University partnership to address the shortage of healthcare professionals in Africa

Breaking Borders: How Barriers to Global Mobility Hinder International Partnerships in Academic Medicine

This article describes the authors' personal experiences of collaborating across international borders in academic research. International collaboration in academic medicine is one of the most important ways by which research and innovation develop globally. However, the intersections among colonialism, academic medicine, and global health research have created a neocolonial narrative that perpetuates inequalities in global health partnerships. The authors critically examine the visa process as an example of a racist practice to show how the challenges of blocked mobility increase inequality and thwart research endeavors. Visas are used to limit mobility across certain borders, and this limitation hinders international collaborations in academic medicine. The authors discuss the concept of social closure and how limits to global mobility for scholars from low- and middle-income countries perpetuate a cycle of dependence on scholars who have virtually barrier-free global mobility-these scholars being mainly from high-income countries. Given the current sociopolitical milieu of increasing border controls and fears of illegal immigration, the authors' experiences expose what is at stake for academic medicine when the political sphere, focused on tightening border security, and the medical realm, striving to build international research collaborations, intersect. Creating more equitable global partnerships in research requires a shift from the current paradigm that dominates most international partnerships and causes injury to African scholars.

The international partner universities of East African health professional programmes: why do they do it and what do they value?

BACKGROUND

Globalization and funding imperatives drive many universities to internationalize through global health programmes. University-based global health researchers, advocates and programmes often stress the importance of addressing health inequity through partnerships. However, empirical exploration of perspectives on why universities engage in these partnerships and the benefits of them is limited.

OBJECTIVE

To analyse who in international partner universities initiated the partnerships with four East African universities, why the partnerships were initiated, and what the international partners value about the partnerships.

METHODS

Fifty-nine key informants from 26 international universities partnering with four East African universities in medicine, nursing and/or public health participated in individual in-depth interviews. Transcripts were analysed thematically. We then applied Burton Clark's framework of "entrepreneurial" universities characterized by an "academic heartland", "expanded development periphery", "managerial core" and "expanded funding base", developed to examine how European universities respond to the forces of globalization, to interpret the data through a global health lens.

RESULTS

Partnerships that were of interest to universities' "academic heartland" - research and education - were of greatest interest to many international partners, especially research intensive universities. Some universities established and placed coordination of their global health activities within units consistent with an expanded development periphery. These units were sometimes useful for helping to establish and support global health partnerships. Success in developing and sustaining the global health partnerships required some degree of support from a strengthened steering or managerial core. Diversified funding in the form of third-stream funding, was found to be essential to sustain partnerships. Social responsibility was also identified as a key ethos required to unite the multiple elements in some universities and sustain global health partnerships.

CONCLUSION

Universities are complex entities. Various elements determine why a specific university entered a specific international partnership and what benefits it accrues. Ultimately, integration of the various elements is required to grow and sustain partnerships potentially through embracing social responsibility as a common value.

Banana fruit: An "appealing" alternative for practicing suture techniques in resource-limited settings

PURPOSE

Suturing is an important core surgical competency that requires continued practice. The purpose of this study was to evaluate bananas as a medium for practicing suture techniques in resource-limited settings.

MATERIALS AND METHODS

Using a crossover design, 20 University of Rwanda medical students practiced suturing on banana peels and commercial foam boards. Students were randomized into 2 groups: group A practiced on foam boards first and then bananas, and group B practiced on banana peels first and then foam boards. A post-workshop survey was then administered to students to gauge their attitude towards banana peels as a suturing practice material. Suture performance for each student was graded by three fellowship-trained facial plastic surgeons based on consistent spacing, knot location, appropriate knot, absence of air knots, and adequate bite size.

RESULTS

Suture performance graded by facial plastic surgeons demonstrated that suturing outcomes with bananas were equal or superior to foam in 56.7% of instances. Twenty students participated in the workshop; 16 students responded to the survey (response rate = 80%). Students were comfortable practicing suturing with banana peels (Mdn = 4, IQR = 1) and strongly agreed that suturing banana peels was a useful activity (Mdn = 5, IQR = 1). Students thought banana peels and foam were comparable learning platforms (Mdn = 3.5, IQR = 1) and felt their suturing abilities improved with practice on banana peels (Mdn = 4, IQR = 1.3).

CONCLUSIONS

Banana peels are a low cost, equally viable alternative to synthetic suture media.

Assessing the impact of a partnership-based work/study nursing upgrade programme in a low- and middle-income setting

AIMS AND OBJECTIVES

To evaluate the 15-year impact of the work/study nursing upgrading programme in East Africa.

BACKGROUND

Working nurses in Africa are often primary family income earners, with limited ability to leave jobs and upgrade qualifications. In 2001, the university established a work/study upgrade programme for enrolled- and diploma-level nurses, allowing them to upgrade their qualifications while continuing to work and support families. Donor partnerships provided scholarships to further increase programme access.

DESIGN

A mixed-method design was used involving an online alumni survey and 24 interviews and 23 focus groups with 172 purposively selected representatives of nursing graduates, employers, regulatory bodies, professional associations and senior nursing officials.

METHOD

Quantitative data were analysed using frequencies and percentages. Inductive thematic analysis was used for qualitative data. Equator guidelines informed reporting of both qualitative and quantitative results.

RESULTS

Of the 549 graduates who completed the survey, 81.2% (n = 446) were female, 93.1% were currently employed and 98% worked within East Africa. They reported improved professional competence (69.4%), nursing practice (25.9%) and patient outcomes (4.6%) on graduation. Extracted themes included the following: flexible/accessible programme; friendly learning environment; effective teaching and learning strategies; acquisition of nursing knowledge, skills and competencies; stakeholders' role in the programme; career/professional advancement; and strengthened health systems.

CONCLUSION

The work/study programme was an effective nursing workforce capacity development strategy. Programme access was strengthened via the supporting donor partnership. Positive outcomes were achieved with respect to the university's values of quality, access, relevance and impact.

RELEVANCE TO CLINICAL PRACTICE

Long-term sustainable development of nurses and midwives is fundamental to achieving sustainable development goals. Work/study programmes and private-public partnerships are effective mechanisms to strengthen the development of nursing and the overall healthcare workforce in low-resource settings.

Bidirectional Exchanges of Medical Students Between Institutional Partners in Global Health Clinical Education Programs: Putting Ethical Principles into Practice

BACKGROUND

One-third of US medical students participate in global health (GH) education, and approximately one-quarter of US medical schools have structured programs that offer special recognition in GH. GH clinical electives (GHCEs) are opportunities for students to experience a medical system and culture different from their own. GHCEs are administered through institutional affiliation agreements, often between an institution in a high-income country (HIC) and one in a low- or middle-income country (LMIC). Although these agreements suggest the exchange of students in both directions, GHCEs are traditionally characterized by students from HICs traveling to LMICs.

OBJECTIVES

The goal of this study was to investigate the availability of opportunities for students from LMICs participating in GHCEs at partner institutions in HICs and to describe the costs of these opportunities for students from LMICs.

METHODS

We conducted a web-based search of 30 US institutions previously identified as having structured programs in GH. We determined which of these schools have programs that accept medical students from international schools for GHCEs, as well as the administrative requirements, types of fees, and other costs to the international student based on information available on the web. Descriptive statistics were employed for the quantitative analysis of costs.

FINDINGS

We found that, although the majority of US institutions with structured GH programs sending students to sites abroad accept international students at their sites in the United States, nearly one-fifth of programs do not offer such opportunities for bidirectional exchange. We also characterized the substantial costs of such experiences, because this can represent a significant barrier for students from LMICs.

CONCLUSIONS

Access to GHCEs in US partner institutions should be an important underlying ethical principle in the establishment of institutional partnerships. The opportunities available to and experiences of students from LMIC partner institutions are important areas for future GH education research.

What Makes International Global Health University Partnerships Higher-Value? An Examination of Partnership Types and Activities Favoured at Four East African Universities

BACKGROUND

There are many interuniversity global health partnerships with African universities. Representatives of these partnerships often claim partnership success in published works, yet critical, contextualized, and comparative assessments of international, cross-border partnerships are few.

OBJECTIVE

The objectives of this paper are to describe partnerships characterized as higher-value for building the capacity of four East African universities and identify why they are considered so by these universities.

