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.