Recognising health system challenges

Every partnership involved in health system strengthening will encounter barriers and challenges.

The approach taken by the Global Links Volunteer Programme is to develop a culture in which it is acceptable to talk frankly about those barriers so that they can be addressed or accepted.

The Global Links Volunteer Programme is a partnership between the Royal College of Paediatrics and Child Health (RCPCH) in the UK and partners in Ghana, Kenya, Nigeria, Sierra Leone and Uganda, which aims to improve health care for children in hospitals and community services through training, supervision and support.

UK-based trainee or consultant paediatric doctors work for six or twelve months in African hospitals, and doctors from African hospitals undertake twelve-month placements or six-week clinical observation visits to UK hospitals.

Every partnership involved in health system strengthening will encounter barriers and challenges. The approach taken by Global Links is to develop a culture in which it is acceptable to talk frankly about those barriers.

Those responsible for the project lead by example. John Wachira, lead partner in Kenya, has regular contact with Peter Nash, Global Links manager in the UK, to ensure that challenges are understood and discussed at an early stage. Frequent communication, such as regular (sometimes daily) emails, and a weekly or fortnightly conversation, is key to this.

For challenges to be identified and recognised at all levels, it is important that communication isn’t restricted to one or two central people.

The reality of working in resource-limited settings is also made clear to volunteers at an early stage. To develop a shared understanding of expectations, pre-departure training for UK volunteers is held at the same time as African volunteers complete their pre-placement training. The UK volunteers are encouraged to talk to partners in developing countries, and ask questions before they set off. Returning UK volunteers are also invited to speak at the training events, as well as to write case studies about the key things they have learnt.

It is important for placement volunteers to understand the context they will be working in, and honest recognition of health system barriers enables them to approach their placement with realistic expectations.

Peter explains,

We encourage our partners to be very open, and to not shy away from the challenges that the UK guys are going to experience. This doesn’t always come naturally, as some partners don’t want to put off the UK volunteer.

The partnership tries to find a balance between highlighting the positive and rewarding experiences volunteers have on placements, and explaining the frustrations and challenges they may face. The last thing the project wants, according to Peter is for “a UK doctor to go overseas and to think they’re going to get one thing and then they’re given something completely different”.

Acknowledging challenges and barriers continues on placement. “The fact that essential resources are missing, such as drugs and basic commodities, is frustrating to UK doctors”, says John. “But they are prepared from the course in the UK, then they get orientation in the hospital, and then a week of observation which really helps them to acclimatize and understand the challenges.”

Health worker movement is another common challenge faced by the partnership. This has been particularly problematic in Kenya where staff that have been trained or supported via the partnership are regularly rotated to a new speciality after a couple of months, making much of their learning redundant. Many trainees also leave the hospital altogether, to continue practicing in private hospitals or abroad. Requests to retain some staff have typically not worked, so having understood and accepted this barrier, the partnership has discussed ways to get over it.

The current approach is to make sure that senior doctors, administrators and leaders – those who won’t be rotated in the hospital – understand the partnership and are involved in it, in some way. A particular focus is put on the local paediatricians who, due to low numbers, are likely to remain on the unit. UK doctors are encouraged to seek out the permanent nursing staff and the medical officers, in particular those who have an interest in paediatrics, and work with them directly to ensure that training can be cascaded on any on-going basis once the UK doctor’s time in Africa has come to an end.

Not all barriers can be removed, and the partnership recognises the importance of accepting this. Staff will move on, supplies may not arrive. The partnership has faced other significant barriers to achieving its aims, such as the Ebola outbreak in Sierra Leone and security issues in Kenya.

For the partnership, the key is in recognising these challenges and managing expectations, to ensure that volunteers don’t become demotivated. “Knowing something is going to be difficult doesn’t stop it being difficult”, explains Peter Nash, “but it takes some of the frustration out of it.”

A bad first impression created by a clumsy start to a project can be a more significant barrier to strengthening health systems than infrastructure or cultural difference. Creating a culture that explicitly allows these barriers to be understood, discussed and sometimes avoided is vital to the success of the partnership.

Preparing volunteers well can help the partnership avoid creating extra pitfalls. Nash quotes a senior paediatrician who advises doctors who arrive in a hospital and see 100 different things that would improve quality of care,

step back, stand on one leg, and take a look around for at least a month or so; it’s only then that you can put your second leg down and actually start doing stuff. One important thing to remember is that your relationships are more important than the tasks.