What you need to know about monitoring, evaluation & learning.

In this blog, Emily Burn, THET's Evaluation & Learning Officer, walks you through the key monitoring, evaluation and learning issues health partnerships should be addressing when planning projects. 

Recently I attended an M&E workshop held by INTRAC which brought together many M&E practitioners from the NGO and public sector to share challenges and solutions to common issues in M&E.  The detailed discussions led me to think about the over-arching principles that we should return to when we plan our M&E. Here I summarise the components of a good system for monitoring, evaluation, and learning, which health partnerships should think through when planning their projects.

Your Monitoring & Evaluation needs a rigorous system underpinning it

Your monitoring and evaluation activities need to be underpinned by an efficient system that enables you to focus your efforts and translate data into evidence and lessons.  An efficient system is particularly important to health partnerships which are operating with limited resources for M&E but which need to meet reporting requirements, and make the most of opportunities for learning.

So what does an efficient M&E system look like?

It is thoroughly planned

The project plan clearly articulates the change you want to achieve.  A Theory of Change approach will help you to see the logical flow of your objectives. For more information and a tool for using this approach see: http://www.thet.org/hps/resources/good-practice-guidance/project-planning-theory-of-change-1

You have discussed who your stakeholders are and the types of results they will be interested in, which means that you can plan the analysis, focussing on a limited number of questions that the data could answer, rather than all possible questions.

Each objective has ‘indicators’ (also known as signs of success or measures of progress) that are appropriate and feasible given the time, funds, expertise, and data (etc.) that you have access to.  Also, you know who will gather the indicator data, with what tools, and how frequently.  You know if the data collector has the expertise to do this or you have a plan in place to provide training. You know if you need to create a new data collection tool or if an adequate system is already in place that you can use.

You know how the data will be brought together in a central place. For example, you have an M&E focal person in each project site whose responsibility it is to submit health worker logbook data on a monthly basis (via email ) and then you have a central site where these data are entered into a spreadsheet, ready to be analysed.

M&E planning tool: http://www.thet.org/hps/resources/good-practice-guidance/monitoring-evaluation-plan

It is carried out consistently and in partnership

All those who are part of project implementation understand the objectives and buy in to the indicators.  This may require on-going review and adjustment of the indicators and milestones. 

You have a process in place to disseminate the project’s progress regularly so that those affected by the project understand what is going well and what is not.  The channels for communicating the results take into account the different project stakeholders, from NHS board members, to the staff on the ward, where the former may be most receptive to a presentation from the UK partner, and the latter may prefer to see improvements in practice displayed on a poster or mapped out on a chart in a staff area.

Lastly, an efficient M&E system facilitates learning by making full use of the findings to question how things are going, pinpoint problems, and so make changes based on evidence. At THET, our M&E system includes an analysis process that aggregates qualitative data into a simple spreadsheet where we group findings thematically. We see the benefits of this: when we write reports for our donors; when we need evidence of how best to support health partnerships; or when we need examples of, for example, positive changes in practice. In this way, our system for analysing and recording the data from health partnerships helps us to make use of it, in multiple formats, and for all our stakeholders. 

Discussing protocols at Kambia Government Hospital, Sierra Leone.

Anaesthesia training in Zambia - a volunteer perspective - part 2

Dr Lowri Bowen is currently in a 6 month volunteer post with the Zambian Anaesthetic Development Project (ZADP) working at University Teaching Hospital, Lusaka. In this blog she reflects on her time in Lusaka so far and the importance of not taking things for granted. 

My last blog centered firmly on the educational role of the Zambian Anaesthetic Development Project (ZADP), so this time I thought I would cover a different aspect of my work, which runs alongside the teaching and clinical supervision aspects.

I am sure that most people are familiar with the United Nation’s Millennium Development Goals – essentially a blue print of areas that’s been agreed on by all the world’s countries as essential to improve upon. There are eight of these but I wanted to focus on number 4 – decreasing child mortality.

There are many different ways to combat child mortality and there are many fantastic programmes going on all over Zambia and the world to this very end; however this is the start of our contribution towards getting to the goal of making University Teaching Hospital, Lusaka a safer and better place for children to have their anaesthetics. This is a particularly important topic, so why have I chosen to talk about this now, almost 4 months into my time here?

Well…..   Last week highlighted some of the most exciting times for me as a ZADP trainee. Despite plenty of interesting clinical work and really fulfilling teaching sessions over the course of that week I got incredibly excited about a door.  It does seem like quite a crazy thing to get excited about – I mean it’s something we use on a daily basis – it opens and it shuts and it serves it purpose but it’s hardly the highlight of anybody’s week usually.

So what type of a door was it?

The door in question is a plain, brown wooden door which I confess does not fire up the imagination. So why have I become so excited by this particular door?

If you think about it carefully a door is actually something that appears quite a lot in children’s stories and they are significant not by their appearances, but by what they contain behind them:

There is the wardrobe door to enter Narnia in ‘The Lion, the witch and the wardrobe”, the changing room door where Mr. Ben disappears into his various different worlds wearing his fancy dress outfits and, of course, who could forget the Alice in Wonderland door down the rabbit hole!

Behind my featured door is the new anaesthetic store room for the paediatric (children’s) theatre block.  It is where we will be able to safely store and register all the required equipment for the safe delivery of anaesthetics to children in UTH.  It means that we will no longer have to scramble around searching to find items that may or may not be present or kept elsewhere. We will be able to keep a detailed inventory of all the equipment which will allow timely ordering of things before they run out and also allow the theatres to have less equipment strewn around them and become a more ordered place to work.  This is a project that was started over a year ago. The main focus initially was to secure a storage area in the main theatre complex as there was nowhere for anaesthesia equipment to be kept apart from a small toilet block that regularly leaked and caused damage to vital equipment.

After much work and tireless negotiation by my previous colleagues, this was finally secured last June and since then has become well stocked and ordered with 2 of the anaesthetic MMeds in charge of it. Since this time we have secured a similar area in the emergency theatres and so when I arrived in August my remit was to focus on getting a safe area of storage for the paediatric theatre block. We quickly identified a store area but required a door to serve as a secure area for us to develop. Since this time (3 and a half months) it has taken painstaking negotiations with more people than I could ever have imagined being linked with the hanging of a door! Many a letter and meeting and cajoling visit to the workshops and purchasing departments all added to the momentum that could also be called just plain nagging! The help of the theatre matron was critical and with her additional nagging I think we managed to get the ‘project’ up and running. Initially the victory was getting a door frame placed, as there wasn’t one.

The frame getting placed and held up by batons as the concrete dries.

Once the frame was placed there was then the inevitable three week wait to get the plastering dry and the door frame procured  – no such DIY shop down the road here! So Friday was the celebration of conquering the beaurocracy and of all those frustrating weeks of doubt by the visualization of an actual door sitting in it frame!

