Desire for change

[ By Claudia Isabel Rittel ]

Salome Ngata wants to make a difference in Kenya. The 38-year-old gynaecologist plans to introduce new curricula to improve training for nurses. Because her country does not have enough formally trained doctors, other health workers often have to stand in for them. At present, gaps in care lead to the deaths of many women during pregnancy or labour. “Training doctors takes far too long,” Ngata says. “We need to develop other methods to improve our services.”

The specialist, who advises Kenya’s government on reproductive health, considers upgrade training for medical personnel an option. In Kenya, nurses also perform obstetrics. “That is fine,” Ngata says, “but one issue needs to be addressed: they often fail to identify problems early on in labour.” If difficult cases are to be brought to a doctor’s attention on time, complications need to be recognised before they become serious. Mistakes often have fatal consequences. “That is why I want to develop curricula for training nursing staff who look after pregnant women and women in labour,” Ngata explains.

Ngata is one 20 professionals taking part in a full-year training programme in Germany focused on health-care management. She will complete the practical part – which spans several months – at the Hamburg’s Eppendorf University Hospital, one of Germany's largest hospital complexes. When she returns to Kenya, she will present her concept to the line ministry as well as health-insurance officials, and then develop the relevant curricula.

All those taking part in the training programme in Germany share the desire to improve things back home. Sustainable progress, however, depends on many small steps, so each participant is working on a “transfer project”. The aim is to design viable solutions to everyday problems and to implement them within six months of returning home. “The projects are quite diverse,” says InWEnt’s Johannes Kleinschmidt. One participant may focus on streamlining materials management, another looking at ways to improve health-service financing, and yet another studying how to make patient-flow management more efficient. Waiting times are also of major concern. In many places, they are not a matter of hours – but days.

Ngata’s project builds on government policy in Kenya, where experience has been gathered to identify ways in which the standard of health care can be raised. In 2002, the health minister published a guide on improving performance. Special staff training has already been introduced in certain areas. “But all that is all still very general," the gynaecologist regