Dr Lucy Obolensky/General Practitioner/Plymouth
Dr Lucy Obolensky works in Emergency Medicine and General Practice and has a wealth of experience within the field of Global Health. Lucy is programme lead for the Global Health Masters at Plymouth University, and co-founder of both Future Health Africa and the Global Health Collaborative. From twenty years spent setting up healthcare improvement projects in remote environments, Lucy shares her invaluable advice when considering such work, in the form of a handy ten-point checklist.
In arid, rural Kenya where access to clean water, good grazing for cattle and education for children is sparse, how do you support the delivery of quality and sustainable healthcare to communities?
Since 2000, I have been working with local conservation organisations to improve the health outcomes of rural communities in Kenya. In this article I will share with you some of my experiences, the challenges we have faced and lessons learnt.
A background to tribal culture.
Before envisaging a health system it is first essential to understand the people and the culture that you are working with. I was just 17 years old and about to embark on my medical degree, when I first visited the community of Leparua in Northern Kenya. Since then I’ve spent many months of my life based at their clinic. They have seen me grow up, graduate as a doctor, then a surgeon, get married, have children and ultimately bring my own children to their community. I feel privileged when I consider how I have been allowed to develop a depth of understanding of their culture that not many have the opportunity to. Yet, every time I visit, I am still learning about the traditional practices and beliefs that define their health needs and outcomes.
The communities that I have spent the most time working with are the Maasai and Samburu. These pastoral nomadic tribes live in manyattas (a type of wood and mud hut). Their wealth is demonstrated by the number of livestock they own or if they have a tin roof on their manyatta. Large families, of five or more children, are common. When a daughter gets married, her family receives a dowry in the form of cattle. Domestic violence is not uncommon, nor is female circumcision. Traditional birthing attendants perform most of the deliveries and traditional healers or witch doctors are commonly consulted. There is frequent intertribal fighting and cattle rustling, which is increased during times of drought and poor grazing.
However, times are changing in these communities. Tribal elders are starting to see the importance of women as leaders. They believe that the education of girls as well as improved access to healthcare and education for all will help to achieve this. Our aim is to work side-by-side with communities, conservation NGOs and the Ministry of Health, to both improve provision of healthcare and support this positive cultural change. It takes time, patience and support from many sectors for communities to find a new path which adheres to their traditional values. The journey is long, but overall there have been many sustainable achievements.
The Northern Rangelands Trust
The Northern Rangelands Trust (NRT), a conservation organisation that I work with, has taken a holistic approach to public health for some time. The NRT aims to enhance people’s lives through building peace and conserving the natural environment.
They have worked in union with tribal elders to prioritise the needs of the local community, stating these needs as:
⦁ Grazing for livestock and fair trading of animals
⦁ Peace and security for homes and villages
⦁ Access to clean water, healthcare and education
Perhaps unsurprisingly, these priorities are closely aligned with the 2015 Sustainable Development Goals developed by the United Nations General Assembly.
Delivering Community Healthcare
So, in practice, how do you work with communities to improve the provision of healthcare, address the wider needs of the community and support cultural beliefs, all on a background of limited funding?
You can install a bore hole into a village, but if there is risk of fighting or cattle rustling the tribes will be forced to move away from this clean water supply. You can offer education, but if there is no nearby grazing children will be required to help the family, herding cattle far away, rather than attend school. You can offer healthcare, but it is essential to assess its accessibility and cultural acceptability.
A checklist for designing and implementing community health projects:
From my 20 years of experience in delivering community healthcare to remote locations and austere environments, I have developed a ten point checklist that I use for any project.
In order to better illustrate this checklist, I will use it to talk through a Family Planning Programme that we set up in 2010 in Kenya.
What do the communities want?
I have spent many long days sitting under a shady tree, drinking a heady concoction from a gourd poured by a wizened tribal elder, waiting and listening to get to the bottom of what the residents would really like to see in their community. The lesson is that embarking on any healthcare implementation project, however important you see it to be, without the buy-in of the communities will be doomed to fail.
In this instance the community elders said they wanted to have access to family planning within their community. At the time this was only offered at a clinic which is a 6 hour walk or 3 hour drive away.
Evaluate unmet need.
‘White elephant’ health facilities and pieces of medical equipment from charitable donors may be gratefully received at the time of giving, but, without the resources to staff the centres and maintain the equipment, risk sitting around gathering dust.
Once you have a clear understanding of what the residents would like to see in their community, it is imperative to continue to work together with the communities to evaluate the unmet need for the project. This is an exercise best undertaken with a Ministry of Health representative, in order to understand what resources are available.