METHODS

Forty-two senior representatives of four universities in East Africa described the value of their partnerships. A rating system was developed to classify the value of the 125 international partnerships they identified, as the perceived value of some partnerships varied significantly between representatives within the same university. An additional 88 respondents from the four universities and 59 respondents from 25 of the international partner universities provided further perspectives on the partnerships identified. All interviews were transcribed and analysed in relation to the classification and emergent themes.

FINDINGS

Thirty-one (25%) of the partnerships were perceived as higher-value, 41 (33%) medium-value, and 53 (42%) lower-value for building the capacity of the four focus universities. Thirteen (42%) of the higher-value partnerships were over 20 years old, while 8 (26%) were between 3 and 5 years old. New international partners were able to leapfrog some of the development phases of partnerships by coordinating with existing international partners and/or by building on the activities of or filling gaps in older partnerships. Higher-valued partnerships supported PhD obtainment, the development of new programmes and pedagogies, international trainee learning experiences, and infrastructure development. The financial and prestige value of partnerships were important but did not supersede other factors such as fit with strategic needs, the development of enduring results, dependability and reciprocity. Support of research or service delivery were also considered valuable but, unless education components were also included, the results were deemed unlikely to last.

CONCLUSION

International partnerships prioritizing the needs of the focus university, supporting it in increasing its long-term capacity and best ensuring that capacity benefits realized favour the focus university are valued most. How best to achieve this so all partners still benefit sufficiently requires further exploration.

Reframing undergraduate medical education in global health: Rationale and key principles from the Bellagio Global Health Education Initiative

Global health education (GHE) continues to be a growing initiative in many medical schools across the world. This focus is no longer limited to participants from high-income countries and has expanded to institutions and students from low- and middle-income settings. With this shift has come a need to develop meaningful curricula through engagement between educators and learners who represent the sending institutions and the diverse settings in which GHE takes place. The Bellagio Global Health Education Initiative (BGHEI) was founded to create a space for such debate and discussion and to generate guidelines towards a universal curriculum for global health. In this article, we describe the development and process of our work and outline six overarching principles that ought to be considered when adopting an inclusive approach to GHE curriculum development.

The effect of a bidirectional exchange on faculty and institutional development in a global health collaboration

Purpose

The MUYU Collaboration is a partnership between Mulago Hospital-Makerere University College of Health Sciences (M-MakCHS), in Kampala, Uganda, and the Yale University School of Medicine. The program allows Ugandan junior faculty to receive up to 1 year of subspecialty training within the Yale hospital system. The authors performed a qualitative study to assess the effects of this program on participants, as well as on M-MakCHS as an institution.

Methods

Data was collected via semi-structured interviews with exchange participants. Eight participants (67% of those eligible as of 4/2012) completed interviews. Study authors performed data analysis using standard qualitative data analysis techniques.

Results

Analysis revealed themes addressing the benefits, difficulties, and opportunities for improvement of the program. Interviewees described the main benefit of the program as its effect on their fund of knowledge. Participants also described positive effects on their clinical practice and on medical education at M-MakCHS. Most respondents cited financial issues as the primary difficulty of participation. Post-participation difficulties included resource limitations and confronting longstanding institutional and cultural habits. Suggestions for programmatic improvement included expansion of the program, ensuring appropriate management of pre-departure expectations, and refinement of program mentoring structures. Participants also voiced interest in expanding post-exchange programming to ensure both the use of and the maintenance of new capacity.

Conclusions

The MUYU Collaboration has benefitted both program participants and M-MakCHS, though these benefits remain difficult to quantify. This study supports the assertion that resource-poor to resource-rich exchanges have the potential to provide significant benefits to the resource-poor partner.

Creating a charter of collaboration for international university partnerships: the Elmina Declaration for Human Resources for Health

The potential of international academic partnerships to build global capacity is critical in efforts to improve health in poorer countries. Academic collaborations, however, are challenged by distance, communication issues, cultural differences, and historical context. The Collaborative Health Alliance for Reshaping Training, Education, and Research project (funded by the Bill and Melinda Gates Foundation and implemented through academic medicine and public health and governmental institutions in Michigan and Ghana) took a prospective approach to address these issues. The project had four objectives: to create a "charter for collaboration" (CFC), to improve data-driven policy making, to enhance health care provider education, and to increase research capacity. The goal of the CFC was to establish principles to guide the course of the technical work. All participants participated at an initial conference in Elmina, Ghana. Nine months later, the CFC had been revised and adopted. A qualitative investigation of the CFC's effects identified three themes: the CFC's unique value, the influence of the process of creating the CFC on patterns of communication, and the creation of a context for research and collaboration. Creating the CFC established a context in which implementing technical interventions became an opportunity for dialogue and developing a mutually beneficial partnership. To increase the likelihood that research results would be translated into policy reforms, the CFC made explicit the opportunities, potential problems, and institutional barriers to be overcome. The process of creating a CFC and the resulting document define a new standard in academic and governmental partnerships.

