Global Health: The Northern Irish Approach

90% of blindness occurs in Low and Middle Income Countries (LMICs), the places that are least prepared to deal with this burden, but about 90% of the research funding goes to High Income Countries (HICs).

At Queens University Belfast, as part of a rapidly evolving global health scene, there is much to celebrate and be excited for in terms of the progress being made to change this statistic. As an ophthalmologist, who has spent over ten years in China developing appropriate approaches to vision impairments and diseases, it is an exciting time to be in Northern Ireland and to be part of pioneering global vision programmes which are affecting real change both here and throughout the rest of the world.  

As part of this, we have a number of projects underway including; a new Global Health MPH to ensure that there is improved training in global health and our Global Health Symposium, now in its third year, which continues to bring in diverse participants from all over the world, including the Republic of Ireland. The Global Challenge Research Fund has also enabled colleagues at the Queen’s Centre for Public Health to apply for ‘research aid’ to develop models for Cervical Cancer screening in Vietnam and look into new approaches to diabetic eye disease in China.

Collaboration on these projects has gone beyond Queen’s and has brought together experts from all over the globe, to ensure that the programmes are both clinically focused and needs-driven.

A global model

As the Sustainable Development Goals (SDGs) illustrate, so many global issues from health to education interconnect and create valuable synergies. In this vein, the implications of poor eye health are far reaching. Diabetic eye disease, for example, is the leading cause of global blindness for those in their working years and is a fast-growing problem in LMICs where the loss of the main breadwinner in a family can plunge them into extreme poverty.  

The NHS is an acknowledged global leader in universal health coverage and as seen in numerous schemes can contribute to the furthering of the SDGs. More specifically the NHS’ work on screening for diabetic eye disease is a leading example of excellent practice. The models and techniques employed by the NHS screening program are widely available on the internet, allowing anybody in any country to understand and learn from the practices employed in the UK. At the same time, through working with our counterparts overseas on eye health programmes, we continue to learn new insights in areas such as school vision screening, which can further improve the quality of care in Northern Ireland and the rest of the UK.

Our collaborations incorporate many different actors. Currently, with Orbis International, we are developing and scaling-up models of diabetic screening based on NHS practice and modified for low-resource settings. The first of these will be rolling out soon in Vietnam, and we expect more later in Africa, Latin America and Asia.

We have also been working on incorporating NHS software. Working with Health Intelligence, a provider of NHS image grading software, we are implementing a model for the Vietnam programme through the creation of a version of the software specifically designed for use in LMICs. Thus, there are so many ways and opportunities in which we can apply through an adaptive approach these NHS models in ways that are appropriate for low resource settings.

The need: global and local 

It has become apparent that to think of ‘global health’ doesn’t mean to exclude underserved areas that happen to be in higher income countries. At Queen’s, we also realise the need at home and are working to combat the disparities in care. We continue to work to understand the problems within Northern Ireland, especially as some of the postcodes in the country are among the poorest and most deprived in the UK.

As a response to this we have been working with a group of over a dozen institutions, as part of the Developing Eyecare Partnerships (DEP) project, a programme developed by the NHS with the goal of developing partnerships to create more efficient models of care We are using research to try to further improve the quality, efficiency and equity of care in Northern Ireland for diabetic eye disease, cataract surgery and school vision screening.

NHS as a driving force

There is no question then that the leading NHS institutions have been important drivers in our thinking, both here in Northern Ireland and globally. My work continues to focus on bringing equity of access not just for eye care but also as a result for communities more widely. Improved eyesight also brings wider world of educational and work opportunities in low-resource settings.

It is truly inspiring to be a part of the growing global health arena in Northern Ireland. There is a huge sense of momentum, driving forward programmes both in LMICs and in deprived areas of our own country. Being part of initiatives which use our own NHS models to improve care across the globe, whilst highlighting improvements and new initiatives which we can use to improve care throughout the whole of the UK, is extremely exciting and I am looking forward to what is to come. 

Professor Nathan Congdon, 

• School of Medicine, Dentistry and Biomedical Sciences
• Centre for Public Health
• Queens University Belfast 

Global Health: From National Beginnings to International Partnerships

At the end of June we reached a milestone in the Health Partnership Scheme (HPS) which entered into its seventh year implementation. After six years of global health partnerships it is clear that the model has really come of age. The stats speak for themselves.

In 2011, at the inception of the programme the target was to train 13,000 overseas health workers by 2015. In those four years over 38,000 had been trained and by June this year, following a two year extension over 84,000 health workers had been trained through projects in 31 countries. Impressive HPS figures abound but perhaps the next one to stagger me is that over 90,000 days were spent by UK health workers volunteering.  

This is the true legacy of the HPS and it is sure to be one which only continues to go from strength to strength. There is more engagement from UK institutions than ever before. During the programme over 130 NHS and Health and Academic Institutions from across England, Scotland, Wales and Northern Ireland formed partnerships with their counterparts in low- and middle-income countries, not only delivering invaluable training but also bringing improved skill sets, clinical knowledge and management experience back to an  NHS system facing many challenges.

Health Partnerships beyond the Health Partnership Scheme

The partnership model has also spread well beyond its original parameters with more funding approaches taking up the method than ever before. From Hub Cymru Africa to the Royal College of Physicians and Surgeons of Glasgow, several initiatives are strengthening and furthering the development of UK country and regional approaches to global health development. But it is not just the health partnership community which continues to expand the model, other DFID funding mechanisms are also incorporating the shared value element, and even further afield beyond the UK, organisations in the USA and in Europe are employing these methods.

The NHS - A global force

It is clear that health partnerships are contributing to the NHS’ positioning as a global force, providing a blueprint for other activity, including commercial opportunities which could see the NHS derive an income from engaging overseas. With such a wealth of knowledge harboured in the NHS, one such opportunity could, in the future, come from the deployment of UK health workers to middle and high income countries to assist with paid health system strengthening programmes.

Where once the development community was sceptical of ideas of ‘aid to trade’, it becoming increasingly clear that ODA spending can work to serve the interests of all, both overseas development aims and the wider interests of the UK. 

In Myanmar for example, as the nation continues to move forward with its own complex evolution, new and exciting opportunities are springing up for the UK health care sector to share knowledge and expertise with their local counterparts. From growing private sector investment particularly in the provision of medicines and equipment, to the development of training schemes and curricula o meet the depleted medical education system within the country. I am following with excitement our own expanding in-country presence with Health Education England.

A motor for innovation

A feature of this coming of age are the very diverse approaches that are emerging in the UK. From the dedicated global health policies in Wales to the specialised and thematic programmes within Northern Ireland, each nation is demonstrating innovation and impetus in their devolved states.

In England alone, regional actors are playing catalytic roles in fostering greater engagement. From the East of England where just a few weeks ago Anglia Ruskin University held a Sustainable Health Symposium bolstering the growing body of NHS Trusts and Universities taking up global health programmes, to the North West  where the Universities of Manchester and Salford together with the Global Health Exchange continue to forge new learning and volunteer engagement programmes, to Wessex where the Improving Global Health Leadership Development Programme is recruiting NHS volunteers to work with their counterparts in low-resource settings.

In this newsletter we start the task of ‘spotlighting’ this diversity. From the blog, interview and article captured in this month’s edition it is clear that this is an exciting time for the UK and its global health contribution and one that all countries and regions can continue to collaborate on. It is truly an admirable environment taking shape across the UK and one that collectively amounts to a distinctive and profoundly impressive UK offering to the goal of UHC for all.

THET is proud to be playing a modest role in enabling this to happen.

Ben Simms

CEO

THET

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 

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

CEO,

THET

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.