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Health Information Forum: Working together to improve access to reliable information for healthcare workers in developing and transitional countries

Venue:  Royal College of Physicians, London

Date: Tuesday 14 January 2003    

Chair: Professor Carol Black, President, Royal College of Physicians

1. Health Information Forum (HIF) Update

Neil Pakenham-Walsh opened the proceedings by thanking all those involved in making the meeting happen, including the HIF Organising Group, the speakers and rapporteurs. He thanked the International Office of the Royal College of Physicians for the use of their facilities.

Neil thanked the BMJ Publishing Group and the Exchange programme for their continued support.  The BMJ Publishing Group have just awarded a grant to HIF for 2003, which includes a small amount to support the setting up of local strategy groups in developing countries.

2. Chairperson’s Introductory Remarks

Professor Carol Black noted that her predecessor, Professor Alberti, had been the guest speaker at the launch of the Health Information Forum in 1998. Professor Black explained that international activities and information exchange are very important to the College. At a College meeting to decide priorities for the next 3 years, International Activities were selected as one of the five priorities. The others are: Education; Clinical Standards; Communications; and Patient Involvement. The College has also recently opened an Informatics Department.                      

3. PRESENTATION: ‘Introduction to Surgical Skills’: lessons learned from experience in South Asia and southern Africa.  Andrea Kelly, Royal College of Surgeons of England

The Introduction to Surgical Skills Resource Pack: a collaborative venture between The Royal College of Surgeons of England and The Commonwealth of Learning (text from Professor Arjuna Aluwihare FRCS, Professor of Surgery at the University of Peradeniya, Kandy, Sri Lanka).

The Royal College of Surgeons of England has a long history of participating in the training of surgeons from round the world, and its members and fellows work in many countries, under diverse circumstances.  Most recently it has collaborated with The Commonwealth of Learning, Vancouver to build on the popularity of its 3-day Basic Surgical Skills and Specialist Registrar Skills in General Surgery courses, developed by the College's surgical skills tutor Mr Bill Thomas. The College had felt that a wider international clientele might be able to use the accompanying course handbook and video, with suitable modifications. Accordingly, these materials have been adapted and modularised – so that now in place of the 3-day courses that run in the UK we can offer a resource pack for surgical tutors: Introduction to Surgical Skills. This can be used by surgical tutors on an ad hoc basis – drawing on whichever modules are relevant to the needs and priorities of local programmes.

The materials cover the most basic aspects or surgical technique – including safe handling of instruments & sharps, basic suturing, knot-tying, safe handling of tissue, basic anastomotic technqiue, and an introduction to the principles of minimal access surgery - with additional material illustrating different ways of doing simulations and referring to the various situations surgeons may have to face. Each participating centre receives (free of charge within the Commonwealth, and at low cost elsewhere) one copy of the video for teaching purposes – and one copy of the handbook in both print and CD-ROM format, which may be duplicated locally for trainees within the terms of an agreement that is signed by the centre and the college of surgeons.

This project starts from the premise that there are often several correct ways of doing something, but a trainee must accept and learn “one safe way” before becoming more adventurous! The resource pack demonstrates in a structured and systematic manner safe methods that are potentially multidisciplinary in their appeal. It provides a powerful aid to ‘hands on’ teaching and learning, which can generate feedback from trainee to trainer and vice versa. An intelligent and determined surgical trainee can also benefit from the materials in an isolated location.

The materials were launched in September 2001 and are already in use with great acceptance in Sri Lanka, and by a growing number of surgical departments in other countries (23 the present time). We are now seeking funding to extend the project to other healthcare workers – including rural practitioners, nurses & operating assistants.

In global terms, the economic north can have centres of excellence in surgery and training built upon their experience and modern technology. The economic south delivers excellence in spite of more severe resource problems and in the face of (and with the benefit of) a huge case and work load. In both arenas, inventiveness and adaptability assist in the pursuit of the common goal of excellence.

