Reports in Brief Wycliffe Ndege, Juliet Mwangi, Minnie Kibore, Linda Nyaga, Wycliffe Khaemba, Susan Wanja, and Luke D. Davies. Funding/Support: Funding for this work came from the Office of the U.S. Global AIDS Coordinator (OGAC) and the National Institutes of Health (NIH) through MEPI award number 1R24TW008889. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The content is solely the responsibility of the authors and does not necessarily represent the official views of OGAC or NIH.
References 1 Mullan F, Frehywot S, Omaswa F, Buch E. Medical schools in sub-Saharan Africa. Lancet. 2011;377:1113–1121. 2 Chankova S, Muchiri S, Kombe G. Health workforce attrition in the public sector in Kenya: A look at the reasons. Hum Resour Health. 2009;7:58.
Evolution of a Multiuniversity Monitoring and Evaluation Technical Working Group Francis J. Njiri, MSc, Mara J. Child, MPH, MPA, Gabrielle O’Malley, PhD, Sarah Baird, PhD, MS, Vincent Ojoome, MMed, Luke D. Davies, and James Kiarie, MMed, MPH
Background: Monitoring and evaluation (M&E) of large-scale government and donor investments is essential for tracking quality improvement, documenting lessons learned, and measuring returns on investment. M&E becomes particularly salient when interventions are also large in scale and unproven, as is the case with the Medical Education Partnership Initiative (MEPI). Through the Principal Investigators’ Council, MEPI institutions observed that many schools faced similar challenges in M&E and that there was a need for more collaboration across programs. In response, an M&E Technical Working Group (TWG) was established in 2012, more than two years after the onset of MEPI, to facilitate interaction across the 13 MEPI institutions. The TWG was composed of M&E leads from each school, with technical support from the MEPI Coordinating Center (George Washington University and the African Center for Global Health and Social Transformation), the University of Nairobi, and the University of Washington. Innovations: The M&E TWG leadership facilitated seven webinars starting
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in March 2013, during which each institution gave a 20-minute presentation describing the M&E activities. During the three months of the webinar series, it became clear that there was a need for in-person discussion and additional technical assistance to help move the M&E activities of MEPI forward. With support from the Office of the U.S. Global AIDS Coordinator, a two-day workshop was held in August 2013 with 39 M&E staff from 17 African and U.S. academic institutions. The objectives of the workshop were to build M&E skills and capacity, share experiences, identify MEPI evaluation needs, and develop a work plan for the M&E TWG. Cross-cutting themes for evaluation emerged, and a subgroup was formed for each of five themes: (1) retention of physicians in rural areas, (2) information communication technology and eLearning, (3) local innovation, (4) research and curriculum development, and (5) partnerships. Outcomes: Through the activities conducted by the M&E TWG, a number of observations have emerged. First, although almost all the institutions had functional program M&E strategies in place and monitoring was occurring, assessing the impact of the program was universally a challenge. Second, although each of the MEPI schools had its own individual work plans and unique activities, common cross-cutting topics were identified at the workshop and formed the basis for crossinstitutional evaluation of MEPI. Finally, a functioning M&E TWG is likely to be essential for optimizing the impact of the M&E activities of MEPI. Comment: The TWG was successful in garnering support across schools because of the buy-in and ownership generated via its participatory approach. The addition of the TWG to the coordinating center in support of evaluation activities increased the pace of knowledge sharing across the consortium. Nevertheless, challenges still remain, including lack of resources of the TWG lead institution (both financial and time), difficulty in coordinating across multiple sites in numerous countries and time zones, and the formation of the TWG two years into the duration of the grant. Working through these challenges over the remainder of the MEPI program will be vital. MEPI schools must continue to collaboratively assess the impact of the MEPI program and to disseminate this information to key stakeholders across the
