Global Health Corps Holds Training and Orientation at Yale

Medical Records in Shashemene clinic in 2006 (left) and in 2007 (right), after on-site mentors arrived

        Barbara Bush, ’04, is glad to be back at Yale in a new role – orchestrating orientation for the newest group of Global Health Corps’ (GHC) fellows. Founded two years ago, the GHC provides year-long fellowships for young persons from diverse backgrounds to work on the frontlines of the fight for global health equity.

The Yale Global Health Leadership Institute (GHLI) partnered with GHC in the planning of this year’s orientation. “GHLI also has a commitment to educate young professionals for leadership roles in health care systems around the world. Together, we hope to expand effective partnerships and train the next generation of leadership in global health,” said Elizabeth H. Bradley, Ph.D., faculty director, GHLI.

On July 11, Dr. Bradley presented to GHC fellows about health systems strengthening. Using GHLI’s work in Ethiopia and Liberia as examples, Dr. Bradley discussed “the science of improvement” as contributions to global health systems strengthening efforts. When Ministry of Health officials in Ethiopia and Liberia decided to decentralize the health systems in their countries, GHLI faculty and staff focused on how they could help translate the government policies into practice in hospitals and health centers around the country. As part of the Ethiopia Hospital Management Initiative (EHMI), GHLI worked together with the Clinton Health Access Initiative to place on-site mentors in 16 hospitals across Ethiopia. The EHMI program, now entering its 7th year, also facilitated the establishment of a “CEO” model of hospital leadership, and created a Master’s of Hospital Administration program at two Ethiopian universities to train newly appointed health care executives.

The program grew out of improvements made at the local level. In Sheshemene, the medical record was redesigned to be more complete and locally relevant, and registration was centralized and computerized to prevent bottlenecking among patients. Evaluation of the projects showed tangible quality improvement across the participating hospitals.

During the talk, one GHC fellow in the audience asked how the team members dealt with any negative reaction from the hospital staff or managers. “It starts with listening,” responded Dr. Bradley. “You cannot go in and try to change everything right away. You need to learn how the system is working currently and from there find ways to accommodate people and create incentives.”

Nina Gumkowski, GHLI Intern

Health Care Administrators Present Cost- Saving Innovations to U.K Visitors

At the Yale-SEPT International Healthcare Management Programme session last week, a panel of three health care administrations from Connecticut and New York presented cost-saving innovations that have been implemented in local health management systems.

The first panel member to speak was Gayle Capozzalo, executive vice president, strategy and system development, Yale-New Haven Health System (YNHHS). She explained how the YNHHS – which encompasses three hospitals in diverse demographic regions of the state – was charged with cutting costs that would have resulted in lost jobs. Instead, they hired consultants to observe the hospital staff and determine what changes could be made to increase productivity. Their discoveries – including the fact that more than 50 percent of nurses’ time was wasted on administrative duties – led to an overhaul of procedures, implementation of more efficient technology and standardization of the shift change process. Although administrators faced some resistance to change, staff time is now more productive and patient satisfaction has increased.

Next, on the panel was William Gillespie, senior vice president and chief medical officer of Emblem Health, a not-for-profit health care provider. Mr. Gillespie shared with the audience that Emblem Health is faced with the question of how a health insurer can add value during this time of health care reform. He explained that health care providers need to be patient advocates; helping people coordinate their care and navigate through the sea of information received during medical treatment. Emblem Health’s began by designating nursing personnel, clinical advisors and social workers to assist patients who are transitioning from in-patient to home care. These advisors develop personal relationships with patients and help insure that there are no oversights in a patient’s care. The program has resulted in a reduction in preventable hospital readmissions, saving both money and manpower.

The third panelist was Steven Merz, vice president of administration, Yale-New Haven Hospital (YNHH). Mr. Merz discussed an issue that YNHH faced regarding the care of mentally unstable patients throughout the hospital. The costs of behavioral health services are largely not covered by insurance. Add to those costs, the numerous hours spent by staff trained to service medical and surgical issues trying to assist patients with mental health issues while still trying to keep a safe environment for other patients on the floor. Patients in need of behavior health care were being caught in the middle -- they couldn’t stay in the hospital because insurance wouldn’t pay, and they had nowhere else to go. So, YNHH created Behavioral Intervention Teams. The teams are comprised of psychiatrists, nurses and social workers who accompany the medical and surgical team on rounds to observe patients from admission, essentially upending the consultation process. After a month, the new progress of this innovation was reviewed and revealed that in cases where the behavioral team was involved; there was a significant reduction in the length a patient stay and there haven’t been any denied days by the insurance companies. The team’s involvement also affords each patient better integration between physical and mental health care provision.