The interchange of ideas and suitably adapted materials can only help both the north and the south, without presupposing the dominance of either sector. The willingness to adapt makes available what could not otherwise be implemented and is a challenge to the ready acceptance of the ‘status quo’.  The modern method of delivery used in Introductory Surgical Skills resource pack makes available to learners and teachers far from teaching centres materials that they would, otherwise, have had access to only in large and prosperous cities. The interchange of material and information also helps reduce the intellectual isolation that can affect surgeons in the north and the south and helps maintain professional and social contacts that might be weakened in a purely ‘electronic global village’!

For further information, contact Andrea Kelly [email protected] 

4. PRESENTATION: Internet-based education for health professionals in Africa: The E-learning Certification Programme in Global Health. Steve Allen and Sarah Davies, University of Oxford.

The ‘E-learning Certification Programme in Global Health’ is a new initiative that seeks to forge partnerships with institutions in Africa to develop a resource for Continuing Medicial Education (CME) for health professionals working in Africa. In Oxford, collaboration between the Oxford Tropical Network and Technology-Assisted Lifelong Learning (TALL) brings together existing strengths in Tropical Medicine and e-learning. This programme, which is supported by the Bill and Melinda Gates Foundation, is currently concentrating on malaria, but it is anticipated that it will be extended to cover other diseases such as HIV/AIDS and TB.

Structure and development of the programme

The major aims of the course are to:

• Empower health professionals to support good clinical practice in their own institutions

• Foster leadership skills and help identify future leaders

• Use technology to deliver effective training that runs alongside service delivery

• Produce valued joint qualifications

The target audience are junior doctors as they are seen as people that will have the ability and influence to change practice on the ground and also that have leadership potential.

The course uses a problem based approach whereby students will access information, appraise its quality and relevance and apply it to their own situations. Students will also develop management skills by implementing new knowledge and skills in work based projects. As well as learning about the different diseases, students will also be using Evidence-based Health Care techniques to inform their practice.

The course will work with partner institutions in Africa and use appropriate technology to deliver the learning, support them in their studies and enable them to access the resources that they need.

The themes that run through the project are the building of partnerships between organizations in the West and institutions and individuals in Africa, the use of existing information resources and writing the learning around those resources.

Lessons learned

A number of lessons have been learnt from this project; they include the importance of consultation when starting a project of this type and that consultation is a major and on-going part of the course development. Another point is that the course needs to be valued and recognised in order to be successful; this is being pursued by accrediting the course from Oxford and from institutions in East and West Africa. It is also recognised that local content and local authors are important for acceptance of the course and for local relevance. Enthusiastic ‘champions’ are important to carry projects such as this forward, but continuing success occurs where real core needs are addressed.  

Current activities

Currently the project is concentrating on developing partnerships, authoring education materials in malaria and Evidence-based Health Care and accessing information sources, planning for testing “on the ground” and exploring accreditation from Oxford and from Africa.

For further information see the website: http://tall.conted.ox.ac.uk/globalhealthprogramme

Dr. Stephen Allen, Course Director;
e-mail: [email protected] 

Dr Sarah Davies, Project Manager;
e-mail: [email protected] 

Question from audience: There are only 1,300 doctors in Uganda, but 6,000 clinical officers. Are there any plans to include other health workers, particularly clinical officers, in training? Clinical officers should be included.

Answer: For this project, it was decided to target junior doctors, who are the future leaders, and their training is therefore particularly important; once skilled, junior doctors may deliver the training to clinical officers and nurses. Project developers should not be the ones deciding on the needs in-country. This is the first phase. It would not be difficult to adapt the programme to suit other health workers in the future.

5. SMALL-GROUP DISCUSSION

Group 1: What lessons have been learned about the use of information and communication technologies for CME in developing countries?

Discussion Summary:

1. There is a huge lack of knowledge about technology and an unwillingness to acknowledge this. Basic training in IT is needed.

2. The Internet is not the best way to provide distance learning because of connectivity and access difficulties and the prohibitive cost. CD-Roms are often much more appropriate.

3. Learning that takes away from earning time needs to have incentives attached, (e.g. accreditation or improved career prospects).

4. In designing materials, the difference between reading on paper and reading on screen needs to be recognised. There may also be a need to adapt screen resources for printing.

5. Partnership with local organisations is crucial. Local input at all stages from grassroots level us is necessary to ensure that information resources are relevant to local needs.