The door! I am hopeful there may be a paint touch up at some stage, hopefully after the lock appears. 

There are still things to do – the little problems of a lack of a lock, clearing the space out as it has accumulated lots of ‘junk’ over the years, sort out some shelves, stock up and make an inventory are all in front of us… but this is most certainly a step forwards and a great achievement for the improvement of patient safety in UTH. To celebrate, we managed to decorate the walls of the recovery room and holding bay with some wall stickers that some friends had brought out for me – ok, this is not strictly a UN MDG 4 goal but it is important to provide stimulation and create a child-friendly atmosphere in the theatre block whilst the children wait for their surgeries. It was great to get all of the staff – from theatre porters, nurses, trainees, consultants and surgeons to give their opinions and to help in placing the decorations and become enthused over such a simple but important aspect of emotional care for the children.  As you can see from the snaps below the place looks a lot brighter now! I think both children and staff will enjoy being in the department a lot more now!

To find out more about THET's programme work in Zambia please visit our THET.org

Mental health training in Somaliland - Day 45

Tuesday 5^th November

Another early start, with the first stop being the beach! I have never seen the coastline in Somaliland, and it feels great to breathe the sea air. Then onwards to the mental ward once again. Today we spend time detailing what is available and what is happening on the ward, such as the numbers of patients locked in rooms, the numbers chained, trying to get some more sense of their diagnoses and the medications available on the ward. We speak to ward staff, who are mostly social workers with very little training in mental health. Many have only had three months training in mental health two years ago in Hargeisa and little since.

They all feel that they would benefit from further training. It is incredible really that they have all stayed on the ward for a number of years, despite not even receiving proper salaries. The ward administrator is very helpful and gives much of his time today to help answering questions about the general running of the ward.  It is interesting to find out how the ward runs, with so few staff. There are no trained nurses who work on the ward. Safety issues are striking. With so little staff and training, when patients become violent and wish to abscond, often they are left to go, as it is simply not safe to try and keep them there. Only two weeks ago, a watchman on the ward had boiling hot water thrown in his face as a patient tried to leave the ward. The watchmen have not had training in restraint techniques and so this clearly makes their job more challenging.

Though there is a doctor on the ward, we do not get the opportunity to meet with him today as he is away. He attends the ward from 7:30 am until lunch time each day. It is encouraging to see a system of clinical notes existing, though many are not written in any detail. I reflect on how challenging it must be to work here, without any senior supervision available.  The physical health of the patients remains a challenge, with very little input from doctors in the main hospital. They rarely come across to the mental ward whilst on-call, and so in emergencies patients are sent across to the main medical hospital. The patients only get their vital signs monitored on admission to the ward, and in an emergency. Their physical health is only assessed I am told, when the patients are noted to be unwell.  

We speak to a number of patients who report physical problems. It is clear that much could be done here to help both staff and patients. With better training, the staff would likely feel more able to manage the patients and also feel more empowered in their roles. I hope that we will be able to offer some input here in Berbera.

The journey back to Hargeisa from Berbera proves to be a challenging one. Rather than two and a half hours, we spend seven and a half on the road, and then end up back in Berbera! The road is flooded due to the rain running off the mountains and filling the rivers that the road crosses. We manage to cross two, though there is a real concern that if we try and cross any more, we may not make it across. We can see cars and trucks on the other side who have been impatient and ended up getting stuck in the sand. Many people are well aware of recent deaths when people have tried to cross, as often the waters rise and with such a strong current, cars get pulled downstream. We decide to turn back to Berbera to be safe, though then have to wait as the waters have risen in the rivers we have already crossed. We eventually get back and sleep soundly. 

Mental health training in Somaliland - Day 44

Monday 4^th November

Today we set off early as we are travelling north to Berbera. Berbera is situated on the north coast of Somaliland and as such has historically been an important strategic point due to its port. The drive up is beautiful and it is lovely to be on the road again. I adore being able to see some of the country as usually our movements are limited to between the hotel and places of work. We see many herders with their sheep and goats, lots of camels, including unfortunately those in trucks that shall apparently be exported to places like Yemen for people to eat and even wart hogs along the way. We pass through many villages along the way, with khat stalls still dotted along the way and people going about their daily business. We stop of at the Laas Geel caves on the way up to Berbera, a place I have wanted to visit for some time. These are a set of caves which feature beautiful rock art paintings, which are thought to be some of the best preserved in Africa. It was beautiful, we were taken up into the highest caves and I was amazed at just how clear the paintings were. There were paintings of people with their animals, including cows and dogs and even depictions of giraffes and pregnant women. The views from atop the caves across the arid land were stunning.

Onwards to Berbera and we stopped off briefly at a bakers, intimately tied up with a love poem written by a famous Somaliland poet. Then onto the most famous fish restaurant in Berbera, and home to many of the regions cats who were ready for any left overs.  We quickly checked into the hotel and then myself and film-maker Najaat went on to meet with the Regional health officer, Dr. Abdirahim. He was very helpful in giving us the details of the mental health service in Berbera at present. We join him on a visit across from the main hospital to the mental ward.

The psychiatric hospital is the only one in the whole of the Sahil region and Dr. Abdirahim tells us the population is about 220,000 people. There are no psychiatrists in the region and no trained mental health nurses. The work on the ward is done by ‘social workers’ who have been given some brief training by a medical doctor in how to administer medications and a doctor who spends each morning on the ward. There has been no formal mental health training in this region and the only doctor who was trained in the use of the WHO mhGAP approach has now left the region.

The staff manage on incentives rather than any formal salary and there are a number of watchmen on the ward. Though the ward is very positive in some respects, such as it having a large open area and shade structure, with electricity and running water available, it is clear that much could be improved. Patients are still chained, with five male patients seen to be chained to concrete pillars. The sanitation is poor and many patients are locked in their rooms, with waste draining from the rooms. Though it is very difficult to see, it is also easy to see the challenges faced by the staff here, who willingly dedicate their lives to helping those with mental illness, without proper salaries. With a shortage of trained staff, little in the way of money, a sporadic supply of medications and a rather challenging patient population when admitted to the ward, (often acutely psychotic or manic, with co-morbid khat use which often presents with aggression and violence) it is obvious that these people are trying to do their best under the circumstances. Though it is shocking, it is also positive to see that much could be changed and training would help immensely in order to effect this change. Tomorrow we shall visit the female part of the ward and speak to both staff members and the administrators to compile a comprehensive needs assessment report.

The day is wrapped up with a meeting with Najaat, who has been an incredible support during my time here, often tirelessly and enthusiastically shadowing me over the past 2 months, filming the work we do, so that the footage may be used to make a short documentary of THET’s work here in Somaliland. We work on the narration for the documentary, which she has asked me to do. 

Mental health training in Somaliland - Day 43

Sunday 3^rd November

Today is a day spent in the office, finalising the written report of the last two weeks teaching. Before this, I have breakfast with Mary-Jo and Eqbal and we all go to a local shop to search for camel bells to take back for friends as souvenirs. It feels rewarding to reflect on the last 2 weeks and in fact the last 2 months I have spent in Somaliland and I realise just how much I have managed to do in this time. I started by leading, with local colleagues, two TOT mental health skills training courses for interns and other health practitioners including nurses, in both Hargeisa and Borama. Then, with local colleagues, led revision teaching for the 6^th year medical students in both Hargeisa and Borama and simultaneously worked in partnership with local colleagues and both University Faculties on integrating further psychiatry into the medical students curriculum as a stand-alone clinical attachment. This included developing appropriate learning outcomes for the attachment and organizing suitable people to lead this project, both on the ground and also in UK, via the online learning platform Medicine Africa. This has now been accepted and shall start in November, which is a very exciting prospect as never before have the medical students had psychiatry as a clinical attachment.

The last month has been spent in Borama, and the past two weeks has been taken up with the annual teaching of the 5^th year medical students. Next stop, Berbera! Tomorrow we shall travel up north to undertake a needs assessment of the mental health services available there, in order to see whether THET might be able to offer any assistance with training and in other ways. 

Mental health training in Somaliland - Day 42

Saturday 2^nd November

Up bright and early to leave the hotel that has become my home for the past month. We say goodbye to all the wonderful and friendly staff, who have made our stay such an enjoyable one. The journey back to Hargeisa is beautiful, with the feeling of space all around us. Once back in Hargeisa, I meet with Mary-Jo, my great colleague and friend, and also nurse co-lead for the mental health group. It is such a great joy to see her here finally, as we have never yet been in Somaliland at the same time. She is leaving tomorrow, though we both feel lucky for having had the opportunity to spend at least a night together. We have a lovely dinner with the THET team and other friends.

Mental health training in Somaliland - Day 41

Friday 1^st November

Today was a rest day, and a day to round things up. I was lucky enough to be invited to a female student’s house for a wonderful lunch. Hayat had prepared a feast! We were joined by all the ladies who attended the course, which was a fantastic opportunity to get to know them better. It was a delight for me to have the opportunity to spend this time with my new friends. Later, myself and Mandip had a consultation with the sister of a student, who had epilepsy that was not well controlled and may also have had some anxiety. We were then joined by our friends and colleagues. Then the time came to say goodbye, until next time.

I have been so impressed by the warm welcome I have received from everybody in Borama, I really felt like part of a family here and know that I will return. Su’ed returns from Hargeisa where she will been doing a nursing TOT course with Mary-Jo who has now been in Somaliland for over a week. She is pleased with the course.  We have a very nice send off from all our friends and both Mandip, Jibril and I are thrilled with the outcome of the course and how it has all gone to plan.  Lastly we do a little work on Jibril’s presentations, as soon he is off to Mogadishu to present at a large health conference. It is an exciting opportunity to present all the incredible work he has done in Somaliland. 

Mental health training in Somaliland - Day 40

Thursday 31^st October

Today is the final day of the course. We spend the morning giving out exam feedback to the students and also feedback from the OSCE. The students have all thankfully passed, and in fact, many have passed with very high marks. We are particularly pleased with the progress many of them seem to have made since the beginning of the course. Many have much higher marks on the post-tests than they had on the pre-tests, which is great for us to know as teachers. They are a competitive group and despite very high marks, some think they could have done even better!

Today is a day of Somaliland Psychiatry and we are lucky to be joined by Fatima, the Dean of Nursing, who has been a truly inspirational figure here in Borama in very many different ways, but particularly in mental health. She gives a talk about the development of mental health services in the region and Dr. Jibril then presents all the work he has tirelessly been doing over the last 4 years. It really is incredible what this team have achieved. They have started mental health services from scratch, and integrated the services into primary care, maternal health care and child health. This makes sense for such a community, where most people visit traditional healers or sheikhs before they ever come to the attention of a doctor. The team has mobilized the community, including sheikhs, schools, even the prisons and police, to raise awareness of mental health issues. The Somali diaspora population connected to the area have also been involved heavily, particularly in the development and continued running of the mental health ward at Borama Regional Hospital.

I am astounded by the work that has been done here, much of it on a voluntary basis by Dr. Jibril. We hear of stories of him and Faadumo, walking all day in communities, just to go and find people with mental illness and offer help. We hear of certain cases in the region which really make one realise how crucial it is for change to happen. Dr. Jibril tells us of a family in which there were a number of family members with mental illness. They were ostracized from the community and due to being so poor could not afford food. Due to their mental illness, they were unable to work. Unfortunately three family members starved to death. This represents the extreme end of the picture, and we also heard very positive stories of similar families being helped by the community to live and eat. It was clear that much change was happening in Borama and this was a joy to hear. Finally, we give out the certificates to all the students and all the co-facilitators. The day ends early as the students prepare for the evenings celebrations, and we cannot finish the morning without many many photographs!

The evening is wonderful. As is tradition in Borama, my female students dress me up in traditional Somali dress. This year is a beautiful pink and purple dira (dress), and Hayat. One of the students spends time fixing me up an elaborate head scarf with multiple colourful scarves weaved together. As I walk past people I know in the hotel to go to the party, I am not recognized!

The celebration is a fantastic event. We are all at the University faculty, with the stage set outside and trees in the background. The students have decorated the place beautifully and it looks ornate. The evening is led by one of our female students Nasra, and many people make speeches, though I am touched especially by the student contributions. I had stated that I love poetry and had requested that one of our students, Jama, prepare 20 minutes of poetry for the end of the course, as he was an extremely talented poet. He recited a 6 page poem that he had himself written. I was stunned. He talked about a man who was apparently psychotic, about the challenges of mental illness and the loneliness it often results in, and went on to talk about the capacity people have to make change. He also talked about suicide and the issues related to this in the Somaliland context.  His recital was stunning, insightful, clever and also humorous in parts and I truly felt privileged to have been witness to this. We were also read another poem by a female medical student and even a song by one of our co-facilitators, Hodan. Her voice was incredible and you could have heard a pin drop when she sang. One of our students was in fact a Sheikh and also read a poem. He commented that as my name did not quite fit with the words of the poem, he would have to give me a Somali name.  This was ‘Cawo’ (pronounced Ao) which means lucky or luck. I felt absolutely blessed and lucky! What a gift to me this was! Finally the evening was rounded up with a wonderful traditional Somali dinner, which was delicious and then…..photos! The night was long and a happy one for all and one I shall never forget. The hospitality and the welcoming of everyone was just beautiful. 

