Nursing in Africa

In large parts of Africa, decades of war, conflict and instability have left its people with limited access to basic healthcare services. This is aggravated by the fact that the continent carries 25% of the global disease burden and the lowest number of global healthcare worker per capita.
The challenges that impact healthcare service delivery in Africa include (but are obviously not limited to) lacking infrastructure, poor management, lacking equipment, variable care standards and supply chain issues. In 2001, in an attempt to address some of these challenges, the countries belonging to the African Union (AU) committed to allocate 15% of their fiscal budget to healthcare (Abuja declaration 2001). Sadly only six countries succeeded in doing that. It is estimated that even if all of the AU countries allocated 15%, the size of their budgets are simply not enough to address and overcome some of the challenges that face healthcare systems in Africa.
The budget size and lack of allocation or investment in healthcare leads to another problem: dependency on donor funding. Unfortunately donor funding comes with vested interests and may inadvertently contribute to the vertical development of disease specific fields at the expense of horizontal or strengthening of the whole health system. A good example of this is HIV research that across the continent is disproportionately represented and funded.
Because the burden of disease and the demand for healthcare services that’s continuously rising, larger budgets and more healthcare workers are required. Alarmingly statistics demonstrates that in some African countries there has been a decline in the number of healthcare workers over the past twenty years. In addition, there is a known distribution of healthcare workers towards urban areas, leaving rural areas without adequate healthcare delivery structures and staffing.
In most of Africa, the first healthcare worker to provide care to a patient is a nurse (WHO2008). With nurses being the mostly widely spread and available health professionals on the continent, their role cannot be overestimated. Creating more enabling environments for nurses to be educated and work in better conditions should be prioritized. A few issues that seem to be universal to the ability of nurses to perform in Africa are highlighted below. These issues draw on my experience and my conversations with local nurses in the settings in which I’ve worked.
Quality and appropriateness of nurse training
Formal nursing education was brought to Africa by imperialism. This implies that the people who brought formal nursing education to Africa introduced it in a similar way to how it was done in the countries that they came from. Most of these models were (and still are) based on training nurses in-hospital and where one of the primary roles of the nurse is as team member with a medical doctor and others. This is very different from community based care that’s prevalent and required in rural Africa. In most of Africa, the nurse is often a solo practitioner that’s far from hospitals and other team members. The training of the nurses should prepare them for such roles and situations.
Clinical and educational gaps can be identified by furthering research, especially nursing science research in Africa. This then allows the design of curriculum’s that are contextually relevant to the needs of the continent. This is, however, complicated by other issues, namely:

Limited research on indigenous diseases in Africa
Most of the infectious diseases that are endemic to Africa such as schistosomiasis or trypanosomiasis are not well-researched. With limited evidence based guidance, there can be no best nursing practice for these endemic diseases.
The fields that are researched are according to donor specialization and interest. Sun and Larson (2015) did a review of all nursing research from Africa that was published over a decade and found that the most studied areas were associated with funding resources. They also found that prevalent conditions in Africa e.g. malnutrition, diarrhoea disease and other common causes of death were not studied and/or published. This demonstrated a clear gap between the healthcare needs and the fields researched.
Nursing research needs to focus and address the glaring healthcare issues in Africa. Often care in villages is rendered by persons with no training in healthcare, and addressing issues like the need for reliable community based care when developing curriculums or conducting research could impact the health systems tremendously.

