Improving health outcomes for women in Uganda

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

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

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

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

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

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

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

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

Meeting in the HDU.

Training at Mulgao Hospital.

Infection prevention project in the Obstetric HDU

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

New bins on the ward.

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

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

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

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

NHS expertise, how to reach its full potential

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

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

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

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

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

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

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

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

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

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

Voluntary Engagement in Global Health

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


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

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

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

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

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

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

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

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

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

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

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

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

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

Working Together to Improve Child Health Across Africa

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





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

Improving Paediatric Surgery through Quality Improvement Methodology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1.       An integrated care pathway:

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

2.       New Protocols:

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

3.       Ward data and note keeping:

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

4.       Basic equipment:

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

5.       Communication

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

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

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

Ending the Isolation: Creating an Epilepsy Hub in Sierra Leone

In the last in our series of blogs about health partnership projects in Sierra Leone, THET's Communications Officer, Timur Bekir, visits an epilepsy clinic and training session to document the work of the Basildon-Lumley Partnership.

A health partnership between Basildon & Thurrock NHS Trust and Lumley Government Hospital in Sierra Leone, working closely with The Epilepsy Association of Sierra Leone, is improving epilepsy care by training healthcare workers around the country and creating an epilepsy hub to reach rural communities.

Connaught Hospital in Sierra Leone’s capital, Freetown, sits to the north of the city, not far from the Cotton Tree, a famous landmark that is over 200 years old and marks the spot of a settlement built by freed African American slaves in the late 1700s. 

It’s first thing on a Thursday morning and I’ve been invited by project leader Dr. Radcliffe Lisk, a Consultant Neurologist at Basildon, to sit in on an epilepsy clinic. Patients quickly fill the room and a queue snakes out of the door. The service is obviously much needed.

The clinic starts with patients and health practitioners singing and praying then a Q&A follows. Patients asks questions about their condition and any issues they are having trouble with. For many, this is the first time they are seeking treatment for their epilepsy.

Epilepsy clinic at Connaught Hospital, Freetown, Sierra Leone. Photo: Timur Bekir/THET

50 million people have epilepsy worldwide, but around 80% are found in developing countries. Dr. Lisk explained why:

‘The reason why epilepsy is more common in developing countries than it is in developed is because of additional causes such as poor obstetric practice. A lot children are born with brain damage because of prolonged labour and these are the children at risk of epilepsy in later life. And cerebral malaria has been shown to be one of the main causes of epilepsy in children. Trauma from war and high levels of road traffic accidents also contribute. Most of the prevalence studies that have been done in Africa show that epilepsy is about 2-3 times more common than it is in Europe or America so it is a big problem.’ 

The most reliable data suggests 60,000 people in Sierra Leone have epilepsy. But inadequate health provisions and long-held views among the population that epilepsy is a result of witch craft or demonic possession means that 80-90% of people with the condition will never receive the treatment they need.

During the session I get a chance to speak with some patients who have benefitted from the project. When describing their experience of having epilepsy, patients describe similar difficulties they’ve faced such as stigma, isolation and the general belief that they are ‘crazy’. Jeneba Kabba has had epilepsy for 14 years now and described her ordeal:

‘They gave me kerosene to drink and said that is the way to treat epilepsy. I had this treatment for three years. People were laughing at me and saying I was crazy.’

Jeneba found out about the work of the partnership three years ago and has been able to manage her epilepsy ever since. She is a mother and teacher, and works with the partnership to raise awareness and reduce the kind of stigma she faced for so long.

A health worker administers drugs to epilepsy patients at a clinic in Connaught Hospital. Photo: Timur Bekir/THET

As well as the sessions at Connaught, the partnership is expanding its activities across the country. The project, currently funded under the health partnership scheme, is creating a national epilepsy hub to reach isolated rural communities. Previously, rural patients had to travel long distances or wait for the monthly provincial visits to access any sort of epilepsy service.  To reach the vast majority of patients, the project is training all levels of rural health worker in epilepsy diagnosis and management. Training health workers in the Peripheral Health Units (PHUs) that serve the villages and chiefdoms is a key activity for the project and essential to increasing access for patients.

To see the training first-hand, I travel to Moyamba District in the north of the country. The two hour journey takes five. Slowed down by a never-ending caravan of traffic coming out of Freetown and terrible road conditions once into the district. This helps to highlight how difficult it is for rural communities to access services in Freetown, add to this the cost, and some individuals and families have no chance of accessing healthcare.

Once at the workshop, I watch as Dr. Lisk and his team run through a full days teaching, covering everything from diagnosis, clinical treatment, and breaking down the traditional beliefs that claim epilepsy is demonic possession or witch craft.

To date, 439 health workers have received training, including 6 district medical officers, 89 Community Health Officers and 254 Community Health Nurses & Community Health Assistants. Trainees have reacted positively to the training with the majority acquiring new knowledge such as different types of epilepsy, its association with depression and recognising that the majority of seizures can be controlled with medication. Many trainees are now local focal points for the project.

Along with the training sessions, the partnership has produced a handbook that includes protocols on the management of various aspects of epilepsy. In tandem with this, the partnership continues to raise awareness about epilepsy through TV and radio appearances and newspaper articles. All essential activities in breaking down the long-held but misplaced beliefs about epilepsy in Sierra Leone.

‘The advocacy work is extremely important,’ states Dr. Lisk, ‘because that's how you get them into the clinics in the first place. If you don't change their beliefs you won't get them to the clinics. It's a slow process but our programme also goes into schools so we can educate the new generation. We talk about epilepsy and have our posters in schools too.’ 

Patients receive drugs from a health worker at Connaught Hospital. Photo: Timur Bekir/THET

Back in Freetown, I sit in on an EEG session in the neurology department of Connaught Hospital. The EEG machine used by Dr. Lisk and his team has been acquired with funding from THET. The project has been able to purchase three machines and train four technicians to perform EEG recordings. 

A technician carries out an EEG test for a patient at Connaught Hospital. Photo: Timur Bekir/THET.

A technician assess the EEG reading. Photo: Timur Bekir/THET.

A patient receiving an EEG test. Photo: Timur Bekir/THET.

A patient receiving an EEG test. Photo: Timur Bekir/THET.

I ask Dr. Lisk about the sustainability of the project and he explains that the programme has worked closely with the Ministry of Health from the start to help ensure the future of the project:

‘One of the keys to sustainability is integration into the Ministry's programme. That's why, from the onset, we made sure this wasn't a parallel programme. So by actually training the staff employed by the Ministry of Health they then have the knowledge to carry on the work after the project ends.’ 

In fact, epilepsy has received further recognition from the government and a focal point for epilepsy in the Ministry of Health has been appointed. This is an important development for a project that is really gaining momentum and, from the amount of patients I’ve seen attend clinics, is much needed.

One thing is for sure, the partnership has already been able to produce strong advocates for the project. Over just a couple of days I’ve met health and social workers, teachers and patients who have responded positively to the training and are now advocates engaging in awareness raising and sensitization in their districts. A great example of how training and education can have life changing results far beyond the classroom. 

Find out more about the partnership at www.thet.org

Find out more about epilepsy in Sierra Leone on the Epilepsy Association of Sierra Leone website. 

THET has produced a short film documenting the work of the project. Dr. Lisk, trainees and patients are interviewed about their experience of epilepsy in Sierra Leone and the impact of the project. Help support the work of the partnership and share the video with friends, family and colleagues.

Giving Children a Chance: Reducing Child Mortality in Sierra Leone

In the second in a series of blogs focusing on THET funded health partnerships in Sierra Leone, THET's Communications Officer, Timur Bekir, visits Ola During Children's Hospital in Freetown to document the work of the Global Links project. 

It’s a stifling November day (the locals will later laugh and tell me that November is a cool month) and at Ola During Children’s Hospital in Sierra Leone patients crowd the corridors waiting patiently by the Emergency Room. In the Special Care Unit babies struggle to adjust to their new world. And in the ICU a mother tenderly reassures her child. In each of these vital wards is a volunteer from the UK working with local staff to help improve healthcare for Sierra Leone’s youngest residents. 

The volunteers: Paul Gibson, Liza Waldegrave & Gareth Lewis are part of the THET funded Global Links project, a health partnership between the Royal College of Paediatrics & Child Health and the West African College of Physicians. The THET funded Global Links project places long-term volunteers in five African countries: Sierra Leone, Ghana, Kenya, Nigeria & Uganda. The partnership is working with staff and institutions in each of these countries to establish a consortium of UK and East & West African central and district hospitals that will work to reduce child mortality and help meet Millennium Development Goal 4.

The 8 Millennium Development Goals.
Global Links seeks to address MDG4.

The volunteers work closely with the staff at Ola During, the main referral hospital for the whole of Sierra Leone, to provide clinical support, develop protocols and train staff. And, by all accounts, the relationship between the volunteers and their Sierra Leone colleagues is strong. Gareth Lewis, a Paediatric Registrar and Senior Resident at Ola During, highlights the relationship between volunteers and local staff:

‘All the doctors have been great. I’ve been working with one doctor in particular in the Child Protection Unit and she has been really helpful in teaching me bits of Krio here and there. They’ll help with translation. In general they have been very supportive and you never feel excluded as an outsider here.’

