A Life-line for Rural Communities: Training Community Health Workers in Somaliland

In this blog, THET's Communications Officer, Timur Bekir, describes his visit to a rural village in Somaliland to see how a newly trained group of Community Health Workers are improving healthcare for the local population.

We’re driving along one of Somaliland’s main roads, an artery that cuts across the Sahil Region linking the capital Hargeisa with the coastal city of Berbera, when our driver, Abdi, makes a sharp right turn, leaving the relative comfort of the pot holed tarmac and embracing the undulating and unforgiving terra incognita of the Somaliland desert. As we hit the earth, we’re thrown about in all directions and I make use of any and all handles to support myself. A couple of minutes in and I’m starting to feel nauseous. ‘How long till we’re there?’ I enquire. ‘Two hours,’ comes the reply, ‘maybe three.’ It’s at this point that I realise the herculean task of getting an ambulance to a remote village like the one we’re visiting today, and how truly awful it must be for any sick patient taking that journey.

60% of the population in Somaliland is nomadic and many settlements and villages sit in isolated rural parts of the country. These remote communities have little or no access to healthcare and often only seek treatment when conditions take a turn for the worse. I’m visiting one such village today, Hulqaboobe, to see how THET’s Community Health Worker (CHW) programme is bringing essential healthcare to the local population.

I’m traveling with Amina Abdi, the lead tutor for the Community Health Worker programme. The programme has been developed by THET in collaboration with the Somaliland Ministry of Health and the UK Department for International Development, and takes a three tired approach: train CHWs, update the existing CHW curriculum and training manual, and deliver training to trainers who can continue to deliver the course in the future.

CHW lead tutor Amina Abdi. Photo: Timur Bekir

One of the fundamentals of the CHW programme is that students must be selected by their local community and then return back to that same community to work and provide healthcare, as Amina explains:

One of the criteria was that trainees should be selected by the health committees in their village. The person living there knows the rules and what the situation is in the community. We wanted to make sure the candidate can help their own community.

Hulqaboobe Village. Photo: Timur Bekir

The car slows and Abdi tells me we’re in Hulqaboobe. The village is flanked by mountains on two sides and looks about as remote as you can get.  Up ahead sits a large tree surrounded by huts and a Primary Healthcare Unit, built recently by one of THET’s partners Health Poverty Action. The village elders greet us and I’m introduced to the three CHWs who will be serving the local population. I speak to one, Asiya Awiye Muhumed, about her experience on the course:

When I was selected by my society that was the first time they trusted me, and during my first visit to the village after initial training we organised a community gathering and explained about our objectives. We told them that with the knowledge we are gaining from the training we want to serve them better.

Newly trained CHW, Asiya Awiye Muhumed. Photo: Timur Bekir

Health indicators in Somaliland are extremely poor. According to UNICEF one in every 14 children die before reaching age one while one in every 11 children does not survive to their fifth birthday; the maternal mortality ratio is 1044/100,000; and less than 50% of births are attended by a skilled attendant.*

CHWs embark on a nine month course that is broken down into six week blocks. This includes three weeks of class based study, a week working in their local health facility, and a community placement for a week, which is followed by a week of leave. Amina highlights the scope of the training:

The topics they are learning are really a lot. I can say some of the things they are learning are how to take care of pregnant mothers, how to take care of sick children, how to recognise the danger signs during pregnancy, after pregnancy, or during delivery. The healthy environment is also one of the things we are teaching them so they understand what health means and why we need to have a healthy environment, a simple example being handwashing.

The rugged beauty of Hulqaboobe village is quite stunning. The unexpectedly green landscape is broken up by orange rock and dusty earth, punctuated by the bright, vibrant colours of the Hijabs worn by local women. There is a huge crowd in Hulqaboobe today and Hersi Ahmed, one of the other CHWs selected from the village, explains that this is usual. People come from all around the area to be seen by the health workers:

Every day is like this and there are lots of sick people who need help, that is why I wanted to work for my people.

Hersi describes the impact of the training so far:

The training is going very well. We’re learning a lot of good things and Amina is supporting us to learn many things which we did not know before. We did not know how to measure BP and first aid, we knew none of these! But now we know many things.

CHW Hersi Ahmed. Photo: Timur Bekir

As our time in Hulqaboobe draws to an end I grab a quick word with the village elder. I ask him what impact the CHWs will have on the community:

Before this health facility was built we used to hire a lorry to take pregnant mothers to hospital, but now we get access to ambulances, and when someone gets ill in the village we get medicine from the health centre. Initially, there was only one health worker in the facility, but now we are expecting it to be more efficient because we are going to have the Community Health Workers who are very active in the health centre. So that is huge benefit to the village people, and we are very grateful to those whose support has made this happen and all those who participated in their training. We want to continue from there and improve upon it, I hope that we continue receiving support.

Village elder, Muse Hussein. Photo: Timur Bekir

The engine of our car rumbles into life behind me, signalling that it really is time to go. It’s clear from the people I’ve met today that the appetite for healthcare development is strong in Hulqaboobe. The CHWs are providing a much needed life-line to neglected communities and I look forward to returning again when the CHWs have graduated and are in their posts to see the impact they are having on patient’s lives.

*Summary Preliminary Results Multiple Indicator Cluster Survey, 2011, UNICEF.  

Developing village-based community mental health care in southern Malawi

In the blog, project Co-ordinator, Jerome Wright, charts the development of partnership project work between  the Department of Health Sciences at the University of York in the UK and Zomba Mental Health Services in Zomba, southern Malawi. 

The origin of the Mental Health in Zomba (MHiZ) Project stems from work on a 2005-6 British Medical Association (BMA) Humanitarian grant funded project to pilot the teaching of mental health care to staff posted at health centres around Zomba in southern Malawi.  These health professionals – nurses, clinical officers, medical assistants - were updating their mental healthcare skills, skills they rarely utilised in the midst of challenges besetting the low resourced and overstretched health centres, compounded by the priority afforded to physical health problems of communicable disease and mother and infant health.  The evidence of mental health problems contributing to the global burden of disability, and how the physically unwell and their carers are among the most vulnerable to mental health problems, was only beginning to emerge.  Two things were challenging – HOW to design and deliver mental health training that would be effective and accommodate the social and cultural context of rural Malawi and secondly, WHERE best to target these efforts.

Health Surveillance Assistants (HSAs) are a group of Malawian health workers closest to the communities they serve.  While based at a health centre, they attend there only once or twice a week but spend most of their time promoting health in the villages – directing efforts to providing vaccinations, monitoring children and mothers’ health, supporting the treatment of malaria, TB and HIV, monitoring and promoting community efforts at water and sanitation facilities and tracing outbreaks of infectious disease. Mental health was not included in their training to become an HSA and yet at the teachings HSAs would describe ‘people experiencing madness’ (“anthu a misala”) and other mental health and development difficulties such as learning disability, epilepsy, low mood and suicide.  Though previously untested, the accessibility of HSAs within the communities made them the ideal staff group to be supported to promote mental healthcare for people closest to their homes.   

HSAs from Matiya health centre. 

However, what type of assessment and intervention should be promoted? In the past, initiatives in low income countries have tended to focus on enhancing the often sparse psychiatric service, with the intention that the ‘expert’ knowledge of mental illness from institutions filtering through the interventions and provision of effective care to the public.  The knowledge espoused too would be based upon that evidenced from other (usually high resourced) countries – with the assumption of universal applicability and appropriateness.  While there appears to be an agreement that throughout the world people experience mental distress, the way that these experiences are understood, lived, and ‘treated’ differ according to cultural context.  A decade of experience working with colleagues in rural Malawi – where there are rich traditional African and other religious responses to what might be described as mental health problems, together with its mixed picture of effectiveness and an absence of western psychiatric thought – meant we wanted to tread carefully by introducing a determinedly ‘healthcare’ response to people suffering distress that was also conducive to Malawian social and cultural mores. 

MHiZ Project manager Chikayiko Chiwandira and Nurse Jane Mlumbe providing supervision to HSAs.

To develop such a mental health curriculum that would assist HSAs in recognising and responding to the range of mental health problems they witness in their communities, a mixed group of Malawian and UK health professionals, academics, users of mental health services and HSAs themselves was convened.  Through a series of workshops and deliberations a three day training programme was designed and prepared. The curriculum acknowledged multi-factorial pathways to experiencing mental health problems, accepting the personal value and significance of people’s own attribution beliefs (stress, the use of drugs, bewitchment, the ‘will’ of God etc.) and offering a ‘health model’ as a way of responding to the distress.  Although, within the community, ‘bewitchment’ was the most common attribution for a person experiencing what may be termed a mental health problem, so too was ‘stress’ which provided HSAs with an ideal opportunity to pose a ‘stress-vulnerability’ model to understand the psychological ‘distress’ as a health problem.   Instead of identifying psychiatric diagnoses, a client- and HSA-assessed adjudication of ‘psychological distress’ and ‘risk to self or others’ was sought, together with a  Human Rights framework utilised to determine prioritisation and acceptability of an intervention against a person’s consent.  The response and interventions from HSAs too emphasised the mobilisation of support locally from within the family or wider community, with the health centre available for the most severely disturbed people.

