how we can use this technology to complement our partnership work and apply digital solutions to the strengthening of global health systems.

Monday, 14 November 2016

Characterizing partnerships and measuring their impacts, both intended and unintended

On Day 1 of THET Annual Conference 2016, ‘Evidence, Effectiveness & Impact’, Lawrence Loh chaired the breakout session entitled ‘Network for collaboration: partnership communities and volunteers contributions’. Here the highlights of the session. 

I recently had the pleasure of attending the 2016 Tropical Health and Education Trust conference held 20-21 October at Resource for London and chairing the breakout session titled “Networks for collaboration: partnership communities and volunteer contributions.” 

In keeping with the conference theme of Evidence, Effectiveness and Impact and focus on health partnerships, the presented valuable abstracts covered the full range of tools and topics around partnerships. These included tools to measure and visualise partnerships and networks; frameworks to assess a partnership or coalition’s development phase; strategies to tangibly measure the outcomes of partnerships; and of course, broad descriptions of how partnerships might better support sustainable, positive development impacts on communities worldwide.  

The first presentation, from Kristy Yiu of McMaster University, reviewed the results of a network mapping analysis conducted on a novel community health partnership in the Dominican Republic. The specific aim of this coalition is to bring visiting short-term volunteer groups into the fold of established development efforts identified by the communities, thus eliminating the “parallel system” of programming created by foreign visitors. To move the partnership forward, Yiu and her co-authors analysed the range of connections between coalition partners and evaluated their perceptions around the coalition’s strengths and weaknesses. By doing so, Yiu’s work aimed to show the value of network analysis in planning and developing global health partnerships. 

Dr. Oliver Johnson of Africa Health Placements (AHP) then shared a summary of post-experience survey evaluations from their participants. The studied population was largely junior doctors placed by AHP in Africa based rural hospitals for year-long placements to support health human resource gaps. In doing so, African-based partners were described as having a notable role in leading the recruitment and assignments in question. The surveys found that partnerships with a local facility meant greater engagement between parties, and interestingly, a commitment from participant junior doctors to undertake quality improvement projects while on the ground there – perhaps reflective of an unintended shift in volunteer mindset towards capacity building rather than strict service provision. 

The next talk from Dr. Katie Mageean also emerged from an African project that focused on the evaluation results arising from a partnership-led paediatric triage intervention in Uganda. Dr. Mageean’s work helped demonstrate the substantive outcome of health partnerships. In her specific example, local partner leadership and buy-in was essential to facilitating training and support for local staff, which in turn supported the success of the intervention in changing process outcomes. Her presentation closed by highlighting additional ongoing research work that is targeted at documenting improved patient outcomes from this capacity building partnership effort.

The last and final presentation by Dr. Annalee Yassi presented a “North-South-South” partnership model based on the development of partnerships between a Canadian institution and its South African counterpart. In this specific model, technical expertise around health challenges was sought through an initial international partnership (North-South) that then was distributed through a national network of peers (South-South). Dr. Yassi shared lessons learned and opportunities that such a model might provide, highlighting the need for a strong, respected southern partner to act as the key modulator between the two relationships and bring information and identified needs from their South-South “community of practice” as part of the conversation within the North-South partnership. In turn, that same partner would be expected to bring and disseminate international inputs within the South-South partnership.

The session ended with a panel discussion featuring the presenters that drew out common themes among their work. Questions focused on tools to understand and measure the outcomes of partnerships to show their value, and the importance of flexibility in developing and tweaking differing partnership models depending on context and priorities. The perspective of trust and openness from local partners was also highlighted as one potential area to explore that had not been touched on. 

In all, the session was extremely fruitful and provided a lot of food for thought around how we understand and evaluate the nature of health partnerships in global health work. As with all good sessions, many left with more ideas and questions than they started with!

Lawrence C. Loh, MD, MPH, CCFP, FRCPC, FACPM
Associate Medical Officer of Health, Peel Public Health Director of Programs at The 53rd Week Ltd., Brooklyn, NY

See pages 23-26 of the Abstract Booklet for more information about the work of the partnerships featured in this blog. 