In this example, there certainly was an unmet need for family planning. The existing clinic was a long walk away and many women have 5 children. Subsequently, they spent much of their adult life pregnant or post natal, often with associated anaemia or nutritional deficiencies.
What is the National Strategy?
If your project is not being undertaken on behalf of the government, it is vital that you engage early with local government health officials (most likely the regional public health officer or a county minister of healthcare). By approaching this in the correct manner, it is likely that the local government will be delighted that you are offering to support their health service. Your project should, however, either enhance or develop what is already in place, or be in keeping with priorities of the national health strategy.
In this case, there was a big government drive to deliver family planning to all remote settlements. They were struggling to deliver this project due to funding and logistical challenges, and multiple other factors inherent to delivering healthcare in low and middle income countries that are beyond the scope of this article.
We visited the County Minister of Health to discuss the scope of our project, and the memorandum of understanding (MOU) we already had in place with the local communities involved. He disclosed that the government would be able to provide all the contraceptive implants and medications once the programme had been approved and commenced. This was a positive start, but not all planning meetings are so straightforward.
During the family planning project development stages, we had proposed to develop training for Traditional Birthing Attendants (TBAs). Our idea was to upskill the TBAs to recognise early complications of labour and bring women into the clinic earlier. This seemed like a good idea in theory, however, the government had recently made working as a TBA illegal, citing them as one of the reasons for raised maternal mortality in rural villages.
Proceeding to train TBAs without consultation of the National Women’s Health Strategy and discussion with the government health official would have been to undermine government regulations. Instead, we worked together to train TBAs within government guidelines and offered incentives for TBAs to bring struggling women into the clinic promptly when indicated. This empowered the TBAs, ensured the safety of women in labour, and ultimately brought down maternal morbidity and mortality rates in the community.
Partnership and Governance.
It is important to identify all your stakeholders early in the process. Ideally you will form a partnership with the host party (MoH or NGO) and develop a MOU. It is also useful to be aware of the ‘9 Principles of a Partnership’, written by the Tropical Health Education Trust, and use these as a guide for both parties to abide by.
If you have a signed MoU then you are likely to have at least considered your governance. My general approach is to work through this with the local team, being very clear about your boundaries, roles and responsibilities. There are plenty of examples of MoUs from other partnerships online, so take a look at these MoU before you try to reinvent the wheel. You can find guidance on writing a MOU from THET here.
It would also be prudent to include medical indemnity under governance. It is important to ensure that the organisation that you are planning to work with has an agreement with their government, or is working in partnership with a recognised non-governmental organisation (NGO). If you are going to be working in a clinical capacity, which tends to mean any work involving patients, then you will need to be registered with the health system of the country you are working in. In the UK this is equivalent to being registered with the General Medical Council (GMC). Alternatively you will need a letter from the minister for health for the region you are working in, stating that you are working under their supervision. If you are not working clinically, your usual indemnity organisation should be able to cover you, although this will depend on their individual policy. You do need to contact them to let them know what you will be doing and discuss the available indemnity options for you. Some indemnity providers may offer a reduced fee for indemnity cover while you work with global health partnerships or with humanitarian organisations.
Keep it Simple.
So now you have a project, a partner and a goal. As you embark on your healthcare delivery project, it is highly likely that you will come across other equally important unmet health needs that require action.
While implementing our project, it was not uncommon to see malnourished children accompanying their mothers to the family planning clinic. It is difficult not to intervene but I would caution you not to step outside the remit of what you have set out to achieve, and what you will realistically be able to implement within your timeframe and budget. Malnutrition in children is a hugely important issue, but needs to be undertaken with the same careful planning and consideration as your primary project goal.
It is helpful to use the SMART criteria: your objectives should be specific, measurable, achievable, relevant and time-bound.
Taking time to understand local culture
I cannot stress this point enough, nor can I stress how long this can take as an outsider to an unfamiliar culture. As mentioned previously, I have been working with one community for over twenty years, and yet on many occasions I realise that my cultural knowledge only scratches the surface.
Limitations and challenges
You are bound to encounter problems with the programme. The question is whether you can pre-empt these and do anything to mitigate them. It could be funding, the logistics of supply and demand, or getting buy-in from the community as a whole. Like any community or organisation, what the elders want doesn’t always align with everyone’s wishes.
In the case of the Family Planning project our problem turned out to be buy-in from the whole community. To facilitate acceptance of the family planning clinic by the wider community we had arranged education sessions carried out by specialists from the same tribe and culture. We also held open forums to discuss what family planning is and what it means for the women, the man, and the whole family.
