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. 

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.

Training the next generation of bio-meds

Chris Mol is a volunteer lecturer for THET’s BMET Programme. Here he describes his experience training the next generation of technologists in Zambia. 

I have now been working more than a year at, the Northern Technical College (NORTEC), in Ndola, Zambia. It has been an interesting year. This blog is to share my experiences and my enthusiasm for this attractive country and its friendly people as well as my findings on the world of medical equipment, which is so essential for modern healthcare.

This THET/DFID supported activity is based on a 2011 needs assessment in Zambian government hospitals which established that the medical equipment situation in the country was indeed quite poor.  Typically, only 50-65% of all medical equipment that is found in hospitals is functional. One of the root causes for this was found to be the absence of technical personnel who have been trained to repair medical equipment. No such training was available in the country.

Following up on this, THET has worked with the Ministry of Health as well as the Ministry of Education to set up a training course for Biomedical Equipment Technologists (BMETs). NORTEC, one of the leading Technology Colleges in Zambia, was selected as the training institute to implement this new curriculum. The BMET course is for a good part based on course modules that were already given at NORTEC, such as on electronics, mathematics, and computer skills. THET has supported NORTEC by installing a BMET workshop, acquiring 2^nd hand Medical Equipment for student practice, instruments/toolboxes and last but not least hiring and funding volunteer lecturers to present the Medical equipment specific lectures, this is where I come in.

NORTEC has now taken on 95 students, including 20 women, divided over the three years of the BMET curriculum. The first cohort will complete their studies at the end of 2016. THET is working with the Ministry of Health to ensure that new positions for BMETs will be created at the hospitals by 2017.

While working here at the College, visiting hospitals and talking to local experts, it has become clear to us that more needs to be done in the country to substantially improve the medical equipment situation. To have well-trained BMETs is certainly essential, but if the workshops at the hospital continue to be so poorly equipped, if the number of technical people in the hospital remains so limited (one technical person in a 700 bed hospital is common), if the procedures to purchase spare parts remain so cumbersome, only limited impact can be expected from well-trained BMETs.

Therefore, the THET focus is now moving from education only to also include hospital processes and decision making processes at the Ministry of Health. THET has acquired DFID funding to look further into these issues during 2016. It will be an interesting year. I will keep you posted. 

Working on equipment at Ndola Hospital, Zambia.

Empowering Women, Empowering Societies

Today on International Women’s day, we celebrate the role of women around the world. We work every day to ensure that gender and other inequalities no longer create barriers in access to and provision of health care in lower and middle income countries. In this blog our colleague Louise McGrath, Head of Programme Development, explains what we do to make sure that half of the worlds population is not left behind.  

EMPOWERING WOMEN: A NECESSARY STEP TO ACHIEVE SDG

Gender inequalities continue to hamper women’s access to and provision of health care in lower and middle income countries (LMICs). Women continue to face incredible challenges due to patchy availability of appropriate health services. LMICs account for 99% of maternal and child deaths, with maternal mortality higher in women living in rural areas and among poorer communities.[1] At the same time, even though women make up around 75% of the health workforce, they are often concentrated in lower status health occupations and poorly represented among more highly trained professions such as physicians, pharmacists and managers.[2]

The new Sustainable Development Goals (SDG) recognise the importance of both health and gender equality as crucial tools to empower women and ultimately accelerate sustainable development.[3] Under the SDG 5, universal access to sexual and reproductive health and reproductive rights were put at the core of the mission to achieve gender equality.

At THET, much of our work focuses on trying to improve health services for women and enabling them to take up a range of professional roles within the health workforce. Of the grants awarded to date under the Health Partnership Scheme (HPS), 26% have been to projects focused on maternal & new-born health, child health, sexual & reproductive health. 171 institutions now have new and improved services for maternal and new-born health and these have been used by 19961 women since HPS began.

