Wednesday, 12 July 2017

Addressing Child and Adolescent Mental Health (CAMH) in Uganda

Mental health nurse Emma Gilbert has spent nine months volunteering in Kampala, Uganda, within the Child and Adolescent Mental Health (CAHM) project implemented by the East London NHS Foundation and the Butabika Hospital. What follows is the account of her experience in Uganda. 

With a background in anthropology and a career in radio, my interest for global health only developed at a later stage of my life. I qualified as a mental health nurse and from the beginning I found the idea of working in global health very appealing. When, in 2015, the East London NHS Foundation was looking for a mental health nurse for their health partnership in Uganda, I jumped at the opportunity.

Understandably, the first question that my family and friends asked was: Why are you going?

The answer was pretty easy: when the project was launched there were, I think, only five child psychiatrists in Uganda, a country where 60% of the population is under 16. The lack of specialised human resources was appalling, so in implementing a training course for CAMH the partnership was trying to address a very obvious need.

The training course was designed by Dr Allison Hall, from East London, in collaboration with Dr Godfred Jokundo and Dr Joyce Naluja, the two psychiatrists from Butabika Hospital who run the course in Kampala. The programme promotes a multidisciplinary approach, to foster better integration of services, a real problem in a country where child healthcare often falls under primary care and there is a lack of specialist services. Therefore the training attracted a really interesting mix of health professionals, not only psychiatric clinical officers, but also paediatricians, nurses, social workers, psychiatrists and medical doctors. The enthusiasm of the people I was teaching was probably one of the best things of the job. They took time out of their formative jobs, and travelled from all over the country to take part in incredibly long teaching days. At the end of these, at 6 or 7 pm, we usually had a question session. I did not expect anybody to have the energy to keep going. I was wrong. The dedication - the interest was great. And because CAMH is a relatively new area, you could really feel their hunger for leadership, for pioneering the field.
At the hospital we saw the broad spectrum of mental health disorders. Sometimes that would also include severe learning disabilities or episodes of psychosis and issues linked to trauma or abuse. If a person had emotional behaviour difficulties, which wouldn’t necessarily be classified with a mental health diagnosis, they would still come to Butabika. There were all these factors in play which meant that diagnosis, although important, wasn’t always the first thing that we addressed. In many cases we were operating almost like a children’s home
The majority of our cases, however, were epilepsy. The child’s family often believed that epilepsy was contagious or that the child was bewitched. In many instances we saw evidence of violence on epileptic children. They were often brought to traditional healers and went through all sorts of ceremonies.
There is still stigma attached to mental health in general and by extension to the Butabika hospital, which means that the hospital is often the last resource. I saw a lot of brain injuries that could have being avoided if they had come to us sooner. The work that has been done with the trainees is also helping to overcome and challenge the wrong beliefs, but it is a slow process.
The training has been instrumental in developing CAMH services. It has generated the interest of the Ministry of Health, which we have tried to engage from Day 1. We also have university accreditation which was extremely important in order to attract new students. Before the very few CAMH specialists were operating individually with lack of support, supervision or platforms to share any kind of clinical knowledge, a network for collaboration and discussion has been established. Finally, we collaborated with the Ministry to write policy guidelines on CAMH services. I feel very proud of what the course achieved.
On a more personal level, I also learnt a lot, being forced out of my comfort zone and in the end almost running a clinic where you see fifty patients a day. In the UK, you’d be seeing maybe four patients daily, here it’s more 30 to 40, so my clinical knowledge improved significantly. I 100% feel that I am a better nurse after this experience. The ability I developed to work with different people, and to be open and flexible is extremely valuable back in London where I work with patients from diverse backgrounds.
I now consider myself a strong advocate for health partnerships. I have already encouraged other colleagues within the NHS who want to work overseas that this is the best way to do it. A lot of nurses feel the appeal of working with organisations like MSF, which is of course a very valuable frontline aid service. But health partnerships are amazing because they enable sustainable service transformation.
Emma Gilbert 
Mental Health Nurse
East London NHS 

Tuesday, 11 July 2017

Medical device challenges and global priorities

Linnet, one of our Country Programmes Coordinators, travelled to the WHO in Geneva to attend the third Global Forum on Medical Devices. Here follows an account of her time there. 

The successful 3rd World Health Organisation’s Global Forum on Medical Devices was held over three days in Geneva. It brought together over 600 delegates from around the world, including three THET representatives (Andrew Jones, Anna Worm and myself). The great thing about the forum is the variety of people who attend from Beninese biomedical engineers to representatives of UN agencies and the private sector all exploring how to improve the medical equipment ecosystem.