continent to ensure that successful efforts are sustained beyond the funding period. Correspondence should be addressed to Mr. Njiri, PO Box 2431-00202, Nairobi, Kenya; e-mail: [email protected]. Author affiliations: F. Njiri, University of Nairobi; M. Child, G. O’Malley, L. Davies, University of Washington; S. Baird, George Washington University and University of Otago; V. Ojoome, African Centre for Global Health and Social Transformation; J. Kiarie, University of Nairobi Acknowledgments: The authors would like to thank the following for their contributions to this Short Report and to the TWG: Natalie Brogan, George Washington University; Kalay Moodley, Stellenbosch University; Moses Simuyemba, University of Zambia; Nadia Tagoe, Kwame Nkrumah University of Science and Technology; Rhona Baingana, Makerere University; Netsanet Animut, Addis Ababa University; Esther Lisasi, Kilimanjaro Christian Medical Centre; Kagiso Sebina, University of Botswana; Vanessa Vaila, Mozambique Institute for Health Education and Research; Shemiah Nyaude, University of Zimbabwe; Moise Muzigaba, University of KwaZulu-Natal; and Ademola Oladipo, University of Ibadan. Funding/Support: Funding and support for this work came from the Office of the U.S. Global AIDS Coordinator (OGAC), the National Institutes of Health (NIH), and the Health Resources and Services Administration (HRSA). Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The content is solely the responsibility of the authors and does not necessarily represent the official views of OGAC, NIH, or HRSA. Previous presentation: University of Nairobi Collaborative meeting, January 2014.
The Ghana Emergency Medicine Collaborative Rockefeller A. Oteng, MD, and Peter Donkor, BDS, MS, MDSc
Background: A disproportionate percentage of the 5.8 million annual injury-related deaths occur in low- and middle-income countries because of poor emergency care.1,2 A deficit in the human resources for health infrastructure needed to address this issue is particularly acute in Sub-Saharan Africa. The authors report a process of introducing emergency medicine (EM) training programs in Ghana using funding from the Medical Education Partnership Initiative (MEPI).
Academic Medicine, Vol. 89, No. 8 / August Supplement 2014
Reports in Brief
Innovation: The Ghana Emergency Medicine Collaborative (GEMC) was established in 2008 to provide sustainable, high-quality, in-country training in emergency care for medical students, nurses, and physicians. The collaborative is composed of six institutions that previously collaborated on human capacity building in Ghana: Kwame Nkrumah University of Science and Technology (KNUST); the Komfo Anokye Teaching Hospital (KATH); Ghana Ministry of Health (MoH); Ghana College of Physicians and Surgeons (GCPS); Ghana’s National Ambulance Service (NAS); and the University of Michigan. A three-year curriculum for physician residency training and a one-year diploma for nursing were developed and implemented at KATH. This is the only center in West Africa offering residency and nursing training in EM. A train-the-trainers model was used, including didactic lectures in open educational resource format, bedside supervision/ teaching, and clinical simulations. Outcomes: Two classes of residents have graduated from the physician-training program for a total of 11 EM specialists. The graduates have been employed and integrated into the MoH’s plan to provide emergency training to doctors in rural practice. Two graduates have left the primary training site (KATH) and are receiving mentorship to start emergency departments (EDs) in two other regions of the country. Four other specialists have become instructors in the education program run by the NAS to train emergency medical technicians. Additionally, 24 nurses have completed the diploma program in emergency nursing, awarded by KNUST. From this initial cohort, 3 have received advanced training and are preparing to serve as preceptors for the subsequent classes of trainees. Seventeen nurses remain at KATH, where they are taking on leadership roles in administration, education, and the clinical supervision of rotating nursing students in the ED. The remaining graduates have returned to their home institutions to serve emergency nursing experts. Comment: One critical component to the long-term success and sustainability of the program will be the production of qualified trainers and advocates of EM. While the physician graduates of the training program have all been qualified as specialists by GCPS, they must also complete a two-year fellowship to become