Monday, 31 October 2016

Tackling chronic diseases in Ethiopia

Dr Alice Holmes and Dr Arla Gamper travelled to Gondar in Northern Ethiopia in the summer of 2016. There they assisted with data collection for a novel study concerning diabetes. Here follows an account of their time there.

Gondar University Hospital is situated in the Amhara region in the North of Ethiopia. It serves a population of 5 million, 90% of whom live rurally with poor access to the central hospital. There are 9 health centres in rural settings in the region, and much of the success of the work done by Sir Eldryd Parry and colleagues over the last 15 years is evidenced in these centres, where patients’ health care needs are being met closer to their home.

In our first week we travelled to Aykel health centre, 65km outside Gondar, where we met a 36-year-old male farmer, recently diagnosed with diabetes. If this had been 10 years ago, he would have had to travel a full day by foot to see a healthcare provider. Now, he is able to receive medical care for his diabetes within one hour’s walk of his home. This is one example of the major advances that the chronic disease programme in Ethiopia has made.

THET has been supporting the chronic disease programme for 20 years in Ethiopia to improve care of patients with epilepsy, diabetes, high blood pressure and chronic lung disease. The programme has contributed significantly to the strengthening of chronic disease care in rural Ethiopia. Patients with type one diabetes, that means those requiring insulin from the point of diagnosis, have different characteristics to those who are diagnosed with type one diabetes in the UK. The purpose of our work with the team in Gondar was to assist with a study looking at the reasons for this difference.

Previous studies in Ethiopia have described new diabetics as presenting later in life than in the West, which closely resembles the previously described malnutrition related diabetes[i]. The current study hypothesises that this alternative presentation is related to early malnutrition and possibly chronic illnesses in childhood[ii]. We assisted with data collection from diabetics and age and sex matched controls. We hope that the study will help to understand in more detail the nature of this disease which is seen across sub-Saharan Africa. This knowledge could contribute to better treatment options and prevention.

Treating an Ethiopian rural farmer, who may have had no formal education, to manage his blood sugar with insulin is no mean feat. Prior to the chronic disease programme, this patient would have had to travel many hours to Gondar, to collect insulin, often requiring him to take time off work, thus losing essential income for himself and his family. Educating such patients on the importance of good blood sugar control, managing low blood sugar, and preventing the complications of diabetes has been a remarkable success. The dedication and perseverance of Dr Shitaye and her team has enabled these patients to have an understanding of their disease, appropriate local follow up, and a reliable supply of free insulin. The creativity of the patients who have to keep their 3 monthly supply of insulin cool is admirable – they store their insulin in bags of sand, below ground level, ensuring its safety and efficacy even after some weeks in a hot climate.

During our time on the medical ward in Gondar University Hospital we observed the care of patients presenting with communicable and non-communicable diseases. Treating patients with diabetic complications, such as diabetic foot ulcer, highlights some of the challenges of providing effective health care in this setting. On the ward we met a 24-year-old farmer with a diabetic foot ulcer and underlying bone infection. We observed the difficulties the doctors had in managing his blood sugars on the ward. Without basic equipment, such as that to measure blood sugar, doctors are not able to provide optimal care. We observed limitations to acquiring equipment, reagents and medications on numerous occasions, which is a major limiting factor to providing healthcare in Gondar.

People’s understanding of disease and its cause in this area poses another challenge to providing care. Many patients wait for some time before seeking medical advice for their symptoms; consulting a traditional healer in the first instance, who is often more accessible, before presenting to the hospital. This combined with the fact that the vast majority of the population live rurally and many hours from the nearest health centre means that patients come late and with significant complications of their illness. Challenging health beliefs and educating patients about their medical condition is difficult in any setting, but especially here. The introduction of community-based Health Extension Workers over the past few years has contributed significantly to the reduction in maternal mortality, and increased life expectancy, and it is hoped that the integration of these professionals into communities will add to and enable better disease management and health literacy.

[i] Alemu S, Dessie A, Seid E et al. Insulin-requiring diabetes in rural Ethiopia: should we reopen the case for malnutrition-related diabetes? Diabetologia (2009) 52:1842–1845
[ii] Fedaku S, Yigzaw M, Alemu S et al. Insulin-requiring diabetes in Ethiopia: associations with poverty, early undernutrition and anthropometric disproportion. European Journal of Clinical Nutrition (2010) 64:1192-1198

Tuesday, 25 October 2016

Maximising the potential for further funding in Mozambique.