Mental health training in Somaliland - Day 39

Thursday 31^st October

Today is the final day of the course. We spend the morning giving out exam feedback to the students and also feedback from the OSCE. The students have all thankfully passed, and in fact, many have passed with very high marks. We are particularly pleased with the progress many of them seem to have made since the beginning of the course. Many have much higher marks on the post-tests than they had on the pre-tests, which is great for us to know as teachers. They are a competitive group and despite very high marks, some think they could have done even better!

Today is a day of Somaliland Psychiatry and we are lucky to be joined by Fatima, the Dean of Nursing, who has been a truly inspirational figure here in Borama in very many different ways, but particularly in mental health. She gives a talk about the development of mental health services in the region and Dr. Jibril then presents all the work he has tirelessly been doing over the last 4 years. It really is incredible what this team have achieved. They have started mental health services from scratch, and integrated the services into primary care, maternal health care and child health. This makes sense for such a community, where most people visit traditional healers or sheikhs before they ever come to the attention of a doctor. The team has mobilized the community, including sheikhs, schools, even the prisons and police, to raise awareness of mental health issues. The Somali diaspora population connected to the area have also been involved heavily, particularly in the development and continued running of the mental health ward at Borama Regional Hospital.

I am astounded by the work that has been done here, much of it on a voluntary basis by Dr. Jibril. We hear of stories of him and Faadumo, walking all day in communities, just to go and find people with mental illness and offer help. We hear of certain cases in the region which really make one realise how crucial it is for change to happen. Dr. Jibril tells us of a family in which there were a number of family members with mental illness. They were ostracized from the community and due to being so poor could not afford food. Due to their mental illness, they were unable to work. Unfortunately three family members starved to death. This represents the extreme end of the picture, and we also heard very positive stories of similar families being helped by the community to live and eat. It was clear that much change was happening in Borama and this was a joy to hear. Finally, we give out the certificates to all the students and all the co-facilitators. The day ends early as the students prepare for the evenings celebrations, and we cannot finish the morning without many many photographs!

The evening is wonderful. As is tradition in Borama, my female students dress me up in traditional Somali dress. This year is a beautiful pink and purple dira (dress), and Hayat. One of the students spends time fixing me up an elaborate head scarf with multiple colourful scarves weaved together. As I walk past people I know in the hotel to go to the party, I am not recognized!

The celebration is a fantastic event. We are all at the University faculty, with the stage set outside and trees in the background. The students have decorated the place beautifully and it looks ornate. The evening is led by one of our female students Nasra, and many people make speeches, though I am touched especially by the student contributions. I had stated that I love poetry and had requested that one of our students, Jama, prepare 20 minutes of poetry for the end of the course, as he was an extremely talented poet. He recited a 6 page poem that he had himself written. I was stunned. He talked about a man who was apparently psychotic, about the challenges of mental illness and the loneliness it often results in, and went on to talk about the capacity people have to make change. He also talked about suicide and the issues related to this in the Somaliland context.  His recital was stunning, insightful, clever and also humorous in parts and I truly felt privileged to have been witness to this. We were also read another poem by a female medical student and even a song by one of our co-facilitators, Hodan. Her voice was incredible and you could have heard a pin drop when she sang. One of our students was in fact a Sheikh and also read a poem. He commented that as my name did not quite fit with the words of the poem, he would have to give me a Somali name.  This was ‘Cawo’ (pronounced Ao) which means lucky or luck. I felt absolutely blessed and lucky! What a gift to me this was! Finally the evening was rounded up with a wonderful traditional Somali dinner, which was delicious and then…..photos! The night was long and a happy one for all and one I shall never forget. The hospitality and the welcoming of everyone was just beautiful. 

Mental health training in Somaliland - Day 38

Wednesday 30^th October

Today is the day for the OSCE examination. The students complete their post-course MCQ exam first thing and we leave the co-facilitators to collect papers, whilst myself, Mandip and Dr. Jibril, with the mental health reps Zainab and Abdirahman, go to practice the OSCE stations with the actors.

It is vital that we all standardize our marking, and also the acting, so that each student is fairly examined. We spend much time doing this and are pleased that our individual marks correlate with one another. We are joined by some 6^th year medical students who have kindly offered to volunteer their time to act as patients for the medical student exam. This is also good practice for them, as through acting, one often learns more about the OSCE, what questions are asked, what sound good in an exam scenario and so on.

The whole day goes impeccably, with Aidrous, one of the 6^th years, acting as the most important figure of the day- the time-keeper. The students all turn up on time and thankfully all goes to plan. The evening is spent as a team, with the co-facilitators, marking the examinations and finally inputting data to our spreadsheet. With 68 students, this is a mammoth task and we are so thankful for all the support and help. We all finally end the day with a dinner together at Ray’s. The certificates are written just before bed, which means a late night!

Mental health training in Somaliland - Day 37

Tuesday 29^th October

Business as usual. Today I go to the mental ward with the two mental health reps, Dr. Zainab and Dr. Abdirahman.  The students have the opportunity to meet with two patients and each rep gets the opportunity to lead a ward visit with the students. I am pleased that they have this opportunity as it is something we practiced during the TOT training that they were both part of. Again, I am thoroughly impressed by their leadership and ability to enthuse the students. I have been really impressed throughout the two week teaching at their hard work and commitment, along with their preparation for all their lectures/presentations and their knowledge.

We meet patients on the ward with diagnoses of schizophrenia and Bipolar Affective Disorder. I am always interested to find that the symptoms of schizophrenia present in just the same way and are described by people very similarly to how they are in the UK. It is also interesting for the students as sometimes believing that the theory learnt in psychiatry is true in real life is difficult.

This man presents with thought broadcasting and clear third person auditory hallucinations. It is a joy to see the patients face light up when he finally feels understood by the students asking him questions about his symptoms, and their faces light up when they are presented with the very symptoms that they have learnt about this week. One student comments that his view of mentally unwell people has been completely challenged and changed during this two week course. Before today, he had never been on a mental ward and neither had he wanted to go on one. He stated that now he is no longer scared of people with mental illness and views them just as he does any other person. It is an absolute joy to know that in only a two week teaching course this can be achieved.

On the way back from the ward, I reflect on how amazed I am at the students’ ability to study their entire medical degree in English. This is not any of their first language and I consider just how tricky it must be to not only learn  the new ‘language’ of psychiatry during this two weeks, but also to have to flit back and forth between Somali and English whilst seeing patients and then presenting their cases and doing exams. All the facilitators would agree that we have been very impressed with this group.

Good news upon our return. We find out that the mental ward has won a prize! They have been voted best ward in the hospital! Everyone is overjoyed. This is great news and is testament to just how hard working the team on the ward is. Dr. Gurguurte and Dr. Jibril grin widely, as does Faadumo and then we also find out that Suad, the chief nurse on the ward, has also won a prize, for best nurse! This is great and illustrates that the mental ward and their service are setting a precedent for standards that should be achieved on wards in the hospital. Their prize is $1500 and we all smile when we hear from both Dr. Jibril and Dr. Gurguurte what the money will be spent on. Without hesitation, both of them grin and say, ‘we can buy more medications for our patients!’