IMG_5587IMG_2427
Training facilities
Training facilities across Africa lack enough classrooms, electricity, running tap water and technological advances. Internet has been reported as a scarce resource across various training settings in Africa. The access to electronic resources is limiting for both students and educators. Open-access resources have helped to make science more accessible globally, but there is still a high cost to obtaining research and information making it incredibly tough to stay abreast of new guidelines, especially for nurses in Africa.
Clinical guidance in hospitals is lacking and there are limited simulation models at training facilities. At some of the facilities where I’ve conducted training there have been no CPR manikin’s or other additional models for training. In most places we had to innovate and make our own manikins and other adjuncts.
For healthcare workers in rural areas, obtaining further education or refresher training means uprooting and even leaving a healthcare facility unattended for the duration of their training. This should be considered when we think about educating and upskilling nurses.
Knock-on impact of the doctor shortage in Africa
The lack of doctors, especially in rural areas has resulted in task shifting. Task shifting occurs when tasks that would normally be seen as the doctors’ domain, are shifted to nurses. It increases the nurses’ workload and the nurses are expected to perform tasks that they have not received training for.
The distribution of health facilities and different tiers of care means that the large drainage areas in the rural districts are often manned by nurses without any further medical support close by. This means that the nurses working in rural areas are isolated when dealing with cases that are not within their scope of practice, limited clinical guidelines and difficulty in obtaining help. Telemedicine and technology may offer some solutions provided that it can be reliable in areas with limited electricity, currently no internet etc.

Regulatory issues
In many African countries, graduates are not subject to registration with a statutory body. There may be professional associations, but there is no compulsory registration process and professional licensing. In countries with no regulatory body, there is no representation to lobby for nursing rights or amendments to Acts of Parliament, salaries for nurses or to promote career progression.
Often healthcare worker salaries (including doctors) are not paid on time, if at all. This leads to some healthcare workers having secondary streams of income or funding their own incomes out of privately charging patients’ higher fees.
Gender inequality
In most African societies, gender equality has not yet been achieved. Women receive less education than men, they have less rights and their voice are not heard in the same way. Nursing remains a predominantly female profession and this limits the ability of nurses to assert themselves and it impacts on the ability of the profession to influence national policy.
There is a trend where even though the nurse workforce is mainly female at service delivery level, at top management and policy level it’s represented by men. In the DRC it was established that only 1% of the nurses are male, yet more than 90% of the top levels and education facilities positions are filled by men.
The social determinants allowing people to access healthcare includes basic primary education and gender equity amongst other factors. Sadly neither one of these has been achieved for nurses in Africa and it hampers the progress of nursing education and research across the continent.
Career progression
This tie in with the above, and the fact that because of the role of women in society, nurses being mostly female and the difficulties faced by nurses to render care, career progression may be stunted. Because healthcare workers in rural areas need to travel to further education and because nurses are predominantly women, it is hard for them to leave home and obligations at home to further their career.
Lack of mentorship and language barriers
There is a lack of mentorship to help nurses further themselves as researchers and educators. Organizations such as the AFEM Nurses Group developed a mentorship program with international mentorship support to African nurses. Another program is the Nursing Education Partnership Initiative (NEPI) that was formed in 2011 by PEPFAR to improve nursing and midwifery education in Africa. We need more programs like this.
Mentorship, inclusion into global healthcare networks, research and education are complicated by language barriers. Often nurses working in rural areas do not read or speak English; the language which much of the training material and research is presented in.
Conflict
It has been postulated that there’s a statistically significant relationship between accessibility to care and civil conflict (Rhode 2015). Unrest and conflict creates havoc on the ability to deliver healthcare, train providers, obtain supplies and in violent prone areas access may be restricted as patients are afraid of travelling. During periods of increased violence, the healthcare facilities are looted and healthcare workers intimidated. In violent prone areas, malnutrition is aggravated, harvests are regularly pillaged and access to fields is restricted due to security conditions.
Conclusion
There are various challenges to improving the fragile healthcare systems in Africa. Nurses form the backbone of healthcare service delivery in Africa. The difficulties faced by nurses across the continent are only one challenge; improving dilapidated health facilities and improving on the poor distribution of essential medicines and supplies are other challenges.
In order to improve healthcare systems, nurses needs to be more involved in policy-making, developing healthcare plans and research.

Please note: Africa is not a country and in some of the African countries, the health system is well-established and working. In other’s it’s not going that well. I’m aware that this blog makes blanket statements, however it refers to my experiences and conversations in the country’s that I have travelled to.