The curriculum was successfully piloted in 12 health centres between 2010 and 2012 and involved training 271 HSAs and the current MHiZ Project is now scaling–up that programme to the whole of Zomba District which includes 32 health centres and serves a population of 550,000.  In a development from the pilot project, to support the integration and sustainability of mental health within the role of HSAs further, a one day training course on mental health using the same model was also provided to 240 health professionals based at the 32 health centres in order to acquaint them with the HSAs new role and enlist their support managing mental health problems at health centres. 

In 2013, once a ‘training of trainers’ programme was completed, nine Malawian trainers delivered ten three day training programmes to more than 450 HSAs.  The third day was delivered six to nine months following the first 2 days to incorporate an opportunity for HSAs to review and discuss their new mental health roles.  A pre- and post-training assessment of each individual HSA’s knowledge and confidence in tackling mental health issues was also undertaken, with increases in both recorded on follow-up. 

In the 18 months since the trainings, the small MHiZ team have provided monthly supervision to HSAs at their health centres, reviewing their interventions with individuals and families and also the huge number of mental health promotion activities the HSAs have facilitated.  A record of both HSAs’ mental health care activity with individuals and their families and their mental health promotion activity is being collated.  Records show people are presenting to HSAs with a range of life-problems: bereavement, abuse, marital problems, epilepsy. Carers attend to see the HSA describing clients ‘abnormal’ behaviours such as ‘wandering’, not eating, not sleeping, dizzy, talking to self and smoking ‘chamba’ (marijuana).  The HSAs describe people challenged by difficult social contexts including death of loved ones, abuse, physical illness and relationship problems, with more than 1 in 10 people feeling suicidal.  HSA interventions range from providing information, emotional support and reassurance, communicating with extended family or community to mobilise support, advice on medication or referral onto the health centre.

To date, records of over 800 mental health promotion activities have been collected, with over 40,000 persons attending these events – including public meetings, meetings of village health committees, consultations and support groups for patients and carers.   This demonstrates the huge reach HSAs have within their communities and the potential this has for public mental health promotion and sensitization.

As the project nears its end in March 2015, we look towards sustainability and summative evaluation.  In September last year the Project financed and hosted an Award Ceremony at Matiya Health Centre, Zomba District, to celebrate their efforts as the top performing health centre and the mental health work of individual HSAs.  The event, attended by local stakeholders and national press, has helped to draw attention to the potential of HSAs and to generate interest within the Malawi Ministry of Health and more widely in developing this or similar initiatives. To inform this too, the MHiZ Project team is currently analysing data to determine both successes and ongoing challenges in developing this innovative approach to community mental health care. 

MHiZ Project manager Chikayiko Chiwandira and Assistant DHO Mr Mlotha presenting HSA Shadreck Chinsima with his award of bicycle for his excellent and sustained contribution to mental health promotion and care.

In the coming weeks, we are looking forward to testing the degree to which the MHiZ Project has developed a way of increasing primary mental healthcare that is responsive to local understandings and experiences of distress and provides humane and effective care for some of the most vulnerable people in society.

MHiZ Project Lead Jerome Wright congratulating top HSA Shadreck Chinsima on his award.

Improving health outcomes for women in Uganda

Sarah Muwanguzi is a Senior Midwife at the Mulago Hospital in Uganda working with the THET funded Liverpool-Mulago Partnership to train health workers and improve health outcomes for patients. As she prepares to visit the UK and speak at THET’s 25^th anniversary event in Salford on the 25^th November, we asked Sarah to reflect on her experiences of health partnerships, the improvements that have been made in her hospital and the challenges now faced by her team.

It all began when I was deployed as a Deputy Sister in charge of the High Dependency Unit (HDU) in July 2011. My major role was to team up with the then in charge, Prosy Namukwaya, to improve the quality of care for women with critical conditions in the department of Obstetrics and Gynaecology.