I am, again, thrilled by the enthusiasm, dedication and kindness shown by the team here who work with people with mental illness. They often work beyond their hours, and treat patients for free, as evidenced this week by Dr. Jibril consulting with numerous community patients we have seen after the students have taken their histories, for free. What a happy day! We end the evening by meeting again with all the co-facilitators and running though the plan for tomorrow OSCE examination. We have to examine 68 students, each doing two OSCE stations each and so we know we will have to run like clockwork to make it work. A big day tomorrow. 

Mental health training in Somaliland - Day 36

Saturday 26^th October

Dr. Idiris, one of our intern doctor co-facilitators, begins the re-cap this morning. We are all impressed by how he manages to control the class and with the confidence he shows when teaching. Today we have nine community patients joining us and Dr. Jibril visits the mental ward with the students. The case mix is interesting and varied, with cases of psychosis, psychosis associated with khat use, depression, learning disability, epilepsy, possible ADHD or conduct disorder in a child and a child with epilepsy, whose mother believes she has been possessed from ‘djinn from the sky.’

The beliefs and stigma associated with epilepsy are akin to those for schizophrenia or psychosis. There is huge discrimination against people who suffer with epilepsy and Dr. Jibril’s talk on organic disorders today illustrates this with cases he has seen. Epilepsy is not considered a neurological disorder for many here and so comes under the remit of psychiatry. Dr Jibril describes a case where a young boy with epilepsy was forced out of school as he kept having seizures and these resulted in incontinence. His teachers allegedly spoke of him as ‘crazy’ and asked his parents to remove him from school. We hear of many other fascinating cases from Dr Jibril. He reminds the students that not all seizures are in fact epilepsy and uses the example of a case of a young girl who presented with seizures and was treated with benzodiazepines; however, it turned out that she was in fact pregnant and had eclampsia. She died as she did not get the treatment she required due to mis-diagnosis.

It is a real joy to have Dr. Jibril here with us this year and we are so grateful to him for having organised the whole set-up of the teaching this year. His teaching is excellent and is a great person to be able to present real life examples of cases to the students. I know that I will never forget the examples he has used in his lectures. He really managed to bring alive the topic in a way that few here could. I am genuinely impressed by his knowledge, teaching skills and commitment to his career as a doctor/future psychiatrist.

Mental health training in Somaliland - Day 35

Friday 25^th October

Today is our day off - time to breathe and think a bit about how the teaching is going and whether we might change anything to improve it. One of our main challenges is the high number of students this year, which means that organizing them into groups can be tricky; however, we are all pleased with how the teaching is going so far. Today we meet and draw out a timetable for the OSCE examinations that the students will all sit next week. This is crucial, as for this to work for 68 students, our logistics will have to be impeccable!

Aidrous, a 6^th year medical student who I taught in May this year is thankfully helping us with acting and organizing the other actors, and we decide to run three separate circuits of two OSCE’s, with six markers in total. 

Mental health training in Somaliland - Day 34

Thursday 24^th October

Today’s teaching was a success. It was the first day that the medical students met with patients. Faadumo brought in 10 people with mental illness, who kindly volunteered their time to speak with the students. I, along with Zainab, the mental health rep, also took a group of students to Borama Mental ward, where they had the opportunity to take a history from a patient. This means that all the students will get both an experience of meeting with patients from the community, and also more acutely unwell patients on the in-patient ward. This for some of the students, is the first time they have met with and spoken to a person with mental illness in this context. Many are scared and wonder what it will be like.

It is a joy to witness the students talking with patients and showing respect and curiosity when taking their histories. Even more wonderful is to witness the change in the students when they return from seeing the patients. None of them now say they feel worried about meeting people with mental illness and many of them have clearly been challenging their own beliefs about mental illness whilst taking histories. Faadumo and Dr Jibril have done a fantastic job at managing to arrange this learning experience for the students, for it has taken a lot of organisation. Again today, I am thrilled to see the mental health reps presenting and Abdirahman does a great job with his presentation of mood disorders. Mustafe led the re-cap session and also did a fantastic job. I really am impressed by their teaching skills and their preparation and confidence.

As a short exercise, I ask students to write out cases of attempted suicide or suicide/self-harm they have witnessed or heard about. It is sad to find that every student has a story to tell, of a neighbour, a friend, or a relative. Many have seen neighbours who have attempted suicide. Most often, the cases the students describe are women, 69%, but it is striking that 31% of cases they report are also men. The most common method of attempted suicide or suicide is burning, though also interestingly, there are other methods used such as hanging, shooting, pesticide poisoning and also drug overdose. The students also point out how much stigma results from such acts, with those who have attempted suicide being ostracized and discriminated against. 

Mental health training in Somaliland - Day 33

Wednesday 23^rd October 

We began the psychiatry teaching in full force today, with lectures and discussions around history taking, mental state examination, suicide and risk assessment, as well as psychosis/schizophrenia. I am so impressed by the teaching skills of our co-tutors. Dr. Hodan leads our morning re-cap session and is excellent, well prepared, clear, audible, enthusiastic and informative. She began the day well and the students were clearly enthused by her teaching.

Dr. Abdirahman, one of this year’s mental health representatives gave a talk on how to take a history and perform a mental state examination and, again, had prepared well in advance. He was logical and clear in his approach and was able to answer questions from the students with no trouble at all. I was impressed by his ability to really push the students and test their learning. Dr. Zainab talked about suicide and risk assessment, a very sensitive topic in Somaliland, which she handled with ease and also with a great degree of insight, in terms of the local Somaliland context. She generated some very interesting discussion surrounding why people commit suicide or attempt suicide in Somaliland. We do a number of group exercises with the students which work well and it is great having nine of us to facilitate the group work. It means that the students have the opportunity to hear from different teachers and our co-facilitators this year include more intern doctors - Drs. Idiris, Hassan and Mustafe. 

Dr. Jibril is our lead co-facilitator this year, as an experienced previous mental health rep himself and his case histories and ability to talk about psychiatry in the Somaliland context is a great addition to the teaching. We learn from each other and for me, it makes the whole experience even more exciting, the more times I visit Somaliland, the more I learn about the culture and how psychiatry fits in within this context. We are also pleased to be joined by the Head of Medicine, who is curious to see how our teaching is organized and presented. And Faduumo and Su’ed, two mental health nurses who recently also attended the TOT training. The students enjoy the day and we end with Mandip leading discussions about psychosis and us utilizing the WHO mhGAP-IG to guide assessment and management of disorders. This is something we have used since last year and now underpins our medical student psychiatry teaching. I am reminded just what a privilege it is to be able to do this teaching, alongside my Somaliland colleagues, who have impressed me so much today. I can easily see these tutors as leaders in their chosen fields in the future.