Nina Gumkowski, GHLI Intern

U.K. visits U.S. to Examine Health Care System

 Elizabeth H. Bradley, Ph.D., faculty director of the GHLI and Patrick Geoghegan, OBE, chief executive, South Essex Partnership University NHS Foundation Trust, are joined by physicians, nurses and health care providers from the United Kingdom as part of a week-long session held in July at Yale.

      Last week, the Yale Global Health Leadership Institute and the South Essex Partnership University National Health Service (NHS) University Foundation Trust (SEPT), is holding an executive management training session at Yale. Members of the NHS will examine the U.S. health care system and learn from Yale faculty. This year’s session is of particular importance with the U.K. in the midst of a major health care reform that aims to transform the NHS into a more competitive and increasingly privatized system. At the same time, recent American health reform has been aimed at eliminating disparities and moving toward the provision of increased, if not universal, access. “With current re-evaluations taking place in both the U.S. and U.K. health care systems, this session comes at a crucial time to provide insight and dialogue on major health care issues and methods for both countries,” said Elizabeth Bradley, Ph.D., faculty director of the Yale Global Health Leadership Institute.

Dr. Bradley opened the sessions on Monday with a talk entitled Health System Change: Competition and Collaboration. She focused on three features that must be considered for policy making: quality, efficiency and access. Dr. Bradley also explored the pros and cons of competition and collaboration, and discussed the conditions under which each is the optimal approach.

The U.S. health care market allows for fairly unregulated competition in an effort to achieve Pareto optimality – a state of market equilibrium where no one can be made better off without making someone worse off. However, this efficiency is only possible under certain conditions, all of which the country is unable to sustain or control. In contrast, the National Health Service favors collaboration, which allows for less money to be devoted to marketing, provider incentives and organizational profits but encourages integration of care services. Dr. Bradley highlighted the fact that competition and collaboration can coexist in the health system. Competition might most appropriately be applied in places where product is a commodity and consumers can readily judge quality or where unequal distribution is acceptable. Collaboration could be successfully applied where output and outcomes can be monitored and sanctions are possible for poor performance.

Dr. Bradley wrapped up her presentation with some comments on the current health care reform occurring in the U.S. While the need for change is clear, reform on the federal level faces many obstacles due to the size and diversity of the country’s population. Where health care reform seems to be taking form most quickly is at the state level. Here, populations are smaller, potentially making it easier to delegate resources to necessary areas.

Nina Gumkowski, GHLI Intern

Arriving in Liberia

Shatreen Masshoor, GHLI Student Fellow

June 2011

Arriving in Liberia is stunning. As the plane descended below wisps of clouds, I forced myself to peer out the window. Normally, I am an extremely nervous flyer, but I couldn’t resist seeing the landscape. Lush foliage and small, shimmering lakes stretched out below. The dull blue of the Atlantic Ocean drifted into view as the plane circled in for landing at Robertsport Airport, which is a 45-minute drive from Monrovia, the capitol. 

The city itself is packed: taxis negotiate space with white Toyota Land Cruisers stamped with various NGO insignias, while pedestrians dart in between cars and pem-pems (motorbike taxis). Women balance large plastic containers of sweets on their heads, such as pineapple slices and hot doughnuts, selling them for five Liberian dollars (roughly 7 U.S. cents). The Ministry of Health teems with the same level of activity as the rest of the city. An assistant to the deputy minister of health provided me with a tour of the building and numerous health divisions. The officials were consistently involved in policy meetings or briefings, but they were always pleasant and eager to offer a “Welcome to Liberia!” greeting. 

I encountered the same kindness at the TB Annex, the seat of the Montserrado County Health Team. The Montserrado County Health Team business official paused in the middle of signing checks in the dark – due to lack of electricity – to give me the Liberian handshake (similar to a handshake in the US, but you snap your fingers against each other’s at the end of it). 

Although Monrovia can be chaotic and daunting, the warmth and persistence of those I have met has drawn me in. Dr. Camara said it best: “Once you come to Liberia, it stays with you.” 

First Week in Ghana

Rebecca with mental health nurse, Gloria 

Rebecca Distler, GHLI Student Fellow

June 2011

I’ve been in Ghana now for a little over a week and it’s amazing how quickly the time has passed.  Upon arriving, I immediately began work – I’ve just returned from a trip to the Ho district, about three hours outside Accra. I went with one of the workers in the Ghana Health Service to speak with mental health workers about the relatively new mental health training program at Kintampo. We were interested in whether the workers wanted any particular skills or lessons to be emphasized in the training and what kind of services they thought would be most useful to their work. Consensus among all hospital workers was that the number one issue was a lack of personnel. One woman in particular stuck with me: her name was Gloria, and she was the mental health nurse at the Polyclinic. In her one-room office, she not only saw and assessed patients, but also treated them – she even had a bed in there. She told me that if she does not come in for work, the psychiatric unit closes for the day because she is the only mental health nurse there. It’s meeting people like Gloria that remind me why I wanted to pursue public health – the upbeat, hard-working characters who go and go and go because if they don’t, no one will. I have so much to learn from the Glorias of Ghana about personal strength, determination and perseverance, and I hope that I will have a chance to meet many more of them during my time here.