Walking around the wards I can see this inclusivity first-hand. The local staff and volunteers have a professional, but easy manner with each other, undoubtedly vital in ensuring a positive and productive working relationship.

Gareth Lewis in the SPU. Photo: Timur Bekir

Gareth Lewis with House Officer. Photo: Timur Bekir

There’s a huge need for support at Ola During, as Dr. Baion, Medical Superintendent, highlights starkly:

‘We have nine wards which means, at the least, we need nine doctors, but we have only two doctors in this hospital. So even having just one person from Global Links helps a lot. They are covering so many areas that we cannot do on our own.’

Paul Gibson, a Consultant Paediatrician in Lancaster, is midway through his twelve month placement. He kindly spends the day showing me around the hospital and introducing me to staff and patients, his energy and enthusiasm doesn't flag for a second. Dr. Gibson is well aware of the need he’s here to address:

‘When last measured, the mortality in Sierra Leone was approximately 170 per 1000 so about 17% of children died before their fifth birthday. What that means at Ola During Hospital is that approximately 10-14% of our admissions die, which is tough on the staff and the whole operation.’

Dr. Paul Gibson. Photo: Timur Bekir

Dr. Gibson and local team. Photo: Timur Bekir

Typical cases at Ola During include malnutrition, malaria and respiratory tract infections. And it’s a constant numbers game – not enough skilled health workers to deal with the cases that come in on a daily basis. As Dr. Gibson notes:

‘One of the features of health and healthcare in Sierra Leone is simply a shortage of numbers of health workers. Then there’s also the quality of skills those health workers have. If you start with the nurses, often they feel poorly paid and unrecognised. And training isn't just about giving people new knowledge and new skills, it’s about giving people a reward. So one of the things that external people like Global Links, funded by THET, can do is bring that in and send a message to nurses or nurse aides that what you do is valuable,  and it’s important to invest in you and your training.’

Emergency Room. Photo: Timur Bekir

Local nursing staff. Photo: Timur Bekir

Nurse attending to a patient in the ER. Photo: Timur Bekir

Patient in the ER. Photo: Timur Bekir

During my two days at Ola During it’s encouraging to see the emphasis placed on evaluating and measuring impact. Away from the wards and in the classroom I sit in on the weekly Mortality & Morbidity session. These meetings are not only a chance for the team to analyse and improve mortality rates in the hospital, but are also the start in rebuilding a much needed medical postgraduate life for the institution.  

The addition of ‘speed learning’ at the end of each day on ICU is helping to supporting and nurture leadership, team working, and improvements to clinical governance, team development and clinical leadership too. Led by the local Staff Nurse, these fifteen minute sessions are a chance for staff to get answers to questions that come up on ward rounds. The sessions foster a culture of sharing and learning as each member of staff contributes by imparting the knowledge they have to answer daily queries.

In addition to these sessions, the volunteers are helping to deliver more training, including twenty hours of undergraduate lectures and a regular, weekly, Continuing Professional Development programme for paediatric staff, including sessions on HIV testing, clinical assessment, and treatment of shock and dehydration.

Liza Waldegrave with nurse in the ICU. Photo: Timur Bekir

Dr. Gibson with patient in the ER. Photo: Timur Bekir

A mother feeds her child in the ER. Photo: Timur Bekir

Dr. Gibson tends to a patient. Photo: Timur Bekir

As my time at Ola During draws to a close, I reflect on spending the day with a really motivated team who clearly care passionately about their role. The challenges are numerous and can sometimes seem overwhelming. But the local staff, with support from UK volunteers, are making gains in a large number of areas. The RCPCH Global Links project is forging a relationship with Ola During and other hospitals around Africa in order to work together to train health workers and improve healthcare for children far into the future. As Dr. Gibson states:

‘Success for colleagues in Sierra Leone would be that in five years there would be an internal self-sustaining confidence that nurses, doctors and midwives actual felt that they were the leaders, that they could control things and come up with ideas. And that the workforce is self-sustaining.’

It’s that emphasis on long-term, sustainable healthcare that is fundamental to the health partnership approach, and why training and developing the skills of local health workers, not just delivering services, is key to realising that approach for real in hospitals in Sierra Leone and around the world.

Dr. Gibson with nurse and mother in the ER. Photo: Timur Bekir

Record keeping in the ER. Photo: Timur Bekir

Patients rest in the ER. Photo: Timur Bekir

House Officer in the SCU. Photo: Timur Bekir

A mother with her child waits to be seen in the ER. Photo: Timur Bekir

To find out more about health partnerships in Sierra Leone and around the world, visit www.thet.org 

To find out more about Global Links and how you can volunteer, visit the RCPCH website.