Maternal mortality rates in Uganda are very high, at 438 deaths per 100,000 live births, with a still birth rate of 30 deaths per 1,000 total births. Mulago Hospital is a national referral hospital which carries out approximately 70 deliveries per day, with neonatal and maternal mortality rates also very high.

The idea to start a High Dependency Unit (HDU) came up after Dr. Muyingo Mark and Dr. Nakubulwa visited Liverpool Women’s Hospital in the UK with the Liverpool-Mulago Health Partnership. With funding from The Eleanor Bradley Fellowship Trust, the Obstetric HDU Project was initiated in October 2010, with the aim of improving the hospital’s ability to render improved services to the large female population.

We were a group of twelve midwives newly deployed from other wards to work in the HDU and were not conversant in managing critically ill patients. Thus, a training workshop was organized by the UK team, Professor Andrew Weeks and Dr. Sarah Hoyle, to build capacity for all the HDU staff. The knowledge gained from this workshop, plus continuous mentorship and supervision, meant the HDU midwives were able to use their new knowledge and skills to assess and manage acutely ill adults.

I will never forget a woman who was returned from theatre immediately post-surgery. The midwife had not carried out her post-operative observations and had hurried her out of theatre to go off duty. She wheeled her to the HDU and left without handing over to the HDU team. The woman was sitting in a pool of blood, very pale, and with an African Maternal Early Warning Score (AMEWS) of 8. (It is now mandatory for all women admitted in the HDU to be scored and intervention carried out based on the AMEWS score.) UK volunteer, Dr. Emily Lewis, was summoned for help and immediately put up a normal saline 0.9%, which was run very fast and also established a second line to resuscitate for adequate fluids. With that promptness the collapsed woman was revived and returned to theatre for further interventions. She was a near miss!

Learning from Dr. Emily the importance of a good team and promptness in managing emergencies, I was motivated to train, guide, and support the HDU team, and other midwives, to strengthen their knowledge and skills in managing obstetric emergencies. Together with Dr. Jo Sinclair and other UK trainers, we conducted a training workshop at Kansagati HCIV in preparation for the proposed re-opening of the operating theatre, where emphasis was on post-operative observations and infection control measures.

We have also successfully developed a unit culture to review all maternal deaths and near misses (Maternal and Perinatal Death Review, MPDR), so as to generate next steps in improving care. The HDU is now a model ward, where prescribed drugs are administered on time and with good record keeping. The challenge now faced is the high staff turnover due to frequent change over. This calls for more funds and time to conduct more training for newly deployed staff.

Meeting in the HDU.

Training at Mulgao Hospital.

Infection prevention project in the Obstetric HDU

My trip to Liverpool in 2012 was very interesting and informative. I saw and admired how things are done differently and greatly desired to bring about a change at my unit. I recalled the situation back home, where there were inappropriate hand hygiene practices carried out by the doctors and midwives while making ward rounds. The unit had many faulty hand washing sinks; we lacked infection control protocols and basic reminders when going in to the main labour ward; the shower rooms were not functional and women went in to labour in a very unhygienic state. Waste disposal methods within the labour ward were inexcusable, with very old broken waste bins, without lids, predisposing new mothers to postpartum infections. The exposure I got while on my exchange visit at Liverpool Women’s Hospital, prompted me to lay down strategies to improve infection control measures at my hospital. Among these was to conduct mandatory trainings in infection control, establish a link system, and to carry out clinical infection control audits for each unit in the department.  We managed to conduct a number of trainings and also identified link staffs on all obstetric wards. However, due to limited funding, we were not able to conduct training on clinical audits.

New bins on the ward.

There is generally a new outlook to the entire hospital, which the HDU has painted. There are now alcohol rubbing facilities mounted near entry points for the HDU and labour ward. More thanks to Mulago Hospital’s top management and the Deputy Director, Dr. Birabwa Male, who lobbied for funding to roll out the hand hygiene project to all of the hospital’s wards. Twelve pedal bins were bought and placed within the labour ward and surrounding units, to improve waste management within the labour ward.

I’m grateful to the UK volunteers for the contribution they made towards strengthening our midwives capacity to implement simple, routine procedures. I have continued to guide midwives to put into practice what they had learnt from the UK volunteers. Such as triaging in the admission area of the labour ward, newborn resuscitation skills, labour monitoring using a Partograph, infection control measures and using the AMEWS.