Mental health training in Somaliland - Day 32

Tuesday 22^nd October

The first day of teaching sixty-eight fifth year medical students! We meet early to prepare the room and get ready for the students. This is an exciting, though slightly daunting, day. We are all aware just how many medical students we will have to manage during the next two weeks and though we have been planning for a long time, we hope things go smoothly. Today is about introducing the students  to psychiatry and mental illness, and setting the scene for the next two weeks. We ask the students to all write down a case of mental illness they have seen. Most of them recall cases of psychosis, which is the usual pattern and perhaps unsurprising as many of them have witnessed people with acute psychosis on the streets at some point. 


It is fascinating to hear the beliefs surrounding mental illness that the students voice. Many are scared of people they feel are ‘mad,’ others say that as children they felt that all people with psychosis were ‘killers’ and some admit that as children they would throw stones at people who were mentally unwell. They agree that many people with psychotic symptoms are thought to harbor ‘djinn’ or ‘evil eye’ and as such are ostracized from their communities, as are their families. We suggest that they keep in mind these beliefs as the two weeks progresses, and to think about whether these have changed or not during the time of teaching, and meeting people with mental illness. We take time today to talk about professionalism- as this is an important part of the teaching we offer. We also teach on communication skills, in preparation for students meeting patients and also trying to do psychiatry OSCE’s. The class is large, though we are impressed with their interaction and participation.

Mental Health Training in Somaliland - Day 31

Monday 21^st October

This morning we attended Dr. Walhad’s teaching workshop in the university faculty, and then together we prepare things for teaching tomorrow. Later in the day, we are joined by another doctor from the UK, who will co-teach during the next two weeks. As a team, we all meet together in the evening, to plan the first day tomorrow. It is great to be in a big team of teachers this time, with many of the co-tutors having just been participants on the TOT courses. I am positive about the teaching and we all look forward to it. The students have all arrived from Hargeisa and are warmly welcomed by their peers from Amoud University. For many of them, this will be the first time they have been out of Hargeisa and as well as this being a learning experience, it is also the opportunity for them to mix with their peers and make new friends and future colleagues. I am always impressed by just how much effort both students and faculty makes to welcome visitors to their town and University, and it happens in both Hargeisa and Borama. I also feel truly welcomed, though more like a familiar face when they say I am now like a ‘doctor of Borama.'

Mental health training in Somaliland - Day 30

Sunday 20^th October

This morning was spent meeting with Dr. Jibril. We discuss his upcoming residency, his career plans, the medical student teaching, a paper we will co-write about our recent TOT training and various other areas. We are met by Dr. Abdirahman Gurguurte, the other doctor who works on the mental ward here, and have a good discussion about psychopharmacology and issues surrounding poly-pharmacy. It is very interesting here that, as I found out from nurses, it is often looked down upon if a doctor should check their BNF for a drug dose before prescribing. As such, doctors may often avoid doing the check. I tell stories of the chief pharmacists in the UK always carrying around their Maudsley Guidelines or BNF and often checking them before giving advice, to try and encourage this sort of practice.

The discussion is lively, useful, and I am also taught much by these two. I hear the stories and of the work that went into ensuring the mental ward was built last year. The community initially wanted the ward to be placed a number of kilometres from the main town, though eventually there was an agreement to have it on the hospital site, much more appropriate and useful to the patients, who often need lab tests and medical care. I hear about the experience these doctors have had working in different parts of the country and the varied challenges they faced during their training and work. Most of all I am impressed by the enthusiasm, dedication and love both of these doctors show in their work with mentally ill patients and they I walk with them to teach our 6^th year medical students inspired by their commitment. We have a good afternoon practicing OSCE stations and Dr. Jibril chooses the cases this afternoon. We concentrate on documentation as a task, as this is something that can be improved in every area of medicine and having the students practicing it now is useful. 

Mental health training in Somaliland - Day 29

Saturday 19^th October

Today I meet with Dr. Jibril, Dr. Zainab, Su’ed and Faduma on the mental ward at the hospital. We do a ward round together and use it as a learning experience. Dr. Jibril presents the new admissions that he clerked two days ago and together we all discuss the management decisions. We are trying to encourage an atmosphere where discussion together among nurses and doctors is usual and where each member of the team may ask questions related to management decisions, if they are not clear or do not agree with proposed plans. Though there is often a very clear hierarchy between doctors and nurses here, I am impressed with how the team works together. Dr. Jibril consistently empowers the nurses that work alongside him and values their importance.

One of our main discussion points again today is prescribing.  I realise just what a difficult position these doctors are in; working hard on the ward without any senior supervision on the ground. Though Dr. Jibril is supervised online by a number of international doctors and makes great use of this, there is nothing like having someone there, face to face to discuss things with. I wonder how I might manage if I were in his position. I have great admiration for them all.

I also begin to understand better why patterns like polypharmacy and high dose prescribing of antipsychotics become routine here. It is easy to say that it is wrong, though considering that there is no supervision available, very few staff available to work on the ward and very high risk patients, perhaps it is understandable why this is resorted to. Patients tend to be prescribed high dose antipsychotics and even depot antipsychotics on admission to the ward, when the diagnosis may still be unclear. Our discussion is very helpful and Zainab, who will be taking over from Jibril when he leaves for his upcoming residency also finds it useful. She will also be here with only international mentorship to help guide her management of patients. Again, I see photographs of patients who are now on the ward who have been chained. During the ward round, one patient tells us a story of how he was chained by his wrists/hands when unwell and chained to a tree, very high up, for 7 days. He was taken right out to the border of Djibouti and Somaliland and left there, like this. Now, the man was calm, coherent and very pleasant and I felt so sad that he could have been treated in this way simply because he had a mental disorder. Essentially tortured, as Jibril pointed out.

There was a very interesting case presented by Jibril, a new admission to the ward. The most striking feature was his substance misuse/dependence, his extremely traumatic history and his significant risk to others. In the UK, this man simply would not be on this type of ward. He would be in secure forensic services, detained under the Mental Health Act and likely the Consultants looking after him would be answerable to the DOJ. Here there is no Mental Health Act, no forensic services, no seniors to guide management. So this patient was being managed on the ward.

I was thrilled today as I had the opportunity to visit the community mental health service. Fadumo the nurse leads and teaches ten community health workers who are trained in mental health, child and maternal health. We visit the community in which they work in Borama. Jibril tells me it is one of the largest slums in the area and houses around 37,000 families. I am lucky to be able to meet with the community health workers who do such fantastic work in this area. They are all females, and have been selected as they live within the community. They are trained for 3 months and then work closely with Fadumo. They find people with mental illness in the community and encourage them to attend appointments in the community with the doctor, or Jibril visits them in their homes with the nurses. They do a lot of psychoeducation work, which they say they feel has spread through the community. This helps to reduce stigma surrounding mental illness and therefore to lessen practices such as chaining and they report that chaining has decreased in the area they work in the time they have been there. It is interesting to hear one CHW comment on how before she began her job she too would throw stones at people with mental illness, though now loves to see people get better with treatment and really values her role and job. It is so positive to see this kind of work happening in the area. 

