Health partnerships in a post-conflict state: a responsive way of working

In Somaliland, a health partnerships programme involving a small specialist NGO (THET) and King’s College Hospital NHS Foundation Trust (now part of an Academic Health Science Centre called Kings Health Partners) has supported the transition from immediate post-conflict health needs to a focus on health system strengthening. Emily Burn and Yassmin Mohamed from THET tell the story, and colleagues from health institutes and the Ministry of Health reflect on the partnership’s progress.

Background: Kings-THET-Somaliland Partnership

Somaliland’s self-declared independence (in May 1991) followed a civil war that saw the overthrow of the military dictator, Siad Barre, and the loss of thousands of lives to violence and famine. Despite on-going internal clan-based tensions and potential threats from the south, Somaliland has achieved an admirable level of stability in the last twenty years. In this context, the Kings-THET-Somaliland Partnership (KTSP) grew to support the development of Somaliland’s own skilled health workforce and improve health sector governance.

Established in 2000, KTSP’s first training trip was held at Edna Adan Maternity Hospital, Hargeisa. With support from THET, King’s staff members have made regular trips to the country. KTSP has grown its partner base throughout Somaliland to encompass health training institutions, professional bodies, and the Ministry of Health. Since its inception, KTSP has aimed to be responsive to, rather than instructive of, Somaliland’s own development, ensuring that the ownership and design of the partnership is rooted in Somaliland.

Initial focus was on the delivery of training and training materials to develop clinical and administrative staff capacity; this expanded to administrative staff capacity. Today, KTSP is providing support for governance activities in response to the increased capacity within the Ministry of Health to manage, plan and finance the health sector, and to work effectively with other actors in Somaliland. The partnership is also encouraging the development of independent regulatory accreditation and examination bodies that will ensure service delivery standards and the quality of ongoing support to health workers. Professional bodies also have an important role to play in acting as advocates for their members, offering representation in coordination and planning fora, and supporting health workers’ other needs, such as training.

Here, three partners reflect on their work and the partnership:

Amina Hasan Husein – Director of Sool Institute of Health Sciences and a teacher

Giving some context to her role and the Institute, Amina explained, “I am among the teachers who began this Institute in 2008. Back then, we had no support and as teachers we used our initiative and resources to build up this Institute. The first group [of students] are graduating in July 2011, the second group have just completed their first year and we are in the process of enrolling new students who will start the course in May 2011.”

Amina described how the Institute has benefitted from the partnership: “The Institute has seen a lot of benefits since joining the partnership in mid-2010. We receive support through the provision of books, training equipment, curriculum design and support with our finances. The partnership has supported our initiatives and allows us to train our healthcare workers. The Institute sends students to mother and child health centres and the two hospitals within the region of Sool (Central Referral Hospital and Manhal) to further develop their skills.”

When asked about her hopes for the future of the partnership, Amina replied, “I hope to see the Sool Institute progress alongside other members within Somaliland’s health sector. I hope to see cohesion and [that we will] continue to work together with the other institutes and within the partnership.”

Thinking about the benefits that the partnership has brought, Amina responded, “As a nurse, I possessed the skills to treat people and I had other skills that were not fully developed. Working for the Institute, and having access to the partnership, has allowed me to further my knowledge in administrative skills such as finance and planning, especially lesson planning. I hope to pass these skills on to my students and to encourage them to progress forwards and never backwards.”
(Interview April 2011)

Khadar Mohamud Ahmed – Director of Planning at Somaliland’s Ministry of Health

Reflecting on the history of the partnership, Khadar gave this perspective: “The start of the health systems strengthening initiative in Somaliland in 2006 paved the way to advance receiving more strategic and harmonised assistance from DFID and other donors in health systems development, including investing in the integrated package of health care services.”

Support for the partnership from the UK side is voluntary and Khadar commented that: “Volunteer support provides CPD for senior health staff and the exchange of ideas and resources. As I know, they provide technical support to the academic management of the health institutions such as Amoud University, University of Hargeisa and nursing schools of Hargeisa, Burao and Las Anod. The volunteers also gain experience that builds on their own capacity and knowledge. The best things they [volunteers] do are the provision of the medical instructors to medical schools of Amoud University and University of Hargeisa. They also provide medical volunteers to the teaching hospitals like Edna and Hargeisa group hospitals.”