You can find out more about the Liverpool-Mulago Partnership here.

If you'd like to attend the event in Salford, you can register for free here. 

NHS expertise, how to reach its full potential

The International Development Committee (IDC) recently published a report on the findings of an inquiry into DFID’s work on strengthening developing country health systems. Graeme Chisholm, THET’s Volunteer Engagement Manager talks about its recommendations and what it might mean for the future of volunteering from the NHS. 

In my previous blog, Voluntary Engagement in Global Health, I asked, partly rhetorically, whether a leap of faith was required for us to believe that engaging in global health can be good for everyone. I didn’t expect an answer so quickly and certainly not one as resounding as the one I read in the recently published report Strengthening Health Systems in Developing Countries from the House of Commons International Development Committee. In this report the highly influential Committee states in no uncertain terms their firm belief that volunteering overseas can indeed be of great benefit to the NHS as well as to developing country health systems.

The report calls for volunteering schemes to be well coordinated, structured and of sufficient scale to achieve lasting change. Engaging in global health comes in all forms but let’s not forget that there are a number of wonderful examples of volunteering schemes funded by the Health Partnership Scheme (HPS) that display all the qualities called for in the report. Take Global Links, managed by the Royal College of Paediatrics and Child Health, for example. Since it started in the spring of 2012 36 paediatricians, trainees as well as consultants, have volunteered for periods of six months in some of the toughest conditions in East and West Africa. A number of Global Links paediatricians have been working, for example, in Ola During Hospital, the only children’s hospital in Sierra Leone, alongside Sierra Leonean doctors and nurses. What they’re achieving is summed-up by Timur Bekir in Giving Children a Chance: Reducing Child Mortality in Sierra Leone below. One other thing to celebrate about Global Links though is how the RCPCH have worked hard to ensure that paediatricians from west and east Africa get the chance to come to the UK, 17 so far, to learn and share knowledge with us before returning to their countries to help lead their health services. And I know that all this hard work has helped greatly to counter the Ebola threat currently faced by the people of Sierra Leone.

So what else does the report say? At its heart is a call for us all, however we engage in global health, to make better use of NHS expertise. The report recommends that NHS staff should be supported in seeking to apply their skills where need is greatest. It rightly points out that the new guidance, Engaging in Global Health, from the Department of Health, Department for International Development and the NHS, should lead the way. But it’s worth pointing out that Engaging in Global Health is simply that, guidance rather than policy. So how do we take the next steps and create ‘formal structures to facilitate the participation of many more’ to engage in global health as the report goes on to recommend?

There are two things that can make this happen. One is more money and the other is policy change. But where can we find the money in these austere times and what needs to change in terms of policy? Here are some ideas.

When it comes to engaging in global health through partnerships, a patchwork of charitable donations and support from philanthropic and commercial sources all provide vital funding. But the lion share of funding is currently provided by DFID through the Health Partnership Scheme. The report commends HPS but it also says that its level of funding is but ‘a drop in the ocean’. There is clearly an appetite for more partnerships that can demonstrate value so shouldn’t we be lobbying DFID right now for a higher level of funding to allow partnerships to flourish beyond 2017 when HPS is currently due to end?

These are exciting times we live in as Healthcare UK and UK Trade and Industry look to markets overseas to export the UK’s healthcare knowledge and expertise. And as profits from these commercial partnerships begin to flow and we continue to understand more and more the value to the UK’s health sector of voluntarily engaging in global health isn’t the time now right for us to explore the relationship between commercial partnerships and voluntary health partnerships and how they can mutually support one another?

As for policy change where to begin? In terms of direction from the top, there has been some progress. Even though Engaging in GlobalHealth is guidance rather than policy it does provide solid foundations to work from. And earlier this year a new clause supporting voluntary engagement in global health by the UK workforce was included in the refreshed Mandate from the Department of Health to Health Education England. But what is notable is the absence of anything similar in the government’s Mandate to NHS England. This is worrying. Shouldn’t we be calling for support for engaging in global health from NHS England? I think we should for if the de facto system manager of our health service has nothing to say on the matter then doesn’t this legitimise inaction and insularity?