faculty members in the college. Therefore, the next phase for physician development is the creation of a core faculty in the GCPS through these fellowships. The continued progress of nurse training also depends on the creation of fulltime in-country faculty. Acquiring the needed nursing human resources and infrastructure requires that graduates are provided master’s-degree-level training. The MoH has a plan to create emergency centers in each of Ghana’s 10 regions within 5 to 7 years, thus providing career opportunities for the graduates. This collaborative training model is one that may be applied to developing health care worker capacity in other low- and middle-income countries. Through funding from MEPI, the GEMC has developed formal training programs in emergency care for physicians and nurses and is continuing to work at securing the sustainability of these programs. Correspondence should be addressed to Dr. Oteng, University of Michigan, Department of Emergency Medicine, 24 Frank Lloyd Wright Dr., Suite H 3200, Ann Arbor, MI; e-mail: roteng@ med.umich.edu. Author Affiliations: R.A. Oteng, Department of Emergency Medicine, University of Michigan, Ann Arbor; P. Donkor, Kwame Nkrumah University for Science and Technology, Kumasi, Ghana Acknowledgments: The authors would like to acknowledge the residents and nurses involved in GEMC, the government of Ghana, Prof. Paul Nyame, Dr. Carl Seger, and the staff and administration at KATH. The authors would also like to acknowledge Dr. George K. Oduro, Sue Anne Bell, Dr. Victoria Bam, Dr. Nathan Brouwer, Dr. Ellis O. Dabo, Nadia Tagoe, Dr. Patrick Carter, Dr. Rebecca Cunningham, Dr. Terry Kowalenko, and Dr. William Barsan. Funding/Support: Funded by R24 TW-10-008 (PI = Donkor), September 27, 2010 to August 31, 2015; the National Institutes of Health, Fogarty International Center (MEPI), and the Ghana Emergency Medicine Training Program. Other disclosures: None. Ethical approval: Reported as not applicable. Disclaimers: The content is solely the responsibility of the authors and does not necessarily represent the official views of National Institutes of Health or the Ghana Emergency Medicine Training Program.
References 1 WHO Global Status Report on Road Safety Time for Action 2009. 2 Doney MK, Macias DJ. Regional highlights in global emergency medicine development. Emerg Med Clin N Am. Feb 2005;23(1):31–44.
Academic Medicine, Vol. 89, No. 8 / August Supplement 2014
Developing a Medical School Psychiatry Training Program in Botswana: Overcoming Obstacles With Innovation Margo Pumar, MD, MTS, Philip Opondo, MBCHB, MMed (Psych), CML, James Ayugi, MBCHB, MMed (Psych), and Michael Reid, MD, MA
Background: Despite the huge burden of psychopathology, mental health services in Botswana are hampered by limited resources and clinical capacity. The University of Botswana School of Medicine (UBSOM), established in 2009, has committed to training students to be skilled in psychiatric care. This report discusses key innovations that have been integral to UBSOM’s initial approach to developing a medical school psychiatry clerkship. Innovation: • Step 1: Develop strong partnerships. When UBSOM was founded, there were no psychiatrists on faculty and no psychiatry curriculum. Leveraging resources from partner institutions in high-income countries was essential.1 In 2009, UBSOM established informal ties with Hull and York Medical School in the United Kingdom, adapting its problembased learning curriculum to the cultural and epidemiologic specifics of Botswana—namely, emphasizing the role of traditional healers and focusing on the impact of HIV on psychopathology. Starting in 2012, UBSOM’s psychiatry program has also received support from experienced clinician–educators from the Department of Psychiatry at the Perelman School of Medicine, University of Pennsylvania (UPenn), with grant funding from the Medical Education Partnership Initiative (MEPI). Visiting UPenn faculty provide on-site didactic and clinical teaching for UBSOM students and research mentorship for faculty. Clinical examination methods have been adopted from UPenn to ensure that UBSOM students achieve a high standard of clinical competency. To pass the clerkship, for example, students must complete observed psychiatry evaluations on psychiatric inpatients and present their full assessments to faculty. These evaluations are graded using scoring criteria adapted from UPenn. • Step 2: Employ high-tech and low-tech solutions. One obstacle to implementing a psychiatry clerkship has been the
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References 1 Mullan F, Frehywot S, Omaswa F, Buch E. Medical schools in sub-Saharan Africa. Lancet. 2011;377:1113–1121. 2 Chankova S, Muchiri S, Kombe G. Health workforce attrition in the public sector in Kenya: A look at the reasons. Hum Resour Health. 2009;7:58.
