The African Family Medicine Education and Development Initiative (AFMED)

Progress and Future Directions - April 2008

The African Family Medicine Education and Development Initiative (AFMED) is an effort by Maternal Life International (MLI) to improve maternal and family health care in Nigeria by increasing the level of in-country health care training for family medicine physicians, nurses, midwives and allied health care personnel. This report examines MLI’s AFMED pilot-program training February-March in Jos, Nigeria.

BACKGROUND

AFMED is a collaboration of MLI and the National Center for Health Care Informatics (NCHCI), both of Montana; Our Lady of Apostles Hospital (OLA), Jos, Nigeria; and the Catholic Secretariat of Nigeria (CSN), the administrative arm of the Nigerian Catholic Conference of Bishops. The CSN’s Health Unit oversees more than 300 medical facilities in Nigeria and provides some 40 percent of the health care in the country.

AFMED is an extension of an ongoing program of MLI and CSN, called Safe Passages, to reduce maternal and infant mortality and to improve delivery of services to prevent mother to child transmission of HIV/AIDS (PMTCT). In 2003, CSN's Health Unit approached Maternal Life, asking for assistance in developing a Safe Passages strategy, which resulted in the program and ongoing five-year collaboration. The AFMED/Safe Passages program is centered in Nigeria, a country that experiences 10 percent of the world's maternal deaths.

By 2007, through a series of eight intensive workshops over four years, MLI had trained and equipped some 600 Nigerian health care providers in basic and emergency obstetrical procedures. During this time, Maternal Life realized that a complex social, educational, economical and developmental paradigm surrounding maternal and family health exacerbated maternal and infant mortality. In addition to a lack of adequate medical training, supplies and facilities, discrimination, poverty, illiteracy, and a lack of adequate housing, safety, and community services (water, sewer, transportation), also contributed to the dire situation in-country.

For example, preventable maternal deaths happened because women couldn’t afford a doctor’s care, couldn’t get transportation to a clinic in emergency situations, or underestimated the seriousness of the situation. If a woman reached a medical facility and was treated rudely or if the facility didn’t have trained personnel, medicines and equipment to help, the hospital or clinic lost the trust of that woman, who often returned to the care of a traditional birth attendant.

Over the years, Maternal Life has learned that to reduced maternal and infant deaths requires more than training and equipping medical providers. You also need to support and build trust in the health care system, increasing the availability of its services. This understanding fits well with MLI’s mission of providing excellence in holistic health care based on the value and dignity of the human person. MLI also realized that maternal health went beyond childbirth and PMTCT services to include family care for treatment of infectious diseases such as malaria and tuberculosis.

Thus, MLI examined different ways to enhance family medicine and increase trust in the system. After working at OLA Hospital in Jos, Nigeria, MLI realized a need for Nigerian family physicians to have more advanced family medical training. MLI also realized that poor women needed access to hospital care.

Maternal Life shifted its focus from large training conferences to training smaller groups of doctors, nurses and mid-wives who would deal with a whole range of family health issues and who could become community care leaders. Additionally, MLI’s New York affiliate, Aiding Infants and Mothers (AIM), would pay for all medical services for 500 women in Jos and surrounding areas from pregnancy through six months post partum. This would help solve the access issue.

Thus the AFMED program was developed with CSN and the staff of OLA Hospital. The goal was to provide a certified, advanced residency program for family physicians along with additional training for nurses and mid-wives. The doctor’s program would include ongoing medical educational opportunities through distance learning in which Nigerian family physicians would have access to medical specialists in the United States. By emphasizing on-site residency training in Nigeria, the AFMED model would help prevent the exodus of African physicians that takes place when post-graduate training is done in non-African countries. Also, using technology is not only cost effective but, when perfected, will allow for timely uptakes in new medical practices and applications. AIM’s assistance program would help provide a way to determine the effectiveness of treatment and to ascertain levels of community acceptance.

THE PILOT PROGRAM

With the pieces conceptually in place, a MLI team traveled to OLA Hospital in February to conduct the AFMED pilot program. OLA is a regional medical facility that is becoming a center of excellence with a family medicine residency program and a nurse-midwifery school. OLA also has established relationships with several rural clinics, making AFMED/AIM multi-dimensional in application.