Under the HPS, out of 41,200 health workers trained, 23,000 were women (data: THET 2015). This includes 1,305 female doctors, and women form the majority of medical and healthcare students trained, 5,513. These are significant figures, but we know that in order for this progress to be replicated and sustained health partnerships also need to put women at the centre of health care initiatives and support them to be health care leaders.

OUR WORK IN SOMALILAND: THE IMPACT OF COMMUNITY HEALTH WORKERS

Somaliland has one of the worst maternal and child mortality rates in the world. The situation is particularly critical in rural, isolated areas, where many people cannot access healthcare. When I flew to Hargeisa for the first time I could observe this dramatic reality first-hand. To improve access of this population to basic health care services and to make sure we respond to their needs with programmes that take into consideration the local context, we train Community Health Workers (CHW) who provide frontline care to those communities. In Somaliland, through a number of programmes, we have already trained dozens of CHWs. As Amina, the lead tutor who trained CHW in Burao, explains: “The CHW were selected by the community health select committees. While explaining our selection criteria we made it clear that we were particularly looking for women. Most of the women in Somaliland would find it difficult to openly talk about pregnancy or any sort of women’s sickness if there is a man sitting there in the room. It is easier for them to talk about their issues with another woman.”

Community Health Workers provide basic medical assistance, health education and awareness, and act as a link between the community and their nearest health facility, helping to contribute to the significant reduction of maternal and child mortality. In communities that have limited or no access to healthcare, CHW might be the only thing that stands between life and death.

We have also trained nurses in Basic Emergency & Obstetric Care so they can refer or carry out caesarean sections. I’m particularly proud of the double impact this programme has on women’s lives: on one hand, it helps women deliver their babies safely and, on the other hand, it empowers women working for their community offering them an important role to play in their society. Hawa, one of the women who had a caesarean recalls the difference this is making to women’s lives: “Women used to deliver at home bleeding and suffering there. Some may have died like that. Now that we have trained workers we don’t have cases of bleeding and complication during deliveries and women do not suffer any more in Abdal.”

If you want to know more about our work in Somaliland, the training of CHW and how this is changing the life of women watch this short video.

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[1] http://www.who.int/mediacentre/factsheets/fs348/en/

[2] http://www.who.int/hrh/statistics/spotlight_2.pdf?ua=1

[3] Described by the World Health Organisation (WHO) as, the socially constructed characteristics of women and men – such as norms, roles and relationships of and between groups of women and men, gender equality has been put firmly on the development map with the introduction of the Sustainable Development Goals (SDGs) and the UK Government’s new aid strategy.

SDG 3 states the need for the international community to ensure healthy lives and promote well-being for all at all ages, the wording of which is inclusive and implies a world where everyone, regardless of gender, has access to safe, quality care. But it is SDG 5 which puts gender centre stage: Achieve gender equality and empower all women and girls.

Health Partnerships: An Effective Response to the Global Health Agenda

ABOUT THE SERIES 

THET is very pleased to announce the release of the first publications in our special series in the academic journal, Globalization and Health, ‘Health Partnerships: an effective response to the global health agenda’.  The series sets out to explore the concept of international ‘twinning’ relationships between healthcare delivery or training institutions in high-income countries and counterparts in low or middle-income countries.  Health partnerships build the expertise and capacity of an institution’s health workforce not only in clinical areas, but also leadership, management, patient safety, research, and monitoring and evaluation.  Partnerships may also work on the implementation of standards and protocols, develop curricula, or influence health policy.

Health partnerships frequently publish in journals specific to their clinical specialism  but this is the first time that a journal has published a collection of articles dedicated to health partnerships’ work.  So this series is a milestone for health partnerships, which shows how far we have come; it is the product of a movement that puts partnership at the heart of strengthening health systems.