Evolution of a Multiuniversity Monitoring and Evaluation Technical Working Group Francis J. Njiri, MSc, Mara J. Child, MPH, MPA, Gabrielle O’Malley, PhD, Sarah Baird, PhD, MS, Vincent Ojoome, MMed, Luke D. Davies, and James Kiarie, MMed, MPH
Background: Monitoring and evaluation (M&E) of large-scale government and donor investments is essential for tracking quality improvement, documenting lessons learned, and measuring returns on investment. M&E becomes particularly salient when interventions are also large in scale and unproven, as is the case with the Medical Education Partnership Initiative (MEPI). Through the Principal Investigators’ Council, MEPI institutions observed that many schools faced similar challenges in M&E and that there was a need for more collaboration across programs. In response, an M&E Technical Working Group (TWG) was established in 2012, more than two years after the onset of MEPI, to facilitate interaction across the 13 MEPI institutions. The TWG was composed of M&E leads from each school, with technical support from the MEPI Coordinating Center (George Washington University and the African Center for Global Health and Social Transformation), the University of Nairobi, and the University of Washington. Innovations: The M&E TWG leadership facilitated seven webinars starting
S110
in March 2013, during which each institution gave a 20-minute presentation describing the M&E activities. During the three months of the webinar series, it became clear that there was a need for in-person discussion and additional technical assistance to help move the M&E activities of MEPI forward. With support from the Office of the U.S. Global AIDS Coordinator, a two-day workshop was held in August 2013 with 39 M&E staff from 17 African and U.S. academic institutions. The objectives of the workshop were to build M&E skills and capacity, share experiences, identify MEPI evaluation needs, and develop a work plan for the M&E TWG. Cross-cutting themes for evaluation emerged, and a subgroup was formed for each of five themes: (1) retention of physicians in rural areas, (2) information communication technology and eLearning, (3) local innovation, (4) research and curriculum development, and (5) partnerships. Outcomes: Through the activities conducted by the M&E TWG, a number of observations have emerged. First, although almost all the institutions had functional program M&E strategies in place and monitoring was occurring, assessing the impact of the program was universally a challenge. Second, although each of the MEPI schools had its own individual work plans and unique activities, common cross-cutting topics were identified at the workshop and formed the basis for crossinstitutional evaluation of MEPI. Finally, a functioning M&E TWG is likely to be essential for optimizing the impact of the M&E activities of MEPI. Comment: The TWG was successful in garnering support across schools because of the buy-in and ownership generated via its participatory approach. The addition of the TWG to the coordinating center in support of evaluation activities increased the pace of knowledge sharing across the consortium. Nevertheless, challenges still remain, including lack of resources of the TWG lead institution (both financial and time), difficulty in coordinating across multiple sites in numerous countries and time zones, and the formation of the TWG two years into the duration of the grant. Working through these challenges over the remainder of the MEPI program will be vital. MEPI schools must continue to collaboratively assess the impact of the MEPI program and to disseminate this information to key stakeholders across the
continent to ensure that successful efforts are sustained beyond the funding period. Correspondence should be addressed to Mr. Njiri, PO Box 2431-00202, Nairobi, Kenya; e-mail: [email protected]. Author affiliations: F. Njiri, University of Nairobi; M. Child, G. O’Malley, L. Davies, University of Washington; S. Baird, George Washington University and University of Otago; V. Ojoome, African Centre for Global Health and Social Transformation; J. Kiarie, University of Nairobi Acknowledgments: The authors would like to thank the following for their contributions to this Short Report and to the TWG: Natalie Brogan, George Washington University; Kalay Moodley, Stellenbosch University; Moses Simuyemba, University of Zambia; Nadia Tagoe, Kwame Nkrumah University of Science and Technology; Rhona Baingana, Makerere University; Netsanet Animut, Addis Ababa University; Esther Lisasi, Kilimanjaro Christian Medical Centre; Kagiso Sebina, University of Botswana; Vanessa Vaila, Mozambique Institute for Health Education and Research; Shemiah Nyaude, University of Zimbabwe; Moise Muzigaba, University of KwaZulu-Natal; and Ademola Oladipo, University of Ibadan. Funding/Support: Funding and support for this work came from the Office of the U.S. Global AIDS Coordinator (OGAC), the National Institutes of Health (NIH), and the Health Resources and Services Administration (HRSA). Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: The content is solely the responsibility of the authors and does not necessarily represent the official views of OGAC, NIH, or HRSA. Previous presentation: University of Nairobi Collaborative meeting, January 2014.