Anna ran an interactive workshop (Gradian Health and THET collaboration) on the role of BMETs in the Healthcare Technology Management lifecycle and presented new data that suggest the status of medical equipment in sub-Saharan Africa is more positive than most publications indicate. It was great to see so many backgrounds coming together to look at not just problems but solutions. The outcome of the workshop will be shared with the participants, and the presentation on African data is now available; click here to get a copy.

On Thursday, Andrew co-chaired two sessions, one on Human Resources and Medical Devices, where six abstracts were presented by LMIC representatives on collaboration and their experiences as BMETS in low resource settings and a plenary session with international partners sharing ideas and views.

Throughout the three days there were plenary sessions showing how the issue of medical devices is an intrinsic part of so many global health priorities from NCDs to Reproductive, Maternal Neonatal Child and Adolescent Health and looking at how medical device challenges effect these global priorities.

The collaborative feeling of the conference was reinforced by the messages from all corners of the world emphasising how we must all work together, from funders to government representatives, supranational organisations to the engineers on the ground, we all have a part to play. As one delegate from IFMBE (International Federation of Biological and Medical Engineers) said “partnerships are vital.” With so many challenges to overcome we need to all work together.

The global forum was a great chance to share experiences and lessons learnt from all over the world, and while each context faces its own challenges and different stakeholders have different priorities, there were great examples of innovations being showcased and it was clear that we could all take something from each other’s experiences. 

Linnet Griffith-Jones
Country Programmes Coordinator

Thursday, 22 June 2017

Re-learning that ‘worn out tools’ are still the most reliable

From an NHS in ‘meltdown’ to domestic politics in turmoil and recent tragic news events, ‘crisis’ seems to be the word on everyone’s lips and certainly the media’s! Last month as I sat at Heathrow watching the BA screens turn black, just a week after being in the midst of a cyber-attack on the NHS, Rudyard Kipling’s famous lines came to mind; ‘If you can keep your head when all about you are losing theirs and blaming it on you’, I realised that I had already learnt that there is always another way of doing things.

The newly elected WHO Director General, Dr Tedros Adhanom Ghebreyesus, reminded us that the status of global health is in a far direr place; ‘still, half of our population doesn’t have access to healthcare.’

But why is this still the case and what can we do when our own NHS is struggling? Having proudly worked for the NHS for over 30 years and seen daily the dedication staff continue to apply, I feel a duty to stand up and say that things can change and I know at least one way to go about it. For a start we need to start listening and learning from each other and not just through echo-chambers between NHS departments, but exploring the way healthcare is done around the world.

In the last month, I have acquired first-hand experience of working in an NHS hospital during a cyber-attack, and of trying to board a BA flight on the day of a global IT problem.  These unrelated but equally disruptive events made me wonder what the NHS and the aviation industry could learn from our dependence on the idea that we know best. I came to the conclusion that the NHS, at least, could and should learn from hospital colleagues in lower income countries.

My hospital was not directly affected by the cyber-attack, and compared to some, the disruption was minimal. Others had big problems.  Hospital pharmacies and most other NHS departments are increasingly reliant on computers for pretty much everything.  In many hospitals in Africa, however, medicine bottles and boxes are labelled by hand and ward stock is accounted for by writing in ledgers using a pen. Many health facilities do of course have computers but power outages, surges, and internet issues mean they can’t always be relied on.

My recent experience volunteering in Mozambique with the DFID funded Health Partnership Scheme (HPS) has given me an alternative perspective, and as such I approached the challenges posed by the cyber-attack from a different angle to many of my colleagues. The Scheme’s emphasis on mutual learning, on teaching new  skills to our overseas counterparts whilst improving and furthering our own knowledge left me feeling that I gained more than I gave and as the attack continued, I began to realise just how crucial the experience had been. For a start, the lack of computers and inability to send and receive emails left me unfazed. We still had working telephones, after all. WhatsApp groups were also being used for general advice.

Although no IT expert (ask my colleagues!) I do see the need and great benefits of technology in the health sector, however given the increasing frequency of IT system failures, we must ensure our backup procedures are resilient.  Patients were both treated in hospitals and passengers flew on commercial airlines long before computers – it must be possible.

The HPS has given me the opportunity to think and learn differently, and develop and problem solve in ways I never thought possible. It has also given me new perspectives not only on my NHS role, but also on life in general.  In the grand scheme of things, complaining about a cancelled holiday (and missing by all accounts an excellent party), seemed a rather trivial first world problem.