Self-reported change in practice: a monitoring tool for health partnerships

In this blog, THET's Evaluation & Learning Officer, Emily Burn, shows how the introduction of a self-assessment tool is key in demonstrating the impact of health worker training. 

Trainee nurses at Kambia District Hospital, Sierra Leone. Photo by Timur Bekir

Imagine this situation: A team of doctors were trained in palliative care by their UK partners in a one-week course. There were 30 trainees in the group and the partnership plans to train another cohort of the same size.  The trainee doctors received a certificate of competence at the end of the course if they performed well enough in the final written assessment.  Once they completed the course, the doctors returned to their places of work in the hospitals and clinics both in peri-urban and urban areas. For many of the doctors, they will be the most senior or only clinician at their place of work and they will also be the only ones responsible for delivering palliative care.

What can the partnership do to gather data on the doctors’ practice in palliative care once they have returned to their places of work? In this scenario, the trainees are spread widely geographically making it difficult for those responsible for M&E to visit each of them.  The doctors do not have an appraisal system or a senior colleague who can provide objective feedback on their practice. The doctors do keep practice logbooks but it may not be feasible to retrieve data from all of those logbooks.  The partnership does not have enough funds or supervisors available to visit each doctor in their place of work to assess their skills, and in any case, how thorough an assessment can be made in just one visit?  So the partnership faces various issues in data collection but they do need to come up with ways to gather data on practice that are reasonable given the context they work in.  

The case for self-assessment

This scenario is typical of many health partnerships’ experience of monitoring change in a rigorous way: they have limited staff, time and funds available to monitor and evaluate each health worker’s performance yet they still need to gather evidence that could demonstrate the impact of the training on the health worker’s practice.  Given the context that health partnerships work in, there is a strong case for using a self-assessment tool, such as an online or paper questionnaire.  The obvious issue is the lack of objectivity or external verification of the claims made in a questionnaire and indeed the aim should be to combine it with other sources of information (e.g. clinical records) yet the questionnaire can overcome some of the difficulties health partnerships face in data-gathering to provide interesting insights to trainees’ experiences in their own places of work.    

How can you design a questionnaire for use in your own work? I asked THET’s community of practice for examples of self-assessment tools that they use in their projects. Interestingly, I received several examples of workshop evaluations, which looked at things like knowledge gained, course relevance, and overall satisfaction with the training, all gathered at the end of the course. I had far fewer examples of questionnaires that trainees complete further down the line on if, or how, they applied their training. 

Although any questionnaire must be tailored to the specific techniques taught, the following generic topic areas are a useful starting point for designing your self-reporting tool:

Evaluation of the training

·       This is to understand if the training targeted the right cadre of candidates so the questions should ask how relevant the trainee has found the training to be once they returned to their institution.

Knowledge retention

·      A set of multiple choice questions (MCQs) can directly test how much knowledge the trainee has retained since the training.  You could compare results from a final assessment at the training with this later MCQ assessment.

Confidence to practice

·      How confident does the trainee feel to carry out procedures or new techniques, learnt on the training course?  A Likert scale (e.g. Very confident – Fairly confident – Not really confident – Not at all confident) is the commonest format for this type of question.  Include a comment box to give rationale for their answer.  It could be interesting to compare confidence answers across three points in time: pre training, immediately post training, and 6 – 12 months after training. The comments box could help to explore reasons for notable dips or peaks in confidence.

Change in practice

·      With what frequency does the trainee now practice a set of techniques, bearing in mind what is reasonable for a given context?  Always provide comment boxes for these questions as it is important to understand any barriers to practice, such as lack of equipment or adequate supervision.

·         Include text boxes to gather narrative examples of practice such as cases where they have used the skills gained in training; if appropriate, request that the answer includes any information on the outcomes for the patient.

Lastly, what response rate would you be satisfied with?  It is unlikely that you will get 100% of trainees to complete and  return the questionnaires so make it as user-friendly as possible (test it out on some colleagues before you distribute it), consider creating it online if local bandwidth allows – THET  uses the online tool Survey Monkey because it is easy to use and has useful reporting functions – and review your M&E plans to determine other data-gathering tools so that you are not reliant on just the questionnaire for data on change in practice.

If you have an example questionnaire that you would be happy to share with us, please send it to emilyburn@thet.org or post it on the community of practice.  I am also interested to hear about people’s experience of using self-reporting to gather evidence.

Useful Links

http://betterevaluation.org/

http://www.tools4dev.org/resources/online-based-survey-software-5-pointers-to-look-out-for/