The Ghana Emergency Medicine Collaborative Rockefeller A. Oteng, MD, and Peter Donkor, BDS, MS, MDSc
Background: A disproportionate percentage of the 5.8 million annual injury-related deaths occur in low- and middle-income countries because of poor emergency care.1,2 A deficit in the human resources for health infrastructure needed to address this issue is particularly acute in Sub-Saharan Africa. The authors report a process of introducing emergency medicine (EM) training programs in Ghana using funding from the Medical Education Partnership Initiative (MEPI).
Academic Medicine, Vol. 89, No. 8 / August Supplement 2014
Reports in Brief
Innovation: The Ghana Emergency Medicine Collaborative (GEMC) was established in 2008 to provide sustainable, high-quality, in-country training in emergency care for medical students, nurses, and physicians. The collaborative is composed of six institutions that previously collaborated on human capacity building in Ghana: Kwame Nkrumah University of Science and Technology (KNUST); the Komfo Anokye Teaching Hospital (KATH); Ghana Ministry of Health (MoH); Ghana College of Physicians and Surgeons (GCPS); Ghana’s National Ambulance Service (NAS); and the University of Michigan. A three-year curriculum for physician residency training and a one-year diploma for nursing were developed and implemented at KATH. This is the only center in West Africa offering residency and nursing training in EM. A train-the-trainers model was used, including didactic lectures in open educational resource format, bedside supervision/ teaching, and clinical simulations. Outcomes: Two classes of residents have graduated from the physician-training program for a total of 11 EM specialists. The graduates have been employed and integrated into the MoH’s plan to provide emergency training to doctors in rural practice. Two graduates have left the primary training site (KATH) and are receiving mentorship to start emergency departments (EDs) in two other regions of the country. Four other specialists have become instructors in the education program run by the NAS to train emergency medical technicians. Additionally, 24 nurses have completed the diploma program in emergency nursing, awarded by KNUST. From this initial cohort, 3 have received advanced training and are preparing to serve as preceptors for the subsequent classes of trainees. Seventeen nurses remain at KATH, where they are taking on leadership roles in administration, education, and the clinical supervision of rotating nursing students in the ED. The remaining graduates have returned to their home institutions to serve emergency nursing experts. Comment: One critical component to the long-term success and sustainability of the program will be the production of qualified trainers and advocates of EM. While the physician graduates of the training program have all been qualified as specialists by GCPS, they must also complete a two-year fellowship to become
faculty members in the college. Therefore, the next phase for physician development is the creation of a core faculty in the GCPS through these fellowships. The continued progress of nurse training also depends on the creation of fulltime in-country faculty. Acquiring the needed nursing human resources and infrastructure requires that graduates are provided master’s-degree-level training. The MoH has a plan to create emergency centers in each of Ghana’s 10 regions within 5 to 7 years, thus providing career opportunities for the graduates. This collaborative training model is one that may be applied to developing health care worker capacity in other low- and middle-income countries. Through funding from MEPI, the GEMC has developed formal training programs in emergency care for physicians and nurses and is continuing