We asked Sarah Cavanagh, Pharmacist and Peter Donaldson, Consultant Surgeon, to reflect on what they did to increase the chances of their project lasting beyond Health Partnership Scheme funding; by forging links with the Rotary Club they have secured potential funding for the future. Their project aims to develop patient safety programmes at the Central Hospital of Beira, Mozambique.

Tell us more about how you started to engage with the Rotary Club and where you are at now.
We began to engage with the Rotary club fairly early on in our partnership. We attended the 2014 THET conference which provided inspiration in the form of a workshop that covered fundraising strategies, as well as local stakeholder engagement. 

What was the issue?
The main issue was that our partnership did not have a very high profile locally, either within our hospital or in our local community. We also had no certainty that we would secure funding after the project end which is set for February 2017.

Who said or did what, and when?
We presented to Ipswich-Orwell Rotary Club in December 2014, October 2015, July and September 2016. In October 2015 we also presented to Woodbridge Rotary Club. In March 2016 we were invited to attend a drinks reception with local business leaders and our local MP and former Health Secretary, Ben Gummer, who has over many years been very supportive of both Ipswich Hospital and The Rotary Club. We also met with MP Ben Gummer separately, in his constituency office.

Ipswich-Orwell Rotary Club greet Health Professionals from Mozambique
Photograph taken by Eleanor Bull in Ipswich Hospital, April 2016.

What were the immediate reactions and results? What challenges did you face?
Immediately our profile was raised because we had spoken to these influential people. We also had increased press coverage, specifically in The East Anglian Daily Times and the Ipswich Star, through a Rotary-Orwell contact.

We did face some challenges however, as the vision to involve the Rotary Club and seek wider support, as well as additional funding was not universally shared within the team. This led to some debate and delay, but eventually it was seen to be a good idea for the future of the partnership.

What were the longer-term results?
After presenting twice, and without asking for any money, Rotary-Orwell asked whether they could support us financially. They organised a fundraising event in July 2016 and prior to that held a raffle; the two events raised over £700 for the project! As the July fundraising event (Rotary Mastermind Competition) was held in collaboration with the other three Ipswich Rotary Clubs, it has led to friendly contact with these clubs as well as Ipswich-Orwell. The partnership’s involvement has also helped raise awareness of the great work of the Rotary Club and Rotary International.

Sarah Cavanagh presenting the Rotary Ipswich-Orwell banner to Dr Wingi Olivier in Beira 2016
Photograph taken by Eleanor Bull in Ipswich Hospital, April 2016.

Have you solved the problem of sustainability? What will you do next?
We feel that we have to a certain extent solved this problem. There is a much greater understanding and awareness of our partnership both within our hospital and our community, and we have established good links with five of the local Rotary Clubs. After our next visit, in November 2016, we will have a clearer idea of the next steps with the partnership. We will be maintaining our established links with Rotary, with a view to maintaining or even increasing their involvement in the future.

What have you learnt, and what advice could you give to other partnerships?
One of the most important lessons we learned was that asking for money straight away is not necessarily the best way to maximise fundraising, neither is it the best way to forge longer term relationships with potential funders and local opinion leaders. These things take time and it is important to nurture the relationships.

Orwell Rotary Club presenting a cheque for £703 to our partnership in September 2016 for medical and maintenance equipment for Beira Hospital.
Photograph taken by David Vincent, 2016.

Rotary Club and Rotary International consist of 1.2 million neighbours, friends, and community leaders who come together to create positive, lasting change in local communities and around the world. Differing occupations, cultures, and countries give Rotary a unique perspective. Rotary support a variety of causes both at home and abroad. They are specifically identified and targeted to maximize local and global impact. Rotary uses its network of resources and partners to focus service efforts in promoting peace, fighting disease, providing clean water, saving mothers and children, supporting education, and growing local economies. As such this ethos ties in very nicely with Health Partnerships.

If you would like more information on the work of the Rotary Club and  Rotary International, please visit https://www.rotary.org/en/about-rotary

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: chrisr.mol@gmail.com

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