But what about more practical measures? I’m delighted to report that Health Education England and NHS Employers are working on a Continuing Professional Development toolkit that will help all those who volunteer overseas to reflect on and evidence the competencies they gain whilst volunteering. And we at THET are keen to study how this is received at appraisals when NHS employees return to the UK. We know, anecdotally at least, that lots of good comes from volunteering but we also really want hard evidence to put to bed once and for all the concern that the NHS is losing vital skills and gaining nothing in return. This is a big task so wouldn’t it be great if Local Education and Training Boards helped to roll this initiative out to help to really embed it across the health service?

A final thought. Model policy examples aren’t always necessarily eye catching but my gaze keeps drifting back to the one developed by NHS Employers in conjunction with the Ministry of Defence for NHS employees who are also members of the reserve forces. This particular Model Policy Example manages to tackle the many issues as well as offer solutions and it packages it all up neatly in the one document. I wonder whether we should be pushing for something similar for international volunteering?

Voluntary Engagement in Global Health

THET's Volunteer Engagement Manager, Graeme Chisholm, gives his reaction to the publication of the new framework for voluntary engagement in global health by the UK health sector, Engaging in Global Health, by the UK Department of Health & Department for International Development.


When Lord Crisp published his report Global Health Partnerships back in 2007 I was working for VSO in their marketing department trying to encourage more health professionals to volunteer. When I read what Lord Crisp had written about partnerships and volunteering I immediately felt that this was an important moment and began thinking about how we could help turn the report’s recommendations into a reality. Seven years on I’m lucky enough to be working for THET on just that. 

But so much has happened as a result of Global Health Partnerships. For example, you may or may not know this but the Health Partnership Scheme (HPS) THET manages on behalf of the Department for International Development is, at least partly, the result of Lord Crisp’s visionary report. 

Since HPS began in 2011 so much valuable work has been done by UK health professionals working in partnership with colleagues across Africa and Asia. And as a result more and more health workers in low income countries are now better trained to cope with the enormous challenges they face on a daily basis. Challenges difficult to imagine until you’ve witnessed them. I was in Sierra Leone last year and although they’ve made great strides since the civil war health care coverage is still at best fragile. A hospital I visited had no blood and the laboratory was barely functioning and this was the main hospital serving an entire district of more than 300,000 people. But all is not lost and progress is being made as a State Registered Nurse in the District Hospital in Sierra Leone I visited explained: “I have learned so much, I have learned about neonatal resuscitation. I have learned how to use a bag valve mask for breathing. I have learned about leadership and mentoring. We learned how to triage sick children when they come to the hospital … these things, we can now put them into practice.”

An infant is treated by Volunteer Nurse Aides in Sierra Leone. Photo: Timur Bekir

Another legacy of Lord Crisp’s report was the launch of a Framework for NHS Involvement in International Development published by the Department of Health. And now that the Department of Health is publishing a revised Framework, called Engaging in Global Health, I think we find ourselves at another important moment. 

Two things stand out for me in this new Framework, the first is that engaging in global health can achieve institutional buy-in from the NHS but only if activities are properly organised and risk is managed effectively. If we can do this then we as a partnership community have an excellent case for demonstrating to the powers that be that what we’re doing is legitimate. The second is the recommendation for national quality standards as a starting point for building a wider consensus on what represents good practice in voluntary engagement in global health. So if what we do is of high quality then we can show that it is not only legitimate but it is also great value for all concerned. 

THET is currently developing a partnership standard which will support the community to not only help legitimise the work being done through partnerships but will also help partnerships showcase the quality of work as well. The standard will look at things like how strategic a partnership is, how well organised it is and how committed to learning. 

In our professional careers we all need to monitor and evaluate our projects and if you think about it we do it all the time in our private lives as well be it in relationships or with children. The partner I visited in Sierra Leone summed up why a key component of monitoring and evaluation is so important really nicely with the following, “Why is reliable data so important? As a basis for taking appropriate action”. And that’s it exactly, if we don’t reflect and learn we’ll keep on making the same mistakes. 

Professional development is another one of those areas that is often cited as a way of demonstrating quality and where well organised partnerships can really show-off to NHS boards. A nice example of how one partnership is tackling the question of how volunteers develop professionally is Thames Valley and Wessex Leadership Academy’s Improving Global Health programme. They’re using the NHS’s Leadership Framework to evidence what volunteers gain from their international experiences and to show how this experience benefits the NHS. 