to work at securing the sustainability of these programs. Correspondence should be addressed to Dr. Oteng, University of Michigan, Department of Emergency Medicine, 24 Frank Lloyd Wright Dr., Suite H 3200, Ann Arbor, MI; e-mail: roteng@ med.umich.edu. Author Affiliations: R.A. Oteng, Department of Emergency Medicine, University of Michigan, Ann Arbor; P. Donkor, Kwame Nkrumah University for Science and Technology, Kumasi, Ghana Acknowledgments: The authors would like to acknowledge the residents and nurses involved in GEMC, the government of Ghana, Prof. Paul Nyame, Dr. Carl Seger, and the staff and administration at KATH. The authors would also like to acknowledge Dr. George K. Oduro, Sue Anne Bell, Dr. Victoria Bam, Dr. Nathan Brouwer, Dr. Ellis O. Dabo, Nadia Tagoe, Dr. Patrick Carter, Dr. Rebecca Cunningham, Dr. Terry Kowalenko, and Dr. William Barsan. Funding/Support: Funded by R24 TW-10-008 (PI = Donkor), September 27, 2010 to August 31, 2015; the National Institutes of Health, Fogarty International Center (MEPI), and the Ghana Emergency Medicine Training Program. Other disclosures: None. Ethical approval: Reported as not applicable. Disclaimers: The content is solely the responsibility of the authors and does not necessarily represent the official views of National Institutes of Health or the Ghana Emergency Medicine Training Program.
References 1 WHO Global Status Report on Road Safety Time for Action 2009. 2 Doney MK, Macias DJ. Regional highlights in global emergency medicine development. Emerg Med Clin N Am. Feb 2005;23(1):31–44.
Academic Medicine, Vol. 89, No. 8 / August Supplement 2014
Developing a Medical School Psychiatry Training Program in Botswana: Overcoming Obstacles With Innovation Margo Pumar, MD, MTS, Philip Opondo, MBCHB, MMed (Psych), CML, James Ayugi, MBCHB, MMed (Psych), and Michael Reid, MD, MA
Background: Despite the huge burden of psychopathology, mental health services in Botswana are hampered by limited resources and clinical capacity. The University of Botswana School of Medicine (UBSOM), established in 2009, has committed to training students to be skilled in psychiatric care. This report discusses key innovations that have been integral to UBSOM’s initial approach to developing a medical school psychiatry clerkship. Innovation: • Step 1: Develop strong partnerships. When UBSOM was founded, there were no psychiatrists on faculty and no psychiatry curriculum. Leveraging resources from partner institutions in high-income countries was essential.1 In 2009, UBSOM established informal ties with Hull and York Medical School in the United Kingdom, adapting its problembased learning curriculum to the cultural and epidemiologic specifics of Botswana—namely, emphasizing the role of traditional healers and focusing on the impact of HIV on psychopathology. Starting in 2012, UBSOM’s psychiatry program has also received support from experienced clinician–educators from the Department of Psychiatry at the Perelman School of Medicine, University of Pennsylvania (UPenn), with grant funding from the Medical Education Partnership Initiative (MEPI). Visiting UPenn faculty provide on-site didactic and clinical teaching for UBSOM students and research mentorship for faculty. Clinical examination methods have been adopted from UPenn to ensure that UBSOM students achieve a high standard of clinical competency. To pass the clerkship, for example, students must complete observed psychiatry evaluations on psychiatric inpatients and present their full assessments to faculty. These evaluations are graded using scoring criteria adapted from UPenn. • Step 2: Employ high-tech and low-tech solutions. One obstacle to implementing a psychiatry clerkship has been the
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