ORIGINS OF THE SERIES

It was at THET’s annual conference that the idea for a special series on health partnerships was born, with support and encouragement from Greg Martin, editor-in-chief of Globalization and Health, who was one of our speakers (see also Greg’s YouTube series on Global Health).  The time was right for a series: THET had funded a significant number of projects across multiple grant programmes (International Health Links Funding Scheme, Health Partnership Scheme, Strengthening Surgical Capacity, our country programmes in Zambia and Somaliland) so we knew that there were experiences and results out there that would be valuable not only to the health partnership community, but the partnership movement more broadly.  With the call for evidence ever-present from donors and other stakeholders, a series in a peer-reviewed journal was an exciting opportunity to bring together evidence, insights, critiques, and lessons learned, and to explore health partnerships in detail.  The Sustainable Development Goals, with their many health related objectives, provide the broader context for this series.  Notably, SDG 3 ‘ensure healthy lives and promote well-being for all at all ages’ sets out the vision for universal health coverage and THET believes that health partnerships have a significant  contribution to make to achieving UCH, as described in our UHC Discussion Paper. 

Overall, we were delighted by the number of responses to the call for papers as well as by the breadth of countries, specialisms, and institutions represented; authors hail from Africa, Europe, North America, and South America. The editorial by Andrew Jones – Envisioning a Global Health Partnership Movement –  introduces many of the papers featured in this first issue and these are just the start; with the level of interest shown to date, there will be more issues released in 2016 and we hope well into 2017 too.  Full information on the series and how to submit a paper is available here.

THET’s COMMITMENT TO EVIDENCE

THET is in a privileged position: we give training, advice, and grants to health worker training projects; and we run capacity development programmes in Somaliland and Zambia. We provide a flexible framework for people to work together effectively and responsively for the longer term.  Our wealth of knowledge about health partnerships and partnership working is down to the practitioners whose rich experiences inform our approach and develop our understanding of how best to support them.  We provide training and advice in monitoring, evaluation and learning because partnerships face challenges in tracking the difference they make, such as poor data and limited resources.  We develop resources to improve the quality of health partnerships, from case studies, to guidelines, manuals, and webinars that bring practitioners together in real-time.  In 2016, in addition to continuing this special series in Globalization and Health, THET will bring together researchers interested in the mechanisms, efficiency, and effectiveness of health partnerships, to agree a research agenda and explore opportunities for multidisciplinary work.  This is the next step in our commitment to developing the rigorous evidence base for health partnerships as an effective response to global health needs.

To find out more about THET’s work visit our website www.thet.org, read the special series in Globalization and Health or contact a member of the team – info@thet.org.  You can submit a paper to the journal at any time as this is a rolling, on-going series.  For more information about how you can submit a paper to the series, visit the Globalization and Health website: http://globalizationandhealth.biomedcentral.com/

Getting senior leaders' support for your health partnership

How health partnerships get active support from senior leaders in their partner institutions and beyond

Photo: Anne Jennings

All health partnerships work with the approval of institution leaders, but some go further and win active support from senior leaders in their institutions and beyond. We recently asked some HPS-funded health partnerships to explain how they’ve been able to do that. Here’s what they told us.

• Getting the active involvement of senior leaders in a health partnership project can take time but makes a partnership stronger in the long term. Senior leaders are in a position to delegate partnership work to other staff, embedding it in an institution, while retaining responsibility.

• Health partnerships that make an effort to keep senior managers informed of their work are more likely to get support from those managers when they need it, for granting leave requests for volunteers or helping a partnership team get cooperation from other teams in a hospital. One engaged senior manager can share updates with senior colleagues and networks through formal reporting channels such as management meetings. If there are changes in a senior leadership team, it is important for a partnership to engage early on with new managers who can influence their work.

• LMIC partners may visit the UK, or other LMIC countries (in the case of partnerships with more than one LMIC), for training or planning. Sometimes they are accompanied by government staff or other health sector leaders. These visits are a great opportunity for the leaders of the visited institution to meet health workers and leaders from overseas, and for the partnership to raise the profile of its work.

• Looking beyond the partner institutions, some health partnerships have made an effort to engage the MoH in the LMIC country, by keeping them informed about their project or inviting them to join a project steering committee. Others have aimed to influence the health agenda at a governmental level. They have found success through aligning with existing advocacy networks and opportunities, and using all their contacts to make connections with supportive individuals in Ministries of Health.