References
Munjana OK, Kibuka S, Dovlo D. (2005) The nursing workforce in Sub-Saharan Africa. Issue paper no 7. International Council of Nurses.
Sun C. Larson E. (2015) Clinical nursing and midwifery research in African countries: a scoping review. International Journal of Nursing Studies. 2015 May;52(5):1011-6. doi:10.1016/j.ijnurstu.2015.01.012.
http://www.our-africa.org/women
http://www.who.int/healthsystems/publications/abuja_declaration/en/
Rohde JT. (2015). The relationship between Access to Healthcare and Civil conflict. College of William and Mary. Honors Theses. Paper 99
Abuja Declaration 2001
Klopper HK, Uys LR. 2012. State of Nursing and Nursing Education in Africa: a country by country review. Sigma Theta Tau international
The nursing Education Partnership Initiative in the Democratic Republic of Congo. (2012). Assessment of nursing and midwifery education and training capacity at seven training institutes in the DRC. Synthesis report. Prepared by CapacityPlus, Intrahealth International

The garbage people: unintended consequences of change

With a capacity for 20 000 people, the cave church of St. Simon are said to be the largest Christian church in the Middle East.  The church’s limestone walls have breath-taking carvings.  Getting there requires travelling through a section of Cairo’s Manshiyat Naser neighborhood known as the garbage city. This is breath-taking in a completely different way…

Your senses alert you that this is the garbage city, the putrid smell is intense and there is garbage everywhere.  Garbage fills the narrow streets, the balconies, kids play in it and the shops are hidden between garbage. Garbage city is home to the Zabaleen (garbage people).  The Zabaleen travels from house-to-house in Cairo, collecting household waste and transporting the collected waste back to the garbage city. Each family specialize in a type of garbage that they sort, recycle and sell.

Until 2003 the Zabaleen collected garbage at almost no cost to the government and residents of Cairo.  Their main income came from recycling the garbage.  It’s estimated that in 2003 the Zabaleen recycled 80% of the garbage collected.  This was described as one of the most efficient recycling systems globally and it has earned the Zabaleen international acknowledgement.

 

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View from the car window

 

The Zabaleen are Christians in a Muslim majority country.  In the recycling business this provides them with a competitive advantage: the ability to keep pigs.  The Muslim’s religion does not permit living close to or keeping pigs. Most of the waste collected is food waste; the Zabaleen recycles this by feeding it to their pigs to fattening them up.  Once fat, the pigs are sold, providing further income.

The improvement: fake green grass on the other side of the fence

In 2003, the Mubarak government decided to ‘modernize’ the garbage collection system of Cairo by adopting the systems used in Europe.

Unintended consequences of the change

  • Adverse impact on the socio-economic stability of the Zabaleen
  • The modern mechanism of compressing garbage complicated recycling and the level of recycling dropped
  • Cairo’s streets were too narrow for the mechanized equipment, uncollected garbage was dumped by the residents
  • The new collection system introduced higher fees resulting in further illegal dumping, burning of waste and increased pollution

To compare: in 1997 the Zabaleen collected 3000- 4000 tons of garbage per day at almost no cost to the government; they recycled about 80% of the waste collected.  In 2004 the government was paying ten times more to have only 60% of the garbage collected and 20% of the collected garbage was recycled.

 

Then in 2009, the Egyptian government ordered the slaughter of some 300 000 pigs as precautionary measure to prevent swine flu (H1N1). This effectively destroyed another vital aspect of the Zabaleen’s recycling methods.  The WHO called the killing ‘scientifically unjustified’. The government’s actions against the Zabaleen was almost certainly politically motivated and grounded in religious tensions.

Moral of the story

There is a tendency to view another country, organization or functional work unit’s methods as superior.  It is problematic when these methods are adopted without considering feasibility, cultural differences and why the current system operates the way it does. There is always a reason for the faults in the current system, a few examples would include hierarchies, history or power struggles.

 

cow-jumping-over-the-fence

The grass is not always greener on the other side….

 

Even in healthcare, when low-middle income countries (LMIC) undertake to improve their healthcare systems, they often model their interventions after high income countries (HIC).  However, HIC have the enabling infrastructure to support advanced health systems. In LMIC’s with poor roads, it would be more sustainable to invest in bicycle ambulances than to establish ambulance services.  Rather than develop university curriculums, train community first responders in the rural areas.  Instead of creating an urban center of excellence, provide electricity and running tap water in all the small rural clinics.