In the last two weeks, the UK has been left not knowing which way to turn, and the NHS cyber-attack revealed our need to not forget the ‘worn out tools’. The NHS is considered the greatest learning institution in the world and a global leader on patient safety. We can learn a great deal from colleagues overseas and write in a few simple lines to our procedures reflecting how to best maintain a service, without the luxury of highly complex integrated IT systems.

“In the midst of chaos, partnership has been exemplified and is something I hope will continue to be championed. Certainly as I attended an event in Woodbridge on Sunday as part of ‘The Great Get Together Weekend’ in celebration of Jo Cox’s memory[1], it was clear in my mind, that these events, articles in the media and other joint contributions will continue to demonstrate the need for working and learning together and from each other wherever we come from and whatever our beliefs or established systems.

Sarah Cavanagh

Acting Director of the East Anglia Medicines Information Service, Ipswich Hospital 

Friday, 9 June 2017

From a New Director-General to Women Leaders in Global Health: A Week at the World Health Assembly

Andrew Jones, Head of Partnerships at THET was at the Assembly this year, with Graeme Chisholm, Volunteer Engagement Manager, and participated in events focusing on essential surgery, Universal Health Coverage (UHC), global health security and workforce strengthening and development. Here follows his round-up:

For the last two and a half years THET has been an NGO in official relations with the WHO, which allows us to work collaboratively on areas of common interest, defining a programme of work to suit those goals. One of the privileges it brings is the opportunity to attend the WHA in an official capacity.

Despite an extremely packed schedule and a plethora of events to choose from, I really enjoy attending the Assembly. After all it is a real melting pot of decision and policy makers – anyone who is anyone in global health is there – and it offers such a unique opportunity to network and raise the profile of THET in the global health community.

The WHA is at the forefront of global health initiatives as it is the formal decision making gathering of all of the member states of the WHO. The week has a very formal agenda which often leads to the passing of key resolutions which are then then given to the Director General and the Secretariat to implement. It is where a lot of global health policy decisions are made.

Last year for instance the ‘big piece’ was on Workforce Development 2030. The year before we had the resolution on Essential Surgery and Surgical Care. The difficulty for all if is that it is great to realise the global potential of resolutions and to have them passed but often the funds are not there to implement them and that’s the classic case with surgery at the moment.

Of course the week was dominated by the election of the new Director General Dr Tedros Adhanom Ghebreyesus  who THET are really proud to have worked with in the past within Ethiopia on the development of Non-Communicable Diseases programmes and partnerships. With his particular emphasis on UHC, something THET continues to advocate for, we are excited to see what the next five-years of the WHO will look like.

After the great excitement of the election, many of the themes that arose spoke to THET’s particular focus on workforce development from global health security and resilience to essential surgery. The official side events, provided a great opportunity for us and other NGOs to make official statements within the sessions which helped to identify potential collaborations and networking opportunities.

One of the highlights for me was the official side-event on “Scaling-up access to emergency and essential surgical, obstetric and anaesthesia care for better health systems and sustainable development”. During this session the Zambian government launched their National Surgical, Obstetric, and Anaesthesia Strategic Plan which THET and particularly our country office team in Zambia have helped to develop.

With our current KPI focus on understanding and furthering gender equality within health partnerships it was great to see so many sessions on women in global health. A particularly interesting session was on women leaders in health system strengthening, which featured a cross-sectoral panel who discussed the fight many women have faced in overcoming the many obstacles that stand in the way of progress in women’s leadership.

After a week of events, meetings and networking came to a close and as we look to renew our official relations status in 2018, the Assembly proved just as thought-provoking and vital in furthering the progress of global health actions, particularly for us in terms of collaboration with the WHO on global security, work force improvement, and surgery. 

Andrew Jones
Head of Partnerships

Maternal and Child Health: Breaking barriers in rural Uganda

Vincent Iusa is the manager of the St. Bernards Mannya Health Centre, situated in Masaka Province. Our colleague Edvige met him and his team in March 2017. Here’s the account of how the training he received through the Royal College of Paediatrics and Child Health (RCPCH) and the Kitovu Health Care Complex partnership - funded by THET - has changed the way he works and the experience of so many mothers in rural Uganda.

The sun was just beginning to rise over the eastern shore of Lake Victoria when our trip began. Destination: Mannya, a small village situated about 160km from Kampala. It takes us more than four hours to finally get there, through endless plantations of corn, coffee, tobacco, and forests shining emerald, mint and lime green, such as I had never seen before in Africa. It is clear to see how generously the Katonga River irrigates these lands.