I took my first trotro (the public transportation) the other day, and now I feel as if all of Accra is available for exploring. I’ve made friends with the woman on the corner by my guest house, from who I buy bananas every night. And, another woman, from whom I buy mangoes at lunch, helps me with my Twi, the local language. I’m becoming more confident and at ease with getting around.  I even went to hear live jazz and reggae music on the beach last night with some new friends.   I look forward to seeing what else Accra has to offer, and to traveling throughout Ghana even more.

Observations in South Africa

Ryan Parks, GHLI Student Fellow

June 2011 

The Campus where I am staying

I’ve been in South Africa for two weeks and one of the most striking things I’ve noticed so far is the country’s multiculturalism. While the U.S. may have more ethnic groups within its borders, the sense of cultural diversity seems far more vivid and pervasive here. 

In the U.S., there is constant tension between cultural individuality and a coherent “American” identity – the eternal “melting pot” vs. “salad bowl” debate.  While there isn’t that same conflict in South Africa.  The lines between the ethnic groups here seem much clearer, with immediately obvious differences in mannerisms and accents, not to mention their food, domestic culture and customs.

One example of cultural differences is the custom of pleasantries before any verbal exchange, something I remember distinctly from my summer last year in Uganda. When I walked up to the ticket booth to buy a movie ticket the other day, I asked for “2 adult tickets for the 8:30 movie” and got a blank stare. I then remembered what I had been told by a South African friend and had the following conversation:

“Hello”

“Hello”

“How are you?”
“Fine, how are you?”
“Fine. Could I have two adult tickets for the 8:30 movie please?”

She then smiled and happily gave me my tickets. It was the same situation when asking the security guard what time the mall closed, or calling the taxi driver for a ride somewhere. After a week of enduring blank stares (and judgment), I’ve gotten far better at this style of conversation.

However, none of that seems expected with the Afrikaners or Anglo-Africans here. It doesn’t surprise them if I do start off with usual salutations, but they seem just as happy skipping all the pleasantries.

I’ve been fortunate enough to be looked after by the (Afrikaner) family of one of the delegates to the conference, Dr. Selma Smith. I’ve stayed at their house for two of my three weekends now, and everything I’ve experienced, from the food to the atmosphere and the domestic life seems far more…familiar (I guess Western) than I would have expected. I haven’t been to a black South African household (yet), so I look forward to that experience in the coming months. 

Arriving in Rwanda

Eleanor Hayes-Larson, GHLI Student Fellow

June 2011

I’ve been in Rwanda six days now, and I love it. I work in the Ministry of Health (MOH), where my focus is directed toward developing a national guiding document on research in the health sector.  I started my job in an “American Style” office, meaning it is a large room with clusters of cubicle-like desks. The staff has been very friendly and welcoming.

I recently had dinner at the home of one of the GHLI delegates. I met his family and a few friends. A conversation ensued during dinner centered largely on what people are paid in the U.S., and what sort of safety nets exist for the poor, as well as why on earth I would want to leave the U.S. to  spend a summer in Rwanda.   

The last part of the conversation was easy. Why do I want to be here? I am here to learn, to do what I can to help the MOH, and to get a sense of how more of the world lives.

The earlier parts of the conversation were harder to negotiate: The Rwandan men could not fathom how a country as rich as the U. S. could have homeless people. One of the men told me with pride that in Rwanda, you would “never pass a night outside” -- somebody will always take you in.  Rwanda also has a very progressive, effective mandatory community-based health insurance program, so the same health benefits are available to the very poor as to the very rich.

There I was, coming from the wealthiest country in the world, having to explain to men from a country only 17 years removed from a genocide that decimated their population and infrastructure, why some people were homeless and didn’t have basic health care in my home country.  Shame is not quite the right word for what I felt, but it was certainly a bit uncomfortable. It was a reality check for me both about how the U.S. is often perceived.

After conveying the events of the evening to my dad, he commented “Your description of conversation topics reminded me that you are, in effect, an ambassador for the U.S.” While I don’t know that I would call myself an ambassador, the evening did remind me that I am doing more here than just developing research policy.