Building capacity to develop an African teaching platform on health workforce development: a collaborative initiative of universities from four sub Saharan countries

INTRODUCTION

Health systems in many low-income countries remain fragile, and the record of human resource planning and management in Ministries of Health very uneven. Public health training institutions face the dual challenge of building human resources capacity in ministries and health services while alleviating and improving their own capacity constraints. This paper reports on an initiative aimed at addressing this dual challenge through the development and implementation of a joint Masters in Public Health (MPH) programme with a focus on health workforce development by four academic institutions from East and Southern Africa and the building of a joint teaching platform.

METHODS

Data were obtained through interviews and group discussions with stakeholders, direct and participant observations, and reviews of publications and project documents. Data were analysed using thematic analysis.

CASE DESCRIPTION

The institutions developed and collaboratively implemented a 'Masters Degree programme with a focus on health workforce development'. It was geared towards strengthening the leadership capacity of Health ministries to develop expertise in health human resources (HRH) planning and management, and simultaneously build capacity of faculty in curriculum development and innovative educational practices to teach health workforce development. The initiative was configured to facilitate sharing of experience and resources.

DISCUSSION

The implementation of this initiative has been complex, straddling multiple and changing contexts, actors and agendas. Some of these are common to postgraduate programmes with working learners, while others are unique to this particular partnership, such as weak institutional capacity to champion and embed new programmes and approaches to teaching.

CONCLUSIONS

The partnership, despite significant inherent challenges, has potential for providing real opportunities for building the field and community of practice, and strengthening the staff and organizational capacity of participant institutions. Key learning points of the paper are:• the need for long-term strategies and engagement;• the need for more investment and attention to developing the capacity of academic institutions;• the need to invest specifically in educational/teaching expertise for innovative approaches to teaching and capacity development more broadly; and• the importance of increasing access and support for students who are working adults in public health institutions throughout Africa.

Health professions educators as agents of change in Tanzania: creativity to implement new curricula

Muhimbili University of Health and Allied Sciences (MUHAS) strives to instill in its graduates skills and competencies appropriate to serving the Tanzanian population well. MUHAS leadership, working in collaboration with educators from the University of California San Francisco (UCSF), selected and trained an interdisciplinary group of faculty members to promote effective teaching. We describe the development of this group of faculty change agents - now known as the Health Professions Educators Group (HPEG). The HPEG invigorated the education environment at MUHAS by: engaging many colleagues in special training events that introduced new methods for teaching and assessment; encouraging innovation; and developing strong mentoring relationships. HPEG members piloted courses in education to prepare all postgraduate students as peer educators, teaching assistants, and as candidates for faculty future appointments. Creation of a 'teaching commons' reinforces the new focus on innovative teaching as faculty members share experiences and gain recognition for their contributions to quality education.

Partnering on education for health: Muhimbili University of Health and Allied Sciences and the University of California San Francisco

In 2005, Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania and the University of California San Francisco (UCSF) in the United States joined to form a partnership across all the schools in our institutions. Although our goal is to address the health workforce crisis in Tanzania, we have gained much as institutions. We review the work undertaken and point out how this education partnership differs from many research collaborations. Important characteristics include: (i) activities grew out of MUHAS's institutional needs, but also benefit UCSF; (ii) working across professions changed the discourse from 'medical education' to 'health professions education'; (iii) challenged by gaps in our respective health-care systems, both institutions chose a new focus, interprofessional team work; (iv) despite being so differently resourced, MUHAS and UCSF seek strategies to address growing class sizes; and (v) we involved a wider range of people - faculty, administrators, students, and residents - at both institutions than is usually the case with research. This partnership has convinced us to exhort other academic leaders in the health arena to seek opportunities together to enlighten and enliven our educational enterprises.