On the way to Mannya we pass through a number of small villages: simple huts made of straw and wood, a well here and there, and many young women and children at the edge of the road, staring at us with curiosity, sometimes waving at our car. The last 9km are the worst: it rained only a couple of days ago and the road - more like a mudslide - is almost impassable. It gives us a taste of the kind of difficulties that people from the nearby villages have to face when seeking care at the Health Centre we are on our way to visit.

The buildings of St. Bernards do not look as I was expecting: the health centre is composed of about ten ordered small houses with sandy beige and scarlet walls, so similar to the colour of the land here. Elegant gardens and hedges surround the buildings. At the entrance, waiting for us is a very tall man, at first glance I estimate 6.5 feet probably. He has steady hands that he opens in a hug-like gesture to welcome us, and a calm smile. His name is Vincent, director of the centre and our guide for today.

Vincent, a clinician from Kampala, has been working in this rural area for four years now. His first words are filled with the sense of pride he has in showing us around and it becomes obvious how dedicated he is to his work. We start our visit. Vincent introduces us to his colleagues, mainly nurses and midwives, whilst explaining the activities of the centre and why offering maternal and child care services is so crucial in such an isolated area of the country.

“When I first arrived here, one of the main challenges was to convince pregnant women to even visit the centre! There are so many barriers involved. Fertility rate is high in the region.[1] When a mother delivers her first, second and even third child at home with no complications, she thinks that she doesn’t need any kind of support. Sometimes they would like to come here, but don’t have any means of transport and travelling would be either too long or too expensive for them. Sometimes they are just ashamed of their poor clothes. We have been working closely with the community to help these mothers to understand why it is important to seek care during pregnancy and after giving birth.”

The situation that Vincent describes seems to be very common in other areas of the country as well. As Theo, Clinical Officer at the Kitovu Health Care Complex, who accompanies us during our visit, explains:

“The fact is that today in Uganda only 42% of mothers are attended by skilled health workers. The cause is what we call here ‘the three delays’: one for socio-economic reasons; a second one for geographical barriers, and finally because once the mothers have finally decided to seek treatment they might not find a skilled health worker or a health worker at all!”

The training that Vincent received through the RCPCH-Kitovu partnership addressed this problem, by underlining the importance of building a relationship based on reciprocal trust with the patients.

“Mostly people were scared of coming to the centre. The training taught me how to speak to patients in the right way. And at the same time I could teach colleagues here how important it is to treat patients respectfully. Things are slowly changing. Women are more and more comfortable and have started appreciating the benefits of consulting a clinician when pregnant or after they deliver. They talk among them and for us this means that the number of patients we see regularly has been increasing, with incredible benefits for the whole community.'

To read the full case story please click here

Edvige Bordone
Communications Manager, THET

[1] Total fertility rate in Uganda was 5.8 in 2014 (Accessed online on 07/06/2017). 

Tuesday, 9 May 2017

A multi-pronged offensive against NCDs in rural Ethiopia

Since the 1972 UN Conference on the Human Environment resulted in the creation of the Stockholm Declaration, there has been widespread international consensus that the approach towards developing the planet and caring for those who inhabit it should incorporate a considered and equitable approach. 

Much has changed in the years since then, but many of the principles in the declaration hold true today, even if they have yet to be fully realised. As the World Health Assembly meets, many of these global priorities will be brought to the fore, not least and certainly not soon enough, the burden of Non Communicable Diseases (NCDs) will be discussed.

NCDs are now the leading causes of death globally, and nearly three quarters of deaths due to NCDs occur in low and middle income countries. Unlike communicable diseases these cannot be prevented by an injection or by access to clean water, instead they have complex and multi-factorial etiologies which make them all the more challenging to combat in resource poor situations.

In 2015, the modern manifestation of the Stockholm Declaration, the Sustainable Development Goals (SDGs), were adopted and boldly outline 17 goals to be achieved by 2030. Particularly relevant to addressing NCDs is SDG 17, which calls for:

“Strengthening the means of implementation and to revitalise the global partnership for sustainable development”

This requires all actors to collaborate towards building the capacity for low income countries to address their own needs and requirements. A coordinated and broad approach that addresses economic, educational and geographic inequalities is required. This is not a task that one organisation is able to tackle alone.

THET in partnership with the University of Southampton and University hospitals in the districts of Jimma and Gondar, Ethiopia are an example of the multi-stakeholder partnerships dedicated to fighting NCDs. Clinical volunteers from the UK have spent time with their counterparts in Jimma and Gondar as well as with the Federal Ethiopian Ministry of Health (FEMOH) resulting in the training of nurses and health workers to staff rural health centres. This has led to the cost free diagnosis and treatment of NCDs such as diabetes, epilepsy and hypertension in rural and poor regions where historically there were none.