Regarding the partnership’s commitment long-term, Khadar felt that as long as the outcome is satisfactory, “…KTSP is one of the most successful programmes in Somaliland towards strengthening Somaliland’s health system.”

(Interview, January 2011 and correspondence, April 2011)

Fadumo Osman – Director of Buroa Institute of Health Sciences

Giving some background to the Institute, Fadumo explained, “I am the Director of this Institute, which has seen the graduation of 54 nurses in 2008 and 2010. We currently have 40 third-year students who are due to graduate this year, alongside 32 first-year students. In 2008 and 2009, we conducted training for 41 Community Health Workers from the surrounding villages, who have since begun work in these villages. Graduates from Buroa Institute have begun working across Somaliland especially in Sanaag.” [This region is further east and remote, which impacts the level of health care available to the residents].
Considering the benefits of the partnership, Fadumo described how: “We have a great partnership with THET, from which we have gained a lot of support, through teaching materials, laptops, photocopiers and books. Nine teachers were trained in Nursing Teacher Training in 2008-2009 and this has proved very useful in teaching our students. There have been numerous benefits from the partnership, most particularly with regards to teaching skills. We have also benefited from the monitoring and evaluating support received through this partnership, as it allows us to evaluate our work and improve our future efforts.

“We are the only institute in Buroa that offers medical training. Through the partnership, we have been able to improve teaching facilities and introduce new courses. In May 2011 we will start a midwifery course for graduates – there will be approximately 20 students enrolled on this course – and continue the general nursing course.”

Fadumo also gave her hopes for the future: “We hope to provide training in other medical areas, such as laboratory work, alongside the continuation of the midwifery course. We would also like to do a refresher teachers’ training, as this was extremely beneficial in our continuous efforts to improve our teaching facilities.”

(Interview, May 2011)

Haiti: reaching out to the most isolated people

Katia Eloi Cénat is a 32-year-old Haitian nurse. After the earthquake which struck Haiti on 12 January 2010, her right arm was amputated. Katia worked as a Psychologist’s Assistant for MSF, before joining Handicap International in October 2010, where she received on-the-job training as a Rehabilitation Technician. She speaks about her experiences here.

“Today we visited Mr Augustin,” explains Katia. “He is 54 years old, and was working in a funeral home when the earthquake hit. He was the only survivor in the building. He had to undergo a mid-thigh amputation and his other leg remained extremely weak, affecting his balance. Handicap International provided him with a walker and fitted him with a prosthesis, which allowed him to recover some mobility.

However, he cannot yet make full use of this equipment as he is still unable to stand up straight and has to spend a lot of time in his wheelchair. Despite all this, every Friday he makes his own way to church using his walker and prosthetic limb. We worked with him at home to improve his balance and strengthen his muscles, and referred him to the Handicap International Orthopaedic Centre in Port-au-Prince to deal with his healthy leg. His case is extremely complicated but he is very brave, always encouraging others at the centre, even though his own progress remains limited.

“At the centre, we provide rehabilitation services for amputees like Mr Augustin and we make prostheses and orthoses. As a Rehabilitation Technician, I assist physiotherapists, with the aim of making people with disabilities more independent. I am also part of a mobile team, along with a Physiotherapist and a Prosthetics & Orthotics Technician, providing patient follow-up at home and identifying problems they may encounter in their daily lives, such as stairs or obstacles in the house.

“When an amputee arrives at the centre, we start by taking measurements and producing a cast of their stump. Then we prepare the socket and make an appointment for the patient to have a static trial of their prosthesis. If this is successful, dynamic trials are then carried out once a week for one to five weeks. The number of sessions depends on the patient’s physical capacity – for example, elderly people may tire quickly, whereas children adapt much more easily.

During these sessions we carry out functional rehabilitation using muscle training exercises and give the patient exercises to do at home. If the amputee is suffering from psychological trauma, such as difficulty accepting their condition, we refer them to our psycho-social team. For problems related to their home environment, our accessibility team can carry out alterations to make their homes or the plot of land where they live more accessible.