The training team consisted of Dr. Bob Scanlon, MLI's maternal health coordinator and director of AIM of Huntington, New York; Ray Rogers, Chief Executive of the NCHCI located on the campus of Montana Tech of the University of Montana, and Dr. George Mulcaire-Jones, MLI's medical director, Butte, Montana. The program included a maternal health training workshop and hospital and satellite clinic site assessment.

During the course of the visit the following objectives were realized:

1. A SUCCESSFUL TELECOMMUNICATIONS/DISTANCE-LEARNING LINK: Working with Dr. Sam Inyang, a Nigerian physician and owner of a Nigerian-based internet service provider (ISP), a video communication satellite link was established between Jos and the NCHCI’s telecommunications laboratory at Montana Tech/University of Montana-Butte. Using an off-the-shelf, mobile PolyCom unit (owned by NCHCI and hand carried to Nigeria) and running at a relatively low bandwidth of 512K at a sustained 30 frames per second, we were able to establish a near television-quality interactive learning interface. This allowed for real time communication between the two sites for several, sustained, two-hour live sessions. This was no small accomplishment as we had to understand and overcome numerous infrastructure barriers. However, we now know the problems and how to solve them.

Some 35 healthcare providers and administrators from throughout Nigeria attended the first live video demonstration. These participants included hospital administrators, midwifery school principals and the family medicine residents and staff of OLA Hospital. In Montana, some 20 people -- representing the NCHCI, IT professionals, and college faculty and administrators -- attended the video demonstration. When the actual connection between Nigeria and Montana was made, cheers erupted on both sides. Several Nigerian healthcare leaders took the occasion to tell their new colleagues in Montana about the importance of what we had accomplished and the remarkable hope that IT brings to improving healthcare in Nigeria. The opportunity now exists to provide certified, regularly scheduled, and on-going video conferencing training sessions to physicians, resident physicians, nurses, and midwifery students at OLA Hospital and elsewhere.

2. ROOT CAUSE ANALYSIS: As a part of the AFMED pilot workshop, a modified "root cause analysis" process was used to explore the proximate and root causes of maternal and newborn deaths in Nigeria. While much of this information is available from published studies, the input of physicians, midwives and community educators working in rural Nigerian settings contributed a great deal to our understanding of maternal and infant mortality. We understood first hand the need for improvements in institutions, education, community awareness and life-skills training in rural communities. Through this process, we are now in a position to complement our institutional-based learning programs with a strong community education and outreach effort as part of our holistic approach to healthcare.

3. PRIOR SAFE PASSAGES FEEDBACK: A number of workshop participants had attended one of our previous Safe Passages workshops. They reported on actual experiences using basic and comprehensive emergency obstetrical interventions that had been previously introduced. For example, the OLA midwifery school now trains its midwives emphasizing evidence-based approaches to obstetrical care first introduced by Safe Passages. Other examples include improving the management of severe preeclampsia and ecclampsia through the use of magnesium sulfate and a standardized approach to neonatal resuscitation. One hospital has built upon their success with neonatal resuscitation through the development of a special care nursery for premature infants.

4. AIM AND OLA HOSPITAL: During the trip, MLI found that OLA not only had the institutional capacity to provide high level obstetrical and newborn care but also possessed a rural health network. This network allows OLA to reach out into the "bush" and touch people at the village level. We know that many problems in health care occur due to a delay in accessing the system. Understanding OLA’s capacity allows AFMED to limit this delay through an integrated health delivery and education network. One of AIM’s objectives is to encourage the use of the health network by subsidizing the cost of care to the poor.

5. PARTNER COMMITMENT: The relationship between MLI and CSN continues to strengthen. CSN has a new office in Abuja and has expanded its capacity to provide coordination of obstetrical and HIV care among 300 Catholic health care institutions in Nigeria. MLI has a full-time coordinator working directly with the CSN’s Health Unit, which twins with the Christian Health Association of Nigeria (CHAN) and with other family medicine and midwifery schools so that eventually they will be able to access AFMED training.
The Safe Passages Program is included in the Nigerian Catholic Procreative and Family Health Policy, which is published by the CSN’s Family and Human Life Unit in collaboration with ENHANSE/USAID. ENHANSE – Enabling HIV & AIDS, TB and Social Sector Environment -- is a Nigeria-USG bilateral project that creates an enabling policy and legislative environment for high quality, highly accessible health and education programs in Nigeria. It is a five-year (2004-2009) project funded by the United States Agency for International Development (USAID).