An Improving Global Health fellow teaches with local health worker. Photo: Timur Bekir

An NHS Improving Global Health Fellow I met in Cambodia sums it up nicely, “I’ve been here five months and I think I’ve learnt more in this time about leadership and service development and all these really key skills than I’ve learnt in five years in the UK.” 

It doesn’t have to be a leap of faith to believe that engaging in global health is good for us all does it?

Developing Leaders, Improving Global Health is a new video from THET focusing on the impact NHS volunteers are having on healthcare in rural Cambodia. THET funds long term volunteers through the health partnership between Improving Global Health and The Maddox-Jolie-Pitt Foundation.

Working Together to Improve Child Health Across Africa

THET has produced a shot film documenting the work of The Royal College of Paediatrics and Child Health Global Links projects, which is funded by THET. The project seeks to improve child health and reduce child mortality in five African countries. With a special focus on Sierra Leone, we hear first hand from UK volunteers and African doctors who describe the achievements and challenges of this unique project.





Find out more about the project by scrolling down and reading an earlier blog about Global Links.

Improving Paediatric Surgery through Quality Improvement Methodology

Strengthening Surgical Capacity is a programme funded by Johnson & Johnson and managed by THET. Under the programme, a partnership between Great Ormond Street Hospital NHS Trust, UK and Queen Elizabeth Central Hospital, Malawi is using quality improvement methodology to improve paediatric surgery at QECH. 

In this blog, Dr. Bip Nandi, a United Nations Volunteer Surgeon and Consultant Paediatric Surgeon at QECH, details the work of the project and highlights the difference it is making. 

Queen Elizabeth Central Hospital, Blantyre, is Malawi’s largest referral hospital. As such the majority of Malawi’s specialist medical services are found here.

The paediatric surgical unit is one of the biggest units in the department of surgery with three full time paediatric surgeons. We serve a population of about seven and a half million children under the age of fifteen. That’s one surgeon per two and a half million children compared to one per seventy thousand in the UK.

Queen’s is a very special place. Despite being understaffed, underfunded and undersupplied we still manage about 500 major cases per year in paediatric surgery alone. These commonly include surgery for large tumours and complex congenital deformities. While we regularly run out of supplies such as gauze, gloves and antibiotics, we have the support of a 4 bed ICU. While we occasionally struggle to get X-rays, we often have access to free MRI (largely funded through research grants and private fees).

However, despite the lack of physical resources I believe our main deficit is human resources. One nurse may be responsible for 40 children on the paediatric surgical ward. Often there are no nursing staff in recovery. Twelve anaesthetic clinical officers have to cover six operating theatres, an ICU, and run an on call rota to cover emergencies out of hours. There are times when we have no interns on our unit.

Due to the volume of patients, lack of staff, and poor systems, children may sit on our wards for over a month waiting for an operation. We have enough surgeons at present, what we lack is availability of operating time and staff to provide robust care on the wards. Our operating lists are often overbooked, resulting in cancelled cases and children fasted unnecessarily. Some patients catch malaria while waiting and are cancelled again. Others get more sinister infections and suffer. Some even die waiting. Families may decide they have waited too long, that they can no longer neglect their other children, crops or livelihoods. They lose faith in the country’s hospitals and return to the traditional healers. Once children do get through the theatre doors, they may arrive without their investigations, or blood is not available in blood bank. This can result in further cancellation or waste of precious theatre time. In theatre I had started chronicling a series of ‘never events’. Events that should never happen. Antibiotics proven to reduce post-operative infections were sometimes delayed or not given. This means that post-operative recovery was further hampered. Patients were staying longer than they had to. This resulted in our wards being even busier, infections more common, stretched staff stretched even further, and patients suffering avoidable complications and even death. A vicious cycle, not because of a lack of skill or dedication, but because of poor systems and lack of staff.

I do not wish to paint a grim picture of Queen’s. What we manage to achieve with limited resources is remarkable, and we have many successes. However, we recognise that there is room for improvement. It is not within our power to increase staffing levels. However by improving our systems could we operate on more patients, more safely and have them stay on our wards for less time with less complications?

So in September 2012 Isabeau Walker a consultant anaesthetist at Great Ormond Street Children’s Hospital and I applied for the Johnson and Johnson Strengthening Surgical Capacity Grant. We attended quality improvement training at Great Ormond Street Hospital, London. There we met Liz Ball, Quality Improvement Lead for Surgery. She became the third member of our team, and we recruited Mark Clement advanced nurse practitioner on the Children’s Acute Transport Service (CATS), London.

The grant allowed us to fly the UK team out to observe our practise and work with us to help improve our systems. They worked closely with myself, Sister Mallewa nurse in charge of paediatric surgical ward, Sister Chizombwe nurse in charge of main operating theatres, Mrs Rose Kapenda anaesthetic clinical officer and Sister Saka nurse in charge of theatre recovery, as well as many others. I suspect they have learnt as much from us as we have from them.

Quality improvement involves the study of performance and implementation of systemic efforts to improve it. Improvements are made in an on-going cyclical process, using a mix of systems engineering and work place psychology.

Quality improvement methodology will tell you that staff on the ground best know the problems, and best know the solutions. Some will be exasperated in their inability to give the care that they want to give to their patients. Some will work against the odds, in subtly different ways, to produce good results. These are the ‘positive deviants’; our job was to find these people and to support them in their initiatives.

So on the final day of the first visit of the UK team we held an interactive ‘Introduction To Quality Improvement Workshop’. This was a unique event at Queen’s. For the first time we had professors, nurses, anaesthetic clinical officers, doctors, theatre staff and clerical staff, all discussing how they could work better together. The aim was to improve the care of children having surgery in Queen’s; it was an inspirational afternoon, producing over 30 suggestions.

The next year was involved in making some of these suggestions a reality. We prioritised 5 key issues that had emerged from the Quality Improvement Workshop:

1.       An integrated care pathway:

The main output was an integrated care pathway for paediatric surgery. A simple four page document designed by the people on the ground, in an iterative process. The first page is filled out before the patient leaves the ward for theatres. It ensures that the patient arrives in theatre with the correct information - demographics, blood results and investigations, consent and brief medical history. This is easily visible on a single page in an easy to find document. Use of the care pathway should result in fewer cancellations, safer operations and anaesthetics, and improved flow through theatre. It has also resulted in our doctors now spending more time consenting our patients. The second page is our own version of the WHO Surgical Safety Checklist. The third page is an operation note but with specific instructions for analgesia, drains and discharge information which we hope will improve safety and hasten discharge. The final page is a drug chart and forty eight hour observation chart. In our last audit the document is being used in 87% of elective cases, and while it is often not used well (a well reported phenomenon of checklists around the world), we are working on it.

2.       New Protocols:

We have adopted a new blood ordering protocol which we hope will mean fewer patients cancelled on the day because blood is not available and less wasted theatre time waiting for blood to be cross matched. We have a new reserve patient protocol, so children who have surgery cancelled are not fasted as long. We have a new protocol for dialysis patients undergoing fistula surgery and are developing a painful procedure protocol to manage pain on our wards.  

3.       Ward data and note keeping:

We now have a spreadsheet of patients on our wards with demographics, diagnosis and plan, and a daily senior ward round. With up to 60 children reviewed on a ward round, this should improve flow and length of stay, and perhaps even morbidity and mortality. We have spent a lot of time designing a tablet based system to replace this spreadsheet. If this works well it will further improve our workflow, safety and data collection. Often files are lost on follow-up. It is not uncommon to see a patient in clinic with a scar but no notes. We do not know what operation was done. This database will help us understand what has happened to our patients, and better plan future care.

4.       Basic equipment:

The Lifebox Foundation donated pulse oximeters which measure oxygen in the blood. Using money from the grant we purchased blood pressure, pulse and saturation monitors to help our nurses better monitor our patients post-operatively.

5.       Communication

Finally we have improved communication by introducing weekly meetings within paediatric surgery as well as meetings with nurses, paediatricians, theatre staff and lab staff.

Have these changes made a difference? Data collection is difficult in our environment as we are overloaded with clinical work. Despite this limitation we have been able to show improvements in our length of stay, timing of perioperative antibiotics and an encouraging trend in our mortality. We hope to present these results in detail in a scientific paper.

So what does the future hold? We must continue with our quality improvement work. The integrated care pathway is by no means embedded in our culture. If we stop now all the good work we have done will be undone. We must also complete development of the tablet based patient management system, something for which we have high hopes. We must continue with new developments. We need to find funding for all of these and to formalise the link with Great Ormond Street hospital, without whose assistance none of this would have been possible. I wish to thank them. I also wish to thank our staff who have committed to this process, the UNV staff at UNDP Lilongwe who have been supporting me, and THET and Johnson and Johnson who have made the project possible.