These contributions have resulted in a multi-pronged offensive against NCDs in rural Ethiopia, targeting poor health literacy, the lack of appropriately trained and located health staff and the absence of reachable diagnostic and treatment methods.

These results have been achieved at the same time as strengthening the capacity of the Ministry of Health, and provide the type of professional development and opportunities to health workers in order to combat the brain drain of health workers to developed countries in search of remittance work.

For a single organisation, the task of relieving vulnerable populations from the burden of NCDs on a global scale may seem insurmountable; for in all likelihood it is. However, many hands make light work; and in today’s globally connected community there has never been a better opportunity for those with the will and ability to synergise and achieve the ambitious goals we have set ourselves.

Toby Gilbert,
Country Programmes Volunteer,

Thursday, 6 April 2017

Brexit: Self harm or a shot in the arm?

At the recent Global Health Exchange: Improving Global Learning conference in Manchester, Ben Simms, THET’s CEO, gave a stirring keynote speech on the need to go beyond media headlines and act together to promote both a stronger NHS and a fortified global health environment.

Joining speakers and delegates from across the UK and international health sector, from Public Health England, Royal Colleges and NHS overseas volunteers, the day was a fantastic moment in the health partnership movement reflecting the vital energy the Global Health Exchange is bringing to the global health and development space. This blog reflects on the key points of Ben’s speech.

The Choice

I believe we now face a fundamental choice as a country. Whether we are to be “a kind and generous” country, as Theresa May phrased it in her speech to staff at the Department for International development last week; open to the world, mindful of our mutual dependence. Or whether we are to be an insular country, holding our sovereignty close to our chest, suspiciously eyeing our neighbours, both near and far.

Nowhere is this choice more clearly expressed than in the debate around the UK’s commitment to spend 0.7% of GNI on overseas aid.

The UK is now one of just six wealthier countries to be meeting this long-standing UN target. In 2015, the UK provided a total of £12.13 billion in overseas aid. This coming Wednesday, the UK will announce that our contribution increased by an additional £1 billion in 2016. And next week, the OECD will publish their global comparison figures, which will show that the UK has seen the largest increase in overseas aid spending the world over.

It is a profound and impressive contribution. It is both kind and generous.

The Chicken

This 0.7% investment is of course, underpinned by a searing logic, which speaks of our national interest. If a chicken sneezed thirty years ago, so the joke goes, it would have been bad news for the chicken and its relatives, but nobody else would have taken much notice. Today, our increased understanding that human, animal and ecosystem health are inextricably linked combined with our ease of travel, means that such a sneeze will be heard in every capital of the world.
Ebola is often cited as the wake-up call which taught us that the health of one country is dependent on the health of another. Arguably, it’s not the first wake-up call. HIV and AIDS was such a call, as the 33 million people who died from AIDS-related illnesses can testify. Hopefully, Ebola will be the last such call:
The world is awake. It is time to put together a new landscape that will deliver universal health coverage to all its citizens. And UK overseas aid has a crucial role to play in this. It is in our national interest.

The Media

However logical this sounds, it cannot be taken for granted. The 0.7% commitment is under unprecedented attack. Just in January, the Mail on Sunday persisted in its campaign for overseas aid to be re-directed to support the NHS. And it’s not just the Mail. It’s The Times and the Express. In fact, it’s many of the papers that campaigned vigorously for Brexit.
For THET, the choice the Daily Mail gives is one that speaks very poignantly to our vision of a world where everyone has access to healthcare. The decision between investing in ODA or the NHS, is not an either or, they can and should go hand in hand.

The Future

We need to fight for an internationally-focused NHS. At the heart of this is the challenge of ensuring that, as we learn to identify the benefits we can derive from an internationally-minded NHS, to too we must think carefully about how these align with the benefit derived from host countries.
All this means asking and answering difficult questions: not just around how we balance the interests of the NHS with those of overseas health services. But how, for example, we transition from aid dependency to grasping the opportunities for commercial activity overseas which could produce valuable income for the NHS.
To travel on this journey involves making a choice. The choice I talked about at the beginning: about what country we want to be a part of.
Theresa May’s speech last week set the standard by which we can now judge our government’s promises, exemplified by our commitment to spend 0.7% of our national income on overseas aid.
We too need to express this choice, individually and organisationally, to grapple with this complexity to produce an outward facing NHS, one that brings benefit both to countries overseas and to its own patients. In Our Mutual Interest.

Ben Simms