Communities of practice
Health workers need a taste of the community
7 May 2010
Peter Ndumbe was working in London when the new HIV virus began to emerge in the early eighties. One of the multitude of scientists trying to understand the pathogen, he focused on hepatitis and its possible links to the new virus.
Perhaps presciently, he remembers talking about AIDS in the early nineties to a close friend. “I told him if we found a vaccine we would not be able to give the vaccine to all that was needed. He was surprised at my declarations,” says Ndumbe.
His view has not changed. Indeed, he is distinctly unimpressed by the excitement surrounding announcements on the coverage of interventions – from ARVs, to drugs for neglected tropical diseases and childhood immunizations. “We are supposed to be at 95% coverage of vaccines to children under five. The majority are below 80%. Some are below 70%,” he says.
The reality of the situation is that research into new drugs, vaccines and other technologies is meaningless if existing technologies do not get to those who need them. If they exist and are not out there, we have failed, he says.
He concurs that announcements are often devised to emphasize the positives and prevent donor fatigue. However, many of the congratulations are not warranted, he says. “How can we not be concerned about those we cannot reach and be euphoric when we reach 70% [for immunization] or 30 or 40% [for ARV coverage] and throw a party?” (He has said more on this issue in a paper  published in 2008.)
“The number one thing to research on is how to ensure people benefit from technologies we have available,” he says.
Ndumbe now heads a new medical school at the University of Buea (BU) in Cameroon, a new university situated in the south west of the country, near the foot of Mount Cameroon. He began the medical school at BU with the aim to produce Cameroon’s next generation of health professionals and, in doing so, help ensure there are more health workers to help make interventions more widely available.
The health worker crisis in Cameroon has been as severe as anywhere in sub-Saharan Africa. Structural adjustment policies aimed at reducing public sector expenditure in the eighties meant training schools were closed and recruitment of nurses was stopped for over 10 years. More than a third of the nursing staff left, particularly after salary cuts in 1998.
Of course there are some simple changes to management that could improve working conditions, says Ndumbe. Doctors – some in their early twenties – are sent to work in rural areas and must find their own accommodation. Simply helping them, through a change in management policy, would make a difference, for instance. (Interestingly, around 80% of health workers surveyed in Cameroon recently said they had left or planned to leave because of living conditions and 55% said they might be persuaded to stay by improvements in health care system management .)
But improving the quality and quantity of health workers in Africa is not just about preventing the brain drain. It means a wholesale reform of teaching in African countries, says Ndumbe.
Returning professionals have a profound effect on standards of teaching, for instance. They are often influenced by biomedical approaches better suited to institutions in the North, to the detriment of the most common problems in the community, he says.
“People are trained in Germany, UK, US and when they come home; they tend to want to train others as they have been trained. But the context is different,” he says. “That has been a major problem. People wanted to replicate what they went through without taking into the consideration of local context or evolution of local knowledge.” To make matters worse, Cameroon’s rather complex colonial past has led to a collision of German, French and English approaches. Ndumbe has written about faculty board meetings at the University of Yaoundé, where he was dean for eight years, that veered variously between an insistence on basic sciences (German) structured lectures (French) or bedside learning (English).
That is why Ndumbe has introduced courses centred on community-based field work. Groups of student nurses, doctors and laboratory technicians are being taught together in the field from the first year. They are also assigned a health district, in which to design and implement projects that are evaluated in terms of how successfully they progress towards the Millennium Development Goals. “Students must be sufficiently exposed, so that when they graduate they don’t have a problem adapting to the community, because they have been trained there,” he says.
Though laudable, this approach is not ideal. It is subject to the whims of different deans and can be stopped at any time, says Ndumbe. At the University of Yaoundé, for instance, five different previous deans of the medical school disagreed about community-based training, so policies kept yo-yoing.
That is why a national policy on health worker training that ensures community-based training is needed across Africa. It is a policy that must be accepted by everyone from cardiac surgeons to the neurosurgeons, he says.
Community-based training is not an attempt to make health workers deliberately unattractive to the outside world either. Students have to be competitive – to diagnose rare diseases, understand biochemistry or genes, read MRIs and ECGs. “Some colleagues think, in order to retain, we should provide substandard education – only train them to do things they will use in the village,” he says. “I think they should perform as well in Cameroon as the UK. The diseases, such as Alzheimer’s disease, are found in Cameroon.”
Ndumbe has certainly benefited from studying abroad. Originally focused on immunology of the parasite responsible for onchocerciasis, a big research area in Cameroon, Ndumbe’s research interests were aroused when he studied the immunology of viruses in London. Here he focused on a range of viruses, including herpes virus. But it was hepatitis guru Arie Zuckerman, at the London School, who infected him with an interest in hepatitis and HIV viruses.
Some models from abroad can be positive. Cameroon, for instance, follows the French medical school teaching model. Here, student doctors must complete some kind of research as part of their training and are effectively taught how to produce journal-quality papers.
Getting nurses and doctors, laboratory technicians, and soon pharmacists and dentists, to learn together has other benefits. It appears to be part of a deliberate strategy to smash hierarchies that dominate medicine.