6. Successful CME needs a champion locally to create excitement and to sustain enthusiasm.

7. Brain drain: there is a danger that once the health worker gains further qualifications, s/he will leave. Tailoring the CME to the local situation helps to minimise this risk.

8. Global information needs to be linked to the local scene so that it is contextualized.

9. Limiting CME to doctors may create an ‘elite’, who are reluctant to share information with less qualified colleagues.

Group 2: Can generic educational materials be adapted for local relevance? How can local content be included?

Discussion Summary:

1. It is important to develop materials that are appropriate both (a) clinically and (b) culturally.

2. Materials should be translated into local languages.

3. The degree of local adaptation depends on the subject matter, e.g. Malaria or TB.

4. Telecommunications infrastructure can limit the use of technology for transmitting information.

5. There is a need to build local capacity to provide content, e.g., training the trainers courses.

6. It may be possible to involve the local private sector in helping to produce local content.

7. Conclusion: Be Prepared – Prepared to Adapt and Prepared for Hard Work!

Group 3: CME in many parts of the world is currently based on multiple, uncoordinated training workshops supported by various donor agencies. Such workshops are resource-intensive and also take people away from their usual place of work. How can this approach be rationalized and shifted towards on-site learning?

Discussion Summary:

1. NGO Co-operation: In CME, it is easy to waste resources. For example, an example was given where two non-government organizations ran similar courses for the same group of health workers. Collaboration is needed to avoid duplication. 

2. Per diems: It is often the same doctors, nurses and clinical officers who go to all the workshops. In some cases, the per diem allowance for attendance at these workshops can be seen to be a ‘money-spinner’. Per diems are unsustainable economically.

3. Relevance: The subject matter should be (a) relevant and (b) capable of being  applied (for example, the content should not be based on diagnostic tests and treatments that are not available in low-resource settings)

4. Evaluation: CME activities should be evaluated.

5. Danger of removing the health professional from place of work: Often it is the surgeons or senior staff who will be away on a course, leaving junior staff unsupervised. This can translate into morbidity. In Uganda, this is avoided because the CME teachers go to the institutions, rather than the other way round.

6. 80% CME costs 20% money!

7. Way Forward: The group suggested the following steps, drawing on the CME experience in Uganda:

• A national structure is required to coordinate CME activities within a country. In Uganda, coordination is carried out by a CME Council within the Ministry of Health, which includes representatives of all key stakeholders.

• Insist that anyone coming in or within country providing CME must register with the CME Council Secretariat to avoid duplication.

• Long-term partnerships between donors and local centres are vital to ensure continuity and development.

• E-Connectivity: Unless the connectivity is good, CME through the Internet is not likely to be successful (currently only 20-25% of hospitals have access in Uganda).

• Adaptation: Materials should be adapted for local use. Uganda has primary health care packages for example.

• As far as possible, the CME provider should go out to the hospitals to run courses.

• The teaching should focus on local activities.

6. GENERAL DISCUSSION

In the closing discussion that followed, the following points were made:

• It was clear from all the discussions that the concept of teachers going to students rather than having students come to a central location was considered important.

• THET long-term institutional partnerships tend to be hospital-to-hospital partnerships. In some cases, the UK hospital raises its own funding but the partnerships is conducted under the auspices of THET. 

• The Ugandan Ministry of Health policy is that CME is for everyone, not just doctors. An estimated 80% of participants are nurses and clinical officers working at the local level.

• Dr Watkins of the Royal College of Physicians noted that the College was keen to provide educational materials to appropriate groups and hoped to further develop this aspect of their work.

• Professor David Morley announced that the second TALC CD-Rom is now available.

• Andrew Chetley of EXCHANGE announced that Exchange and other ngos will have an opportunity on 19 January to participate in a public ‘Question-time’ discussion with candidates for the post of Director-General of the WHO.

The Health Information Forum is run as an activity of INASP-Health, a cooperative network for organizations and individuals working timprove access treliable information for healthcare workers in developing and transitional countries. Participation is free of charge and without obligation. INASP-Health is supported by the BMA, Danida, ICSU-Press, and WHO. INASP is a programme of the International Council for Science (ICSU).