Educating enough competent health professionals: advancing educational innovation at Muhimbili University of Health and Allied Sciences, Tanzania

Sarah MacFarlane and colleagues share their lessons engaging in educational reform and faculty development with the Muhimbili University of Health and Allied Sciences in Tanzania and the University of California San Francisco.

Strengthening public health education in population and reproductive health through an innovative academic partnership in Africa: the Gates partners experience

Poor reproductive health constitutes one of the leading public health problems in the world, particularly in sub-Saharan Africa (SSA). We report here an academic partnership that commenced in 2003 between a US institution and six universities in SSA. The partnership addresses the human resources development challenge in Africa by strengthening public health education and research capacity to improve population and reproductive health (PRH) outcomes in low-resource settings. The partnership's core activities focused on increasing access to quality education, strengthening health research capacity and translating scholarship and science into policy and practices. Partnership programmes focused on the educational dimension of the human resources equation provide students with improved learning facilities and enhanced work environments and also provide faculty with opportunities for professional development and an enhanced capacity for curriculum delivery. By 2007, 48 faculty members from the six universities in SSA attended PRH courses at Johns Hopkins University, 93 PRH courses were offered across the six universities, 625 of their master's students elected PRH concentrations and 158 had graduated. With the graduation of these and future student cohorts, the universities in SSA will systematically be expanding the number of public health practitioners and strengthening programme effectiveness to resolve reproductive health needs. Some challenges facing the partnership are described in this article.

Addressing gaps in surgical skills training by means of low-cost simulation at Muhimbili University in Tanzania

BACKGROUND

Providing basic surgical and emergency care in rural settings is essential, particularly in Tanzania, where the mortality burden addressable by emergency and surgical interventions has been estimated at 40%. However, the shortages of teaching faculty and insufficient learning resources have hampered the traditionally intensive surgical training apprenticeships. The Muhimbili University of Health and Allied Sciences consequently has experienced suboptimal preparation for graduates practising surgery in the field and a drop in medical graduates willing to become surgeons. To address the decline in circumstances, the first step was to enhance technical skills in general surgery and emergency procedures for senior medical students by designing and implementing a surgical skills practicum using locally developed simulation models.

METHODS

A two-day training course in nine different emergency procedures and surgical skills based on the Canadian Network for International Surgery curriculum was developed. Simulation models for the surgical skills were created with locally available materials. The curriculum was pilot-tested with a cohort of 60 senior medical students who had completed their surgery rotation at Muhimbili University. Two measures were used to evaluate surgical skill performance: Objective Structured Clinical Examinations and surveys of self-perceived performance administered pre- and post-training.

RESULTS

Thirty-six students participated in the study. Prior to the training, no student was able to correctly perform a surgical hand tie, only one student was able to correctly perform adult intubation and three students were able to correctly scrub, gown and glove. Performance improved after training, demonstrated by Objective Structured Clinical Examination scores that rose from 6/30 to 15/30. Students perceived great benefit from practical skills training. The cost of the training using low-tech simulation was four United States dollars per student.

CONCLUSION

Simulation is valued to gain experience in practising surgical skills prior to working with patients. In the context of resource-limited settings, an additional benefit is that of learning skills not otherwise obtainable. Further testing of this approach will determine its applicability to other resource-limited settings seeking to develop skill-based surgical and emergency procedure apprenticeships. Additionally, skill sustainability and readiness for actual surgical and emergency experiences need to be assessed.

Applying innovative educational principles when classes grow and resources are limited: Biochemistry experiences at Muhimbili University of Allied Health Sciences

Teaching to large classes is often challenging particularly when the faculty and teaching resources are limited. Innovative, less staff intensive ways need to be explored to enhance teaching and to engage students. We describe our experience teaching biochemistry to 350 students at Muhimbili University of Health and Allied Sciences (MUHAS) under severe resource limitations and highlight our efforts to enhance the teaching effectiveness. We focus on peer assisted learning and present three pilot initiatives that we developed to supplement teaching and facilitate student interaction within the classroom. These included; instructor-facilitated small group activities within large group settings, peer-led tutorials to provide supplemental teaching and peer-assisted instruction in IT skills to enable access to online biochemistry learning resources. All our efforts were practical, low cost and well received by our learners. They may be applied in many different settings where faculties face similar challenges.