To the Egyptians, investing in the Zabaleen’s existing informal system would’ve probably been more beneficial, cost effective and sustainable.  By disregarding the functioning informal system, the policy makers destroyed a functioning system and adopted a system not suitable for their setting.  This resulted in failure so devastating that it’s even been cited as a reason for the 2011 uprising.

There are a few lessons that we can take from this:

  • Don’t discard local ownership
  • Thoroughly observe and analyze the current situation prior to suggesting change
  • The above implies spending time to explore the current situation
  • The first consideration should always be to augment the local/informal system or to formalize the informal system
  • If the solution is adopted, make it context specific, in other words innovate on what worked somewhere else
  • When formal systems are developed it should be done considering the integration of formal and informal systems from the beginning

Disregarding the above will result in change programs that are not sustainable.  Not integrating formal and informal systems result in parallel systems where the systems compete to the detriment of both.

Conclusion

A year after implementing the ‘modern’ system the Egyptian policy makers had to acknowledge failure. A decade later they are taking steps to integrate the Zabaleen into the formal system.  They are also investing in the Zabaleen that now have uniforms and vehicles.

In short, don’t solve problems that don’t require solving, observe, investigate and find the real and right problems.  Solutions should be feasible, involve the locals and the informal systems and don’t ever blindly adopt, rather innovate and make change context-specific.

To watch a short documentary about the garbage people

https://www.youtube.com/watch?v=D0s7WsoC528

Read more

Wael Salah Fahmi. Keith Sutton.  (2006)  Cairo’s Zabaleen garbage recyclers: multi-nationals take over and state relocation plans.  Habitat International 30 (2006) 809-837

http://www.yourmiddleeast.com/culture/turning-waste-into-wealth-with-cairos-garbage-people-photos_31874

https://www.theguardian.com/global-development/poverty-matters/2014/mar/27/waste-egypt-refuse-collectors-zabaleen-cairo

http://weekly.ahram.org.eg/News/14892/32/Egypt%E2%80%99s%20garbage%20problem.aspx

https://en.wikipedia.org/wiki/Zabbaleen

http://www.samaanchurch.com/en/about_us.php

http://news.nationalgeographic.com/news/2009/04/090430-egypt-swine-flu-video-ap.html

 

Making sense…learning about sense-making

Remember the movie ‘Back to the future’ where Marty (Michael J. Fox) travels through time, whilst figuring out what is happening and how to influence the future whilst simultaneously dealing with the current situation?

It reminds me of sense-making. Sense-making is about how we give meaning to a situation. Sense-making is based in our decisions and beliefs and it is influenced by aspects such as power relations, hierarchy, autonomy, linguistics, temporalization (focus on now, the past or the future), justification, culture and traditional society, equality, bargaining power, locus of control, openness to change. Sense-making is done individually or collectively in organizations and communities.  Capturing these underlying nuances in our perceptions allows deeper insights into why an organization or community are angry, failing, succeeding, innovating, etc.

Brenda Dervin, Gary Klein, Karl Weick and David Snowden are a few of the contributors to sense-making. They all describe their own theory about sense-making either as individual or collective activity.  Snowden combined several sense-making theories into one tool.  For my studies I am using his tool to capture community perspectives regarding cost as a barrier to access emergency care. 

Today I’m sharing my understanding of Brenda Dervin’s metaphor for sense-making.  Dervin sees sense-making as the individual activity of information seeking, processing, recreating and application. Information is described as a tool designed by humans whilst making sense of reality.  Methods of communication and the application of information (knowledge) are key aspects of sense-making.

The metaphor 

timespace

It starts in a time-space milieu, implying constant energy and movement. This environment is never static and time-space energy propels us forward or pulls us back, always fluctuating and never stable.

Moving through time-space we have Mr. Squiggly.  Humans are depicted as squiggly because we are caught between certainty and uncertainty.  Thus there is a constant flux within the person (internal) and between the person and the environment (external).  Mr. Squiggly carries an umbrella, symbolizing mind-set, perceived constraints and enablers. (I feel that it should be a backpack – demonstrating our baggage).