On the day that the clinic opened a long queue of women was waiting outside to be seen. There was excitement in the air and it seemed to be an encouraging beginning. Sadly it was not all plain sailing.
I returned four months later to carry out follow-up of the project, and initially was informed by a delighted nurse how good uptake the uptake had been. I saw a couple of women enter the clinic, but interestingly the nurse had their records in her desk drawer. When another woman came in without her card I pointed out that these should stay with the women, rather than at the clinic. Both the nurse and the woman looked very concerned.
I then noticed that this woman had bruising to her face and was holding her arm in her kikoi (cloth garment worn around the waist) due to an injury (she had an ulna fracture). When I asked her about it she explained that her husband had beaten her when he found out she was on contraception. He told her that this would make him impotent. My heart sank. I later found out about another woman who had been admitted to hospital with a head injury for the same reason. I was faced with the realisation that we had implemented a programme that was ultimately causing women harm.
I initially felt very strongly that the project should stop, or at least be put on hold until we could resolve this serious issue. However, when we met with the local women’s group they were adamant that the programme should continue and felt that huge gains had been seen already.
I supported this decision on the agreement that we, with immediate effect, provided ongoing education sessions, with some men-only sessions delivered by male nurses from the neighbouring clinic. This was much better received, and myths such as ‘having sex with a women who is on contraception will make you impotent’, and that ‘women on contraception can never give birth to boys’, were able to be voiced in an open forum, discussed and dispelled by the education specialists.
The following year I visited the clinic. Whilst I was chatting to the nurse a man brought his wife into the clinic. The nurse went in to see them and, while popping back out to collect some equipment, spoke to me. “You see doc” she said with a smug grin on her face, “now they all bring their wives here for family planning!”.
Within six years of starting the programme we had over 85% uptake of family planning services, with the remaining 15% accounting for times when the tribes may have moved on for grazing. After ten years we began to see a reduction in the number of children per family, accompanied by a reduction in maternal mortality.
Follow-up, evaluation and improvement
Whatever your project, you will need to think about how you are going to carry out follow-up, evaluate it and make any necessary improvements. As per point 4, you need to consider all your stakeholders: what are you giving? What are you gaining? What can be learnt?
Monitoring and evaluation are vital to all projects, but you need to consider who will be able to implement this. Do the local teams have the skills to do this as part of a quality improvement cycle? If not, then part of your project plan should be to train nurses, community health workers and community members to carry this out.
In the case of our family planning project we were lucky to have all of the above to help gather information so that collectively we could review and agree on any changes that should be implemented. We also continued to involve the government from the outset which, as you will see from the points below, is fundamental to the success of any project.
Local sustainability and having an End Point.
These two final points need to be considered together. In my view, many ‘Western’ charities make the mistake of embarking on health improvement projects before really considering where their input will end.
To be truly successful and sustainable, projects cannot continue relying on overseas grants, aid and resources. Any programme must have the capacity to be locally sustainable and be fully owned, delivered and governed by the in-country team. Therefore, at the very start of any programme you need to know the ending. What will mark the end of your time with a project? When you can confidently withdraw knowing that the project is sustainable and self-sufficient.
We alone did not define the end point of our family planning project. We sat with the Public Health officer of the county and agreed on a series of indicators, including numbers trained, percentage uptake or services, presence of mobile clinics, etc. It became apparent that the more successful the early stages of the project were, the more funding the government would invest in subsequent years. Within five years the entire programme was provided and funded by the government. This includes ongoing training, which we all hope will help to maintain sustainability of the programme long into the future.
Planning and implementing community health improvement projects in remote environments is complex. Working with these communities has demonstrated to me the importance of ‘One Health’. The ‘One Health’ approach, as adopted by the WHO, is “an approach to designing and implementing programmes, policies, legislation and research in which multiple sectors communicate and work together to achieve better public health outcomes.”
Failing to deliver health improvement projects in accordance with the One Health approach is likely to result in a failed programme. All services should be implemented and delivered in a holistic manner, with health considered as only one piece of a much wider jigsaw, to ensure long term, sustainable and positive health outcomes.
Dr Obolensky is also the founder of Endeavour Medical. The team at Endeavour Medical run scenario based training courses to explore and teach the knowledge and skills required to provide medical cover in remote locations. One of their core values is a belief in Universal Health Coverage. For this reason they have committed to supporting Global Health Projects in Kenya, like the one you have just read about.