“The patient has follow-up appointments, every two weeks at first, reducing to once a month, then once every two months. During these sessions, we check that the patient feels comfortable with their prosthesis and we train them to carry out day-to-day activities, such as carrying heavy loads. We also check their stump and gait cycle, to ensure they complete the stance and swing phases correctly, and address any abnormalities through specific exercises.

“The idea is to help amputees become as independent as possible in their daily lives so they can use the toilet, take a shower or cook unassisted. If necessary we can resolve problems on the spot by adapting their living space. We analyse what the patient can and cannot do in their home and, where necessary, provide them with technical aids that we make in our workshop. For example, a brush for washing clothes that can be attached to a leg, nail clippers that can be operated using an elbow, or a chopping board that can be fixed to the table with a clamp.

“We may also suggest simple techniques to negotiate obstacles like steep slopes, stairs, rocky paths or ditches. Some families live in houses built on the edge of a cliff or ravine and use bags of earth to make steps or section off a plot of land, making it very difficult for someone using a prosthesis to access the house. We may ask a patient’s family for support if a patient finds it difficult to put on their prosthesis, or to help them do their daily exercises.

“On average we see three or four patients a day, but sometimes we may only see one patient if they live in a particularly isolated area. Port-au-Prince is not very suitable for vehicles so we often leave the car and finish our journey on foot through the city’s alleyways. We spend around one hour with each patient, sometimes longer if the technician has to work on the prosthesis. What is really important is that we reach the most vulnerable and isolated people.

“Some cases are more complicated than others. Each case is different, depending both on the level and type of amputation, and the family and physical environment. The aim is to find the right solution for each person, and that is what I like best about my work.”

Handicap International is an international aid organisation working in situations of poverty and exclusion, conflict and disaster in over 60 countries worldwide.

NGOs and the cluster approach: a worthwhile investment?

The cluster approach to humanitarian disasters offers NGOs the opportunity for greater engagement and influence in humanitarian action. It also presents new practical and (for some NGOs) ethical challenges which each NGO must consider when deciding to participate. Linda Doull, Director of Health and Policy at Merlin, asks: Is cluster engagement a worthwhile investment for NGOs? She reflects on Merlin’s experiences at global and country level in this area since 2005. She discusses the challenges faced and how NGOs need to face up to the criticisms aimed at them.

Background to the cluster approach

In 2005, the cluster approach was launched by the Inter-Agency Standing Committee as one of the three pillars of humanitarian reform. It aims to ensure a more timely, predictable and effective response to humanitarian crises. Today there are 12 clusters. The approach has been implemented in 26 countries since its inception, most recently in Libya.

Through the Principles of Partnership, the cluster approach promotes a more effective and collaborative way of working among the wide range of humanitarian actors within the international system. The intended result is more effective humanitarian action through more transparent inter-agency dialogue, greater recognition of each agency’s role and capacity and their explicit role commitment to each response. The designers of the cluster approach recognized the key role played by both international and national NGOs in every humanitarian response. They promoted increased NGO engagement at country and global level.

Two major external evaluations and several reviews undertaken by NGOs, suggest that, while far from perfect, the cluster approach with NGO engagement, adds value. But there are important questions about how NGOs engage now and in the future. Each NGO should consider whether cluster engagement is a worthwhile investment for them and the response in general. Merlin’s reflections are below.
Why did Merlin become a cluster partner?

Merlin was invited to join the Global Health Cluster by the World Health Organization (health cluster lead agency) based on our commitment to and track record of supporting humanitarian health action in both acute and protracted complex emergencies. Merlin took the strategic decision to become a cluster partner because the approach:

  • Fitted with organizational remit and objectives;
  • Matched Merlin’s commitment to partnership working and belief in the power of collective action;
  • Created opportunities for enhanced resource mobilization and capacity, and
  • Created opportunities to be a catalyst for change, influencing humanitarian health action and promoting the role of NGOs.

What role has Merlin played?

Country level

Merlin has participated in a wide range of cluster activities at country and global level. The greatest engagement is at country level where teams play an active role in defining and delivering the health cluster response strategy for each crisis. Merlin automatically participates in the health cluster as soon as the cluster is officially activated and becomes the main coordination mechanism for the health sector response.