Mr Squiggly.png

Whilst moving through time-space, a gap or barrier is encountered. For the purposes of my work, the gap is a life-threatening injury or illness requiring urgent care. The gap can however be any barrier or difficulty in daily life (in an organization it could be new policies, a new boss etc.). The gap forces Mr. Squiggly to stop until a way has been found to ‘bridge’ the gap and reach an outcome.

The outcome depends on how the gap is bridged.  Some potential outcomes are not obvious in the beginning and it may only become apparent retrospectively, influencing future decisions and beliefs.

Moving from situation to outcome requires a bridge. The building blocks used to build the bridge consists of different types of blocks.  One being the individual mind-set, during a life-threatening emergency it would include individual beliefs about health, healthcare, medication, culture. Building blocks also include inputs from others, the stories within the community about a time that something similar happened to someone else, financial hardships suffered, patient outcome etc.  Mr. Squiggly consciously and unconsciously use all the information in the form of building blocks to create the bridge.

Once the bridge is built, Mr. Squiggly can leap across the bridge to the outcome; this is aptly called gap-bridging.  The building blocks of information is now applied, thus knowledge are created. Dervin use the term ‘verbing’ as an important gap-bridging and sense-making tool.  Everyday examples of verbing include the use of words for example emailing, googling or ubering. Verbing thus occurs when a noun is turned into a verb, creating action or experience.  It certainly fits a methodology where knowledge is seen as a context-specific sense-making activity in a specific point in time and space.

 teh gap.png

I’m using sense-making to capture the various roles within a community perceive gaps, bridge gaps and view the outcomes during a life-threatening injury or illness. Perceptions will be captured using a type of narrative enquiry, where the participant is asked to tell a descriptive story.  After telling the story, the storyteller explains the meaning of their own story by indexing it onto a predesigned framework.  This is very different from ‘traditional’ research where the investigator assigns meaning to the stories. Neutral questioning is used to guide the indexing.  Questions are framed in such a way to capture the nuanced aspects of hierarchy, autonomy, equality etc.  After capturing, the data are combined and the software allows for it to be visually displayed, enabling easy identification of patterns and trends.  More details on the software are a story for another day.

This technique has been applied to monitor, evaluate, communicate, and create feedback loops in projects, organizations, communities and even broader society.

I am using sense-making because I’m passionate about the voice of the ‘voiceless’ in organizations and communities.  I feel that tacit knowledge is often overlooked.  Sense-making provides a tool to capture many voices, combine the different perspectives and seek common ground, emerging trends or underlying moods. This is powerful, whether in an organization, community or development project. It prevents the implementation of one perspective, ‘outside’ views or only top-down approaches. Inclusive sustainable implementation requires more than one story, one perspective and more than one type of knowledge.

 As Chimamanda Ngozi Adichie says in her powerful TED talk about the danger of a single story:

The single story creates stereotypes, and the problem with stereotypes is not that they are untrue, but that they are incomplete. They make one story become the only story.”

References

I adapted the pictures from: Facing a gappy situation. Sense-making methodology: communicating communicatively with campaign audience.  Dervin, B. 2003.  In Dervin B, Foreman-Wernet L (Eds). Sense-making methodology reader: selected writings of Brenda Dervin, Cresskill, NJ: Hampton Press 2003.

http://www.ted.com/talks/chimamanda_adichie_the_danger_of_a_single_story?language=en

The story of clinical facilities planning

For the past two months I have been working on a project involving clinical facilities planning.  This is still a very novel concept in South Africa. It involves planning the hospital’s flow during the design phase.

As far system strengthening is concerned the physical and spacial relationships within the system and the subsequent influence of each relationship on others impact on the full systems operation and efficiency.  Some of what we attempt when we implement improvement programs is to fix wrongly designed systems, physical structures that are outdated, outgrown and to accommodate new technology within the existing structure.   A way to truly fix a system is to rebuild it…correcting the old model.

