Program Aims to Strengthen Health Care Systems in Africa

When nurse Denise Walsh arrived at Redemption Hospital in Liberia, Africa, which is now just emerging from years of civil war, the basic systems that help hospitals run smoothly and effectively were nowhere to be found.

Most beds were empty - except in the maternity ward, where births occurred without water and on blood-stained sheets or mattresses. There was no list of hospital employees; healthcare workers rarely got paid for their work. There were no bed nets to help combat the swarms of malaria-carrying mosquitoes, and available drugs were disorganized and strewn among countless unlabeled and unused boxes of pharmacy supplies.

To help address some of these pressing issues, Walsh, a Yale-Clinton Foundation Fellow, joined a team of health care providers determined to develop strategies designed to change the hospital for the better.

The Yale-Clinton Foundation Fellowship is part of a larger program focused on improving health care delivery in low-income countries through education programs for hospital managers. Elizabeth Bradley, professor and director of Global Health Initiatives at the Yale School of Public Health, and Mae Podesta, country director for the Clinton HIV/AIDS Initiative in Liberia, lead the program, which is funded in part by the Clinton HIV/AIDS Initiative.

“We have had tremendous advances in medical discoveries, but these are not enough to help people throughout the globe who continue to suffer from preventable diseases,” says Bradley. “We need delivery systems that can ensure needed treatment gets to those who need it most.”

In Yale’s programs in Liberia and Ethiopia, teams of Yale-Clinton Foundation Fellows have identified best practices for the management of hospitals. These best practices include improvements in such areas as patient registration and medical records systems, inventory control systems, human resource and financial management, and organizational governance. The Yale programs also include intensive management and leadership training.

“We match the classroom training to the daily realities with focus on problem solving, human resource management, financial management and leadership; assignments come right from the current problems they face,” says Marguerite Callaway, lecturer at the School of Public Health and collaborator on the projects.

Bradley and her team are now seeing results from the interventions. After eight months in Liberia using the Blueprint for Hospital Management developed by the Yale-Clinton Foundation teams, things are looking up in Walsh’s hospital and in many others in the program. Beds now have clean sheets; staff members are provided with hand sanitizers; the building sports new plumbing; and a proper incinerator is almost complete. A new agency in the nation’s Ministry of Health is now piloting a hospital and health clinic accreditation system to monitor and sustain improvements.

The Yale team members are also bringing what they’ve learned to a wider audience. In a recent publication in the International Journal of Health Planning and Policy, they describe a set of 70 indicators to “take the temperature” of hospitals’ management capacity. The set of indicators - based on their Blueprint for Hospital Management - are easy to use and provide a roadmap for what is broken and what needs fixing in the realm of hospital system design.

“It’s a kind of checklist,” explains Laura Rowe, the Yale project manager for the program. “It helps hospitals and ministers of health set goals for what must be accomplished to strengthen the health system in more transparent ways. It helps to determine whether they have made progress and how to reward higher-performing hospitals.”

“Management is particularly important in resource-poor settings, where one has to be creative and efficient to make resources go as far as they can,” says Martha Dale, lecturer in the School of Public Health and collaborator on the Ethiopia and Liberia programs.

“We hope to see measurable improvements in patient’s experience with care,” adds Paul Cleary, professor and dean of the Yale School of Public Health, who will oversee a related study to examine the link between improved hospital management and patients’ views about their experiences in these Ethiopian hospitals.

Global Health Leadership Institute

The success of the fellowship program has helped inspire the creation of the Global Health Leadership Institute at Yale, which will convene leaders in public health from a group of countries that have demonstrated momentum in strengthening their health care systems, a fundamental goal set out by the World Health Organization and the World Bank. Yale Vice President Linda Lorimer announced that, in partnership with the Glaser Progress Foundation, the University would be hosting this weeklong conference on campus in 2009.

The institute’s objectives include exploring best practices in making systemic changes to improve the health of regional populations, and identifying key future research directions to speed up improvements in health around the world. The institute will also develop a set of case studies showcasing examples of innovations to improve population health. The Provost’s Office, the Office of International Affairs and the School of Public Health have worked with Bradley in developing the concept of the institute and will provide ongoing support for its implementation. The institute will also bring together top leaders in global health system-strengthening with Yale faculty from across the University.

Africa’s first Masters in Hospital Administration program

Yale’s involvement in global health has also brought another unique educational opportunity to African countries. The University has partnered with the Ministry of Health, the Clinton HIV/AIDS Initiative and Jimma University in Ethiopia to launch the first Masters in Hospital Administration (M.H.A.) in Africa. The inaugural class includes 27 newly named hospital chief executive officers (CEOs).

“The class is comprised of physicians, nurses and non-clinician managers,” says Bradley. “They are tremendously motivated and are eager to soak up the new information.”

The two-year executive education program allows CEOs to connect online through their own Yale course website, and they visit the campus in Jimma for three-week blocks of classes every four months. In addition, each CEO is matched with a mentor from a team of Yale-affiliated health care managers, including some senior administrators from Yale-New Haven Hospital.

Bradley says, “Since we are only key strokes away from each other, the learning across continents is an unparalleled experience. Liberia and Ethiopia are using similar medical records forms, similar Access databases for pharmacy inventory control, and similar job descriptions - not by coincidence. We are all connected by Yale and the comfortable communication the Internet allows.”

Dr. Sosena Kebede, a Yale-Clinton Foundation Fellow and lecturer at the School of Public Health, directs the M.H.A. program in Jimma. The program seeks to provide assistance and create a pipeline for hospital leaders, with the goal of making hospital administration a respected and important career in Ethiopia. At least one leader from every government hospital in Ethiopia will take part in the program over the next five years.

“The people are amazing leaders; what they are able to do with such scarce resources illustrates the creativity and motivation of these emerging leaders in Ethiopia,” says Kebede. “We just need to equip them with skills, tools and a network of others in the world who share their passion for improving health for all people, no matter where they live.”

- By Karen N. Peart