Mental health training in Somaliland - Day 28

Friday 18^th October

Today was officially the weekend, though we decided to meet as the mental health group, in view of a lack of time available before the 5^th year teaching next week. Myself, Dr. Jibril, Dr. Zainab, Dr. Gurguurte and Aidrous all met as a group. This was the first meeting of this kind in Borama and it was a delight to spend time with the group and discuss matters to do with mental health. The team here are very keen to be involved further and we had an interesting discussion to start with about psychopharmacology and importantly, poly-pharmacy, as it is so often used here. This proved to be useful and we agreed to continue the talk tomorrow on the mental ward, whilst looking at real patient notes. We discussed the potential plan for further integration of psychiatry into the 5^th year medical student curriculum and also discussed further potential input that could be offered, in terms of mental health. Following the meeting, I meet with Zainab, the mental health rep and we discuss and review the lectures she will present next week as part of the medical student teaching. 

Anaesthesia trainee in Zambia - A volunteer perspective.

Dr Lowri Bowen is currently in a 6 month volunteer post with the Zambian Anaesthetic Development Project (ZADP) working at University Teaching Hospital, Lusaka. She will enter her final year of anaesthetic training on her return to the UK in February.

The MMed programme has currently taken its third intake of trainees destined to complete the four year course and become Zambian trained Physician Anaesthetists, which is very exciting. The ZADP mandate has many different guises so I am frequently seen changing my hats of responsibilities! It incorporates teaching on the MMed programme as well as clinical officers (which I’ll touch on later) mixed in with trying to coordinate the department’s patient safety initiatives, resources, and equipment and governance issues.  I know this already sounds hectic – I’ll try and just give a flavor of the supervision, clinical and teaching aspects in this installment!

Monday morning. The day starts as usual with the 20 minute bicycle ride in to work alongside Dr. David Snell, the in-country lead, which is pleasant due to the temperature being cool at 7am (in contrast to the 32C in some theatres by midday). It’s a chance for some exercise and also a great time to plan the day ahead and to debrief on the way home.

I was supervising a second year trainee with a very interesting (to anaesthetists) maxillofacial case who had a HUGE swelling (most likely tumour) over his jaw extending right up to his cheekbone and slightly to the side of his eye (parotid/maxillo/temporal) area. Looked like he had mumps! Anyway he managed to open his mouth a mere 2cm and then I could see that the whole back half of the right side of his mouth was also involved so there was barely any room for doing anything there - never mind the potential bleeding risk. His jaw movements were also pretty non-existent. So goodness knows how he was eating anything solid. So, although I was the supervisor, it was time to phone a friend and off I went to find David. The three of us, Dave, the trainee and I, concocted a pretty robust plan, which included further plans B, C and D to cover all eventualities and scurried around to locate all sorts of equipment that may have been helpful. In the UK this case would have had a specialized fibreoptic guided intubation with the patient awake or a few other more complex options, which are not available to us here. So we had settled on using an inhalational induction (breathing the anaesthetic) to get him off to sleep and then placing the laryngoscope in the left side of the mouth; usually we place the blade in the right side of the mouth – but this was physically an impossibility. We had also insisted the maxillofacial surgeon to be ready for action with his knife to place a tracheostomy if all the plans failed.

Meanwhile the maxillofacial surgeon had clearly got bored of our detailed planning and decided to cut out the middle men (i.e. us) and put in a tracheostomy under local anaesthesia! So there we were - a functioning airway without the stress for us! Once he had secured the tracheostomy we could begin the anaesthetic, which was then thankfully uneventful. Once he was asleep I looked in his mouth with the laryngoscope to see what would have happened had we not placed the tracheostomy in him and actually had a pretty good view of his vocal cords - grade 2a. However, the whole planning and preparation for a difficult airway was something the trainee remarked on being a great learning experience for her (me too I thought as thinking of all eventualities out here isn’t always easy!)

I have been up and back to Ndola in the Copperbelt with another of the trainees a weekend or so ago. That was an interesting ride at night. Amazing amount of trucks and lorries. Some with and some without lights, some dangerous and some not. Some cars in ditches and some not, some pot holes and some speed bumps and some dusty off road bits but a rich pattern of life along the Great North Road. I can now easily comprehend why so many of the emergencies and resulting fatalities in UTH are road traffic accidents.

We are due to teach a Primary Trauma Course aimed at managing trauma in low resource settings – and is pertinent as it is one of the highest – if not the highest cause of deaths in Zambia. Running these courses is great as it will increase the numbers of doctors from all sorts of specialty backgrounds to be able to deal with trauma in a safe and uniform way but it also encourages Zambians to take ownership of teaching on their own courses. After a successful first course last year in Lusaka this will be the second course to be held in Zambia and will have newly trained Zambian instructors teaching on it. A particular delight to me is that one of the anaesthetic MMed trainees is one of the leads in the organization of the course. This is incredibly encouraging for the future of the course and will have further far-reaching benefits for further course developments in Zambia in the future. So as we had lots to do in Ndola and ran out of time, we came back in the dark again - via a wrong turn that almost took us to the Congo, which even I agree probably would have been dangerous!

My Monday afternoons have been devoted to teaching the MMed's alongside David. This is my favorite teaching job as it is the day where we teach our newly started ZEST sessions - Zambian Emergency Simulation Training! Zest as in lime - refreshing and new, a twist on the conventional teaching methods. The sessions are run in the nearby medical School skills lab, which has a few basic resuscitation dummies, which enable a good range of clinical scenarios to be practiced.  We usually run a few scenarios using an ipad bluetoothed to the iPhone as a remote control monitor to show observations that change according to the interventions done – so it’s as life like as possible. The origin for it came after one of the trainee’s asked if we could do a session on defibrillation (electric shock to the heart) as none of them had ever defibrillated a live patient (or dummy for that matter). This in itself is an interesting and eye-opening fact however when thought of in the context that there are no monitors or defibrillators on any wards except Intensive care (and obviously theatres) I guess most cardiac arrests are not identified as those that can be shocked or not. I do think the Vinnie Jones basic life support ‘Staying alive’ video has a role to play out here! The trainees seem to enjoy it though and are now feeling more confident to tackle any such eventuality! Anaphylaxis up next week….  