It is very hard to simply action the rebuilding of an entire physical structure to resolve system issues.  Therefor physical structure is hardly considered a leverage point when improving a system.  It is only a leverage point if it is designed to suit the system’s needs.  Once built we can only manage constraints and inefficiencies with improvement programs to manage limitations, bottlenecks, matching demand and capacity or even work around system failures.

Hospitals are subject to rapid change and a clear operational concept and accurate scope of services is essential during design.  The ability to forecast trends and change requires clinical insight and not just architectural design capability.

Reading through international literature on clinical facility planning, I was amazed to read a statement that there are more than 600 studies demonstrating the impact of hospital design on outcome measures such as reduction in staff turnover, staff stress and even patient pain level perception.   This obviously implies a link between facility design, perceived quality of care, patient safety and error and nosocomial infection.  Some factors to consider are single versus multiple bed rooms, ability to observe patients, distance between beds, availability of hand wash facilities, slippery floors, and distance from nurse station to patient room.

Clinical oversights in facility design in units where I have worked include a unit where the sluice room had limited space to test urine and no cupboard space to store urine and pregnancy test containers.  The sluice room had only a tiny sink and could accommodate one person at a time.  This resulted in an overflowing messy sluice room during busy times, bottlenecks, running around to obtain pregnancy tests, urine sample bottles etc.  Another example is that it was decided to remove an electronic patient system as it was not effective.  In an independent study conducted afterwards, one of the main reasons given by nursing staff for the ineffectiveness was the location of electronic devices within the facility and its subsequent impact on flow and patient care. And then the steps at an emergency exit at a ward for bedridden patients, the mind boggles.

There is a fine balance in meeting the needs of the clinical facility user (patient) and facility management.   By marrying the financial aspects, clinical intent and the physical infrastructure design, a plan can be developed that appropriately balance the patient journey and operational efficiency.

I’m involved in a facility that is being rebuilt with a structured transition from old to new.  My role is to write the functional narrative, which is the expression of the intent and flow within all functional spaces such as patient rooms, utility rooms, medication rooms, nurse duty stations.   As we are hoping to impact a paradigm shift in culture during the transition the narrative is crucial, it is the story of the new facility after all.

I feel privileged to be part of the change process and I hope that it will result in safer patient care and improve access to care in the new facility.

Shift the focus to emergency care!

Global statistic: 2300 children die daily due to injury
(According to the World Health Organization department for violence and injury prevention)

There is a correlation between a country’s economic sustainability and the level of health care that it renders. The Millennium Development Goals (MDG) was set in 2000 by the 189 United Nations members. The members committed to achieving eight goals, three are linked to improving health care (reduce child mortality; improve maternal health and combat HIV/AIDS, Malaria and other disease). As such developing countries have focused and made great progress towards achieving the goals; however I believe that there is an oversight.

International policy makers and donors are following a vertical approach by supporting one aspect of care e.g. HIV projects exclusively. Therefor MDG’s are achieved by improving silos of the health care system as opposed to full system strengthening.
The health system and all systems connected to it have a primary purpose of improving and maintaining health. Each subsystem achieves it in a different way with the distinguishing characteristic separating the emergency care systems is that effectiveness of emergency care depends on time-sensitive interventions.

The ability to render time-sensitive interventions requires a balance between demand and capacity within the system. Any fluctuation in demand directly impacts access and availability of emergency care. Demand is typically unpredictable and dependent on factors such as functioning primary and public health systems, demographics, infrastructure, cultural beliefs about care etc.
What is predictable is that if demand is not met, patients die or suffer long term consequences.

Countries in Africa lack adequate emergency care policy. The exclusion of emergency care as priority in developing countries creates gaps in transition of care and flow between the parts of the system. Receiving vaccinations and wearing condoms cannot prevent death due to limited access to timely intervention.

Research has demonstrated that people in Africa state the measurement of good health as the ability to work. This implies that access to functioning emergency care systems is of the utmost importance to the communities whom we serve.
If we do not focus on emergency care within bigger health policy we cannot meet the essential goal of health care.