“Support from senior leadership,” as described here by health partnerships, includes a diversity of activity by various individuals. If there is a common theme, it is the importance of investing time and effort to build relationships as early as possible – rather than waiting until you need the support of a senior manager or leader.

Thanks to all the health partnerships that have contributed to this list.

Do you have other lessons to share? Please add them in the comments below. 

Dan Ritman - @danonuke
Evaluation & Learning Manager - THET

New Partnerships Essential for Global Health Success

THET CEO, Ben Simms, highlights how health partnerships are best placed to help realise the health focused SDGs, specifically the hope for Universal Health Coverage. 

Photo: James Dowling

The Overseas Development Institute described the newly adopted Sustainable Development Goals as being an architectural marvel, soaring and visionary in their ambition. And so they need to be if they are to do justice to the scale and complexity of the challenges this world faces.

One in 7 people across the world today will never see a qualified health worker. According to the World Health Organization, the worldwide crisis of health worker shortages is set to grow to 12.9 million by 2035.

Without a major effort to recruit and educate health workers, how can the commitment to achieve universal health coverage be realized?

Greater emphasis needs to be placed on supporting and training health workers, building preventative capacity — as highlighted by the devastation of the recent Ebola outbreak — and ensuring that countries have a health workforce that is fit for purpose. One way to do this is to effectively harness the medical and managerial expertise available in high-resource settings.

There is a broad range of ways in which health professionals voluntarily engage in overseas work. The scale and contribution of overseas volunteering has been explored in detail in the report by the U.K. All-Party Parliamentary Group on Global Health. The report recognizes the increasing number of links between NHS Hospitals, Royal Colleges, U.K. universities and their counterparts in low- and middle-income countries.

Over the past four years the Tropical Health and Education Trust has partnered with the U.K.Department for International Development to create and support the development of such partnerships so that they are more effective, as well as to award grants that provide for a diverse range of size, reach and theme. Since the Health Partnership Scheme was launched in 2011, more than 1,500 NHS professionals have volunteered to train over 40,000 health workers across 29 countries, helping to improve training structures and fill knowledge and skills gaps.

The results of this training can be seen in the day-to-day practice of health professionals, in the development of new cadres of health workers, and the broader policy and regulatory environment they are working in. Over 500 improved clinical guidelines, policies or curricula have been generated in the past four years.

Improving the quality of mutually beneficial health partnerships

Alongside greater activity, HPS represents an important opportunity to share information and to gather evidence on what works well and what does not in partnerships and international volunteering. As part of THET’s ongoing approach to quality improvement, we have developed Principles of Partnership to accelerate the quality and effectiveness of how U.K. health care institutions engage in low and middle-income countries. We’ve defined our principles through consultation with the wider health partnership community and we plan to further develop tools and practical resources over time to highlight the most important factors for successful partnership.

A vision of ‘co-development’

At the heart of the health partnership model is the idea of reciprocity, 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. This is what Lord Crisp terms in his seminal book “Turning the World Upside Down” as a vision of “co-development.” These partnerships are in keeping with the framing of the SDGs as global goals rather than for goals set exclusively to benefit the global poor.

Health Education England and the Academy of Medical Royal Colleges recognize the educational and learning opportunities of allowing U.K. health workers to engage in global health. Despite this, across the U.K., contributors to Improving Health at Home and Abroad commonly reported having to keep international volunteering through partnership activity “under the radar.” As a result, the scale of health partnerships remains modest, a fact recognized by the International Development Committee report on health systems strengthening in 2014, which commended volunteering schemes for health professionals but noted that the U.K. has “one of the best health systems in the world ... DfID makes only limited use of it.”

The adoption of the new SDGs is a turning point in the history of how the we live together on this planet. If that was a moment to be soaring and visionary, now is the moment to work out how we are going to deliver on our promises. We must seize this moment to direct the energy and dynamism of health professional volunteers towards the even greater challenge of building health systems fit to deliver universal health coverage to every citizen in this world.