6. LINKAGE WITH COMMUNITY HEALTH: During a second training in March, MLI partnered with Catholic Relief Services of Nigeria (CRS-Nigeria) to present "The Faithful House," an HIV risk avoidance program based upon strengthening marriage and family health. MLI developed this program for CRS-Baltimore under another USAID grant. Previously, the program had been successfully introduced and positively evaluated in Uganda, Ethiopia and Rwanda. The Faithful House serves as an entry point for improving family health - including education about "safe birth," breast feeding and basic disease prevention. Portions of the Faithful House can be incorporated into AFMED.


7. WEST AFRICAN POST-GRADUATE EDUCATION: Detailed discussions were held between MLI, OLA and several family medicine physicians in Nigeria active in the West African College of Post-graduate Medicine. It was agreed that through distance learning the content and quality of education for Nigerian physicians could be greatly enhanced. We discussed ways in which the learning content could be directed towards the specifications of the West African College and, thus, could be used in other countries as well.

8. OLA REGIONAL CENTER OF TRAINING AND EXCELLENCE: Over the past three years, OLA hospital has demonstrated its capacity and commitment to become a regional center for training and excellence. It has developed an accredited family medicine program, has improved the quality of its midwifery school, and recently has become a leading site for antiretroviral treatment through PEPFAR. Additionally, OLA has working relationships with several outlying medical clinics and facilities, providing multiple levels of care. We believe, with further support, that OLA can become a center for training all levels of health care providers in Northern and Central Nigeria, leading to improvements in the delivery of maternal, newborn and HIV, malaria and TB care.

AFMED is now well positioned to take the next step forward in addressing the needs for improved training and health care delivery in Nigeria. We have demonstrated the technological feasibility for ongoing, real-time, distance learning and program development. Over the course of our five-year partnership with the Catholic Secretariat of Nigeria and other key stakeholders, we have a clear understanding of both problems and potential solutions for maternal, newborn and related infectious disease treatment and care. And we have a greater understanding of the need for quality post-graduate training in family medicine in order to improve the quality and continuity of medical care and the acceptance of professional care within a community. We are confident that program development and lessons learned through the implementation of AFMED can be applied throughout Nigeria and other African countries.

POST SCRIPT

Every time we travel to Africa we are struck by the story told in the eyes of those we meet and with whom we work -- from the pride of a first time mother holding her newborn daughter to the haunted gaze of a young boy dying of AIDS. As our distance-learning technology surmounted one barrier after another and came together, we could see the unmistakable gleam of hope emerging in the eyes of the physicians, midwives and nurses gathered around the computer screen. Here was an opportunity, a promise, and a dream -- to learn new skills in new ways, to be connected with others committed to health care development, to believe that notions of human progress and solidarity can find their way even to the most remote corners of the world.

We know it is possible to conduct live, interactive healthcare education and development between the United States and Northern Nigeria, an area with one of the highest maternal and infant death rates in Africa. With an ongoing interface, the "live air" of continuing dialogue and ongoing, accelerated maternal health and family medicine training replaces the "dead air" of waiting for the next in-country training and wondering how past instruction has been implemented.

This technology, combined with our experience in partnering with African healthcare leaders, will enable us to chart a new course in maternal, newborn and family related medical care. It is a vision we have seen; it is a vision we share with our African colleagues; it is a vision that embraces the life, health and well-being of thousands of African women and babies and those afflicted with malaria, tuberculosis and HIV/AIDS. We know it is a vision that can be realized.

For More Information, contact:

Dr. George Mulcaire-Jones
Medical Director
Maternal Life International
326A S. Jackson Street
Butte, Montana, USA 59701
406-782-1719
www.mlionline.org
mlicares@yahoo.com

Raymond F. Rogers
CEO
National Center for Health Care Informatics
1300 W. Park Street
Butte, Montana, USA 59701
406-496-4821
www.nchci.org
rrogers@mtech.edu