I have also got a slot teaching the clinical nurse anaesthetists every other Friday. These guys are not linked to the MMed programme and are not medical doctors. They do a basic physician helper training course and then that is topped up by a two year training in anaesthesia before potentially travelling all over Zambia to deliver anaesthesia. So far I have delivered two sessions and it has been well received and enjoyable to me. In fact I am humbled by their thirst for knowledge. I was worried in the first session as they are all required to attend teaching in their shirts and ties and wear their clinical white coats fully buttoned up. Combining this and the midday heat after a few of them have come straight from a night shift I was totally amazed that the attendance has been 100% and that only one person has exhibited heavy eyelids for a few minutes!

I have found working in Zambia fantastic so far. Yes there are frustrations but the overwhelming positivity stems from the hope for the future and the current batch of MMed trainees (as well as the small interaction I have had with the clinical officers) are certainly giving me plenty of hope for this end.  The staff at the hospital have been very accommodating and friendly, and my Nyanja is coming on leaps and bounds! It is truly a wonderful part of the world to live in and I am very grateful for the opportunity to be here and would like to thank not only the MMed trainees but also the local anaesthetic consultant faculty, the theatre and ICU staff as well as THET for allowing me to transition to life in Lusaka so smoothly. I am looking forwards to an interesting few months and hope to continue with a few further blogs of the programme in due course.

Mental health training in Somaliland - Day 27

Thursday 17^th October

The morning is spent visiting the mental health ward with Dr. Jibril. I join him for the ward round, alongside nurse Su’ed and Fatima. Fatima usually works in the community and leads the training for the ten community health workers that now exist in this area, due to the hard work the team has put in. Su’ed works primarily on the ward and so knows the patients. The patients are seen individually in their bedrooms, after the ward has been cleaned. At present there are 8 patients on the ward and five of them are new admissions!

We see three patients together. One man who was chained by his family and was experiencing psychotic symptoms at admission. He had also been chewing khat. With the right medication and discontinued khat use on the ward, his psychotic symptoms had subsided. He was now calm, able to engage in conversation and there was no aggressive behaviour shown at all. He was encouraged to come out of his room and sit in the open area of the ward to get some fresh air. We discussed the importance of psychoeducation for both the patient and his family.

Often people are chained as there is such stigma associated with mental illness and families simply do not want others to see their relatives when they are unwell. Without psychoeducation, patients simply do not take their prescribed medications, and end up relapsing, as had the next patient. We had seen him only a week or so ago, when he had consented to take part in teaching for doctors. Now he had been re-admitted and was visibly manic, disinhibited and pressured in speech. This man had also been chained up at home prior to his initial admission to the ward. Rather than being chained by his legs, his wrists had been chained together with a large rusty chain. This meant that he was totally dependent on others for his life. No matter how many times I see a person who this has happened to here, or hear another story of this type of treatment of people with mental health disorders, I am consistently shocked. I find it so saddening that people like this man can be treated in such a way. There is such a dire need for country-wide dissemination of information about mental illness and psychoeducation for both patients and their families, which the current system simply cannot support with its capacity at present.  

Following the ward round, we discuss each case and talk specifically about medication. There is a great deal of polypharmacy used to treat mental disorders, particularly psychosis, where often patients may be treated with both Chlorpromazine and Haloperidol. Dr. Jibril is currently working on an audit to analyse what is going on in this area and we discuss the importance of this monitoring to measure practice. I am very impressed with the team’s efforts on the ward. They keep an organized system of notes, with regular progress notes for each patient and are also keeping statistics of admissions and discharges, along with demographic information and information about treatment and diagnosis.

The afternoon is spent with the 6^th year medical students doing OSCE practice. We manage to get through a number of OSCE scenarios today, including mania, anxiety disorders, a couple of child psychiatry scenarios and delusional jealousy. Today I am pleased with the student’s progress. They seem to also be thinking more about OSCE technique, which is great. 

Mental health training in Somaliland - Day 26

Wednesday 16^th October

Today is the second day of the Eid public holiday celebrations. I meet Dr. Jibril at 08:00 sharp to plan a proposal for the further integration of psychiatry to the medical student curriculum. This is something that has been discussed in both Hargeisa and Borama, with senior faculty members. We decide to write a Powerpoint presentation to clarify the details in our own minds. The challenge will be who leads the students whilst they are on their clinical attachments in psychiatry and this is something we spend some time thinking together about. This will be the first time psychiatry is included on the medical student curriculum as a discrete clinical attachment and so, if it comes to fruition, it is very exciting for the Universities and also the students. 

At present, they only get the 2 week psychiatry teaching course that KTSP delivers in close collaboration with local colleagues, and it is recognized that this time period is very short. To give the students the opportunity to follow up patients for a period of a number of weeks would be a fantastic opportunity – to give them insight into the patient journey, to deepen their understanding of mental disorders and their impact upon patients, their families and the wider community, and to give them the opportunity to perhaps face their own prejudices and fears regarding mental illness. It is also a great opportunity to give medical students more time to get involved in psychiatry and perhaps it will lead to changed views about the specialty in general and a further willingness to liaise with psychiatry colleagues when they enter other specialties such as medicine and surgery. 

We email our proposal to members of faculty, the THET team, in both Somaliland and London, doctors on the ground and UK colleagues. There is the potential for this to go ahead this year, if logistically it is feasible. We look forward to their responses. We also discuss Jibril’s upcoming residency  and how we may collaborate on writing a couple of papers together. It is exciting working with Dr. Jibril; he has endless enthusiasm for psychiatry and really inspires others around him. 

Mental health training in Somaliland - Day 26

Tuesday 15^th October

Today is the Eid public holiday. The place is packed with people, families and children all wearing bright colourful clothing. The praying began early this morning and feasting follows the day of fasting yesterday. It is wonderful to see families celebrating and children running around freely. It is customary for each family to slaughter an animal, usually a sheep or a goat on this day to eat together; it is about family and inclusion.

I spend the day making amendments to a paper I have written with Dr. Peter Hughes that has now been peer reviewed and will be re-submitted, hopefully to be published.  It is based upon our work here in Somaliland and so this is an exciting thing to be doing whilst I am here in country.

I meet up with members of the faculty and Dr. Jibril later in the evening for a celebratory dinner. It’s great to hear that many members of faculty are extremely keen to continue with the TOT courses we have now piloted and in particular would like to see more of these such courses for senior members of faculty. I am delighted to hear that the Head of Medicine shall be attending the psychiatry teaching for medical students next week. It demonstrates a keen interest and a willingness to consider psychiatry in other specialties. Liaison is important here and Dr. Jibril and this doctor already act in liaison, referring each other patients that they feel may benefit from cross-specialty input. This is very positive and something that will inevitably improve the care of people with mental disorders.  Cross-specialty management may also help to break down the barriers that exist between mental health and other medical/ surgical specialties. It will also hopefully reduce the stigma associated with psychiatry and mental health in general that exists in many different places in the world, even among health professionals.