Merlin teams help to identify critical service delivery gaps and inform strategic decision-making either through joint assessment, or by regularly sharing information with the health cluster coordination team. Once identified, Merlin ‘fills the gap’ by supporting the Ministry of Health to deliver health assistance, in accordance with the comprehensive service package agreed by health cluster partners.
Through joint planning, Merlin and other cluster partners avoid geographical overlap and service duplication, making effective use of available resources. Merlin also uses its presence and technical expertise to strengthen the health cluster coordination. In Myanmar, we seconded a health information expert to the cluster to coherently manage the overwhelming amount of data received. In both Democratic Republic of Congo and Myanmar our established relations with local NGOs enabled them to access emergency funding and present their views to the authorities.

One of Merlin’s most important contributions – and greatest challenges – has been in the role of cluster co-steward, supporting WHO at national and sub-national level to implement the health cluster strategy. Merlin took on this new role in Myanmar, DRC and Somalia/Puntland, seconding senior staff to strengthen health cluster coordination, particularly at sub-national level, where WHO often has a limited presence. The experience has been important in clarifying the value of co-leadership; the skills, experience and resources needed, and the value NGOs can bring.

Global level

At global level, Merlin participates in two Global Health Cluster (GHC) groups:

  1. The Working Group which focuses on the development and dissemination of cluster tools and guidance; training for health cluster coordinators (including staff nominated from NGOs); and joint country support missions, such as the one Merlin undertook in Afghanistan.
  2. The Policy and Strategy Team where Merlin has actively contributed to the development of GHC position papers on user fees and civil–military co-ordination, designed to assist country teams in decision making. Merlin also represents the GHC to major stakeholders, including donors.

What are the benefits of cluster engagement?

Merlin’s engagement in the health cluster at country and global level has required considerable effort but our internal reviews indicate it has largely been worth the investment. Particular benefits include gaining greater understanding of the humanitarian system and each specific context; increased access to information to enhance our decision-making and programming; access to funding through participation in Flash Appeals and other mechanisms; more open dialogue and strengthened relations with national authorities, UN agencies and donors; increased influence on sector policy and practice; and opportunities to innovate and learn from new ways of working leading to quality improvements with Merlin and beyond.
What are the challenges of being a cluster partner?

Merlin’s engagement in the health cluster has been invigorating and beneficial, but we have faced challenges. An internal review and consultation with other health cluster partners across ten countries identified similar challenges including: the issue of time commitment needed to participate in cluster meetings; ensuring suitably experienced staff are available for key activities such as joint assessments, country support visits and being co-steward; financial resources (all cluster partners are encouraged to mainstream costs within existing budgets, but some activities (e.g. being co-steward) are not cost neutral); the need for more awareness of, and training in, the use of cluster tools such as Initial Rapid Assessment and the Health Resources Availability Mapping System; and ensuring information from the GHC filters through to country health cluster teams.

In addition to these important operational issues, Merlin has reflected on wider concerns raised. Firstly, does being a partner in this UN-led approach reduce our independence as a humanitarian NGO? To date, Merlin does not feel this has been a problem, but remains vigilant in our risk assessment in each given context. Secondly, how can local NGOs and the Ministry of Health participate more effectively in the health cluster? Merlin’s experience shows that it has an important enabling role, using existing in-country relations with both, to bring them and/or their information to cluster meetings, to enhance inter-agency dialogue, planning and response.

Looking ahead

Delivering timely, effective and predictable responses to humanitarian crises will remain a priority in the years ahead as the frequency and scale of crises increases. The humanitarian sector acknowledges that – despite its well-documented faults – the cluster approach adds value. Based on learning to date, the role of NGOs within it should be enhanced. Encouraging though this is, if we are to be effective, NGOs must also think hard about two key criticisms aimed at us:

  • Too many participating NGOs hinders rather than helps cluster effectiveness. In Haiti nearly 400 health NGOs registered as cluster partners, many with no previous experience in such a crisis, and made a limited contribution to strategic dialogue and planning.
  • Being a cluster partner means sharing the challenges and identifying solutions to deliver coherent humanitarian health action, as opposed to the ‘opt-in’ / ‘opt-out’ approach adopted by some NGOs when the situation becomes complex.

Is cluster engagement a worthwhile investment for NGOs? From Merlin’s experience – yes – so long as you are clear about your added value; are willing to commit the time, energy and resources to engage; and are willing to adapt to new ways of working and learn from the individual and collective experience.