Professor Carel IJsselmuiden, Director of the Council on Health for Development (COHRED), agrees and has said that institutions in low-income countries are more bound by rigid hierarchical structures. It is most de-motivating for young and mid-career researchers and technical specialists, he says. Unfortunately many hierarchies still exist. There are plenty of promotions, for instance, within institutions that are not based merit but seniority.
Those between institutions in the North and South are still very much in evidence too, says Ndumbe. It is a relationship he first came across when he returned to Cameroon. “They have used developing country colleagues like sample collectors, like technicians,” he says.
Of course things are changing, through organisations such as the European & Developing Countries Clinical Trials Partnership (EDCTP) and new Fogarty grants are aimed just at developing countries, he says. But today the hierarchy appears to be less about patriarchy and more about inflexibility in donor funding. Many are project-based funds, which means there is little time to build up capacity and infrastructure in recipient countries before the project finishes.
Removing hierarchies amongst health workers is one reason why Ndumbe and colleagues have opted not to have a dedicated public health school. “We know the training of health professionals is done taking into consideration the community situations and therefore obviates the need for a school of public health.
“Initially people who went into public health were thought to be underachievers who couldn’t do, say neurosurgery,” he adds. “That’s the wrong way of looking at it. Public health is as important as cardiac surgery and can even prevent [heart disease].”
Not having a dedicated public health school is perhaps controversial. The Afrihealth project, dedicated to tracking health researchers, said in 2007 that the dearth of public health professionals and public health schools was a big problem for Africa; it found just one department devoted to public health in the whole of Cameroon.
Others believe it is not just health workers that need public health training. Indeed, Professor K Srinath Reddy, president of Public Health Foundation of India, for instance, says this has been India’s downfall. A host of other public disciplines are required, from health economists to experts in biostatistics; that is why a dedicated school is so often essential.
But Ndumbe says there are unlikely to be enough students to justify an entire, standalone school. Instead, public health training is now provided at the medical departments in both Buea and Yaoundé, and to health workers, through intensive community-based courses. A masters in public health is available to those from other disciplines.
Importantly, a lack of health workers – and research – is the result of poor national funding too. Although the government has tried to transform higher education by creating six new universities, there is little funding for health research. Ndumbe had first-hand experience of scant research funding when working as deputy director of the Medical Research Council of Cameroon, Cameroon’s equivalent to the UK’s MRC.
Cameroon spends just $10 per capita on health (according to an NGO, the Africa Public Health Alliance) and devotes less to education as a proportion of its GDP than larger and poorer countries.
One effect of paltry national funding is that researchers work in silos on projects funded and designed by external donors. They do not share ideas enough and there is no overarching national research strategy says Ndumbe.
Luckily, there is plenty of vibrant research going on in the country. BU, for instance, participates in one of EDCTP’s networks of excellence. Here several Central African universities, from Gabon to Congo, have partnered to improve HIV clinical trial capacity. BU is producing research too [3-5]. But if more scientists collaborated, there might be more government engagement nationally and during big international fora.
Research is neglected in daily decision making and there is an assumption that the provision of health services is inherently good and therefore cannot be challenged, says Ndumbe. “If things happen it is because the government leadership is sufficiently briefed and in tune with the desire of the researchers,” he says. “In Cameroon the requesting has been done by individual researchers. We do not have the government’s support. It is our fault.”
But what is clear is that it is absolutely vital that there should be African voices at an international level. That is why Ndumbe is taking part in so many international fora and has consulted for UNICEF, the GTZ, the European Union and WHO. He is working, as he puts it: “to make the voices of the unknown researchers in Africa and other parts of the world heard. Otherwise the agenda gets set somewhere else and the work gets done elsewhere,” he says.
Peter Ndumbe: curriculum vitae
1. Ndumbe PM (2010). Universal access to antiretroviral therapy: are we moving the targets? J Int Assoc Physicians AIDS Care (Chic Ill); 7(6):279-280. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19164137
2. Vujicic M, Zurn P, Diallo K, Adams O, Poz MD (2010). The role of wages in the migration of health care professional from developing countries. Human Resour Health; 2:1-14. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419378/
3. Matee MI, Manyando C, Ndumbe PM, Corrah T, Jaoko WG, Kitua AY, Ambene HP, Ndounga M, Zijenah L, Ofori-Adjei D, Agwale S, Shongwe S, Nyirenda T, Makanga M (2010). European and Developing Countries Clinical Trials Partnership (EDCTP): the path towards a true partnership. BMC Public Health; 9:249. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19619283
4. Takem EN, Achidi EA, Ndumbe PM (2010). Use of intermittent preventive treatment for malaria by pregnant women in Buea, Cameroon. Acta Trop; 112(1):54-58. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19539589
5. Takem EN, Achidi EA, Ndumbe PM. An update of malaria infection and anaemia in adults in Buea, Cameroon. BMC Res Notes; 3(1):121.Available from: http://www.ncbi.nlm.nih.gov/pubmed/20433718/
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