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 

Medical device challenges and global priorities

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

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

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

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

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

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

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

Linnet Griffith-Jones

Country Programmes Coordinator

THET 

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

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

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

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

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

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

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

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

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

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

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

Sarah Cavanagh

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

@SarahM_Cavanagh

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[1] https://www.greatgettogether.org/

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

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

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

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

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

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

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

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

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

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

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

Andrew Jones

Head of Partnerships

@aplj

Maternal and Child Health: Breaking barriers in rural Uganda

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

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

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

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

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

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

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

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

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

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

To read the full case story please click here. 

Edvige Bordone

Communications Manager, THET

@edvigeb

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[1] Total fertility rate in Uganda was 5.8 in 2014 http://www.ug.undp.org/content/uganda/en/home/countryinfo.html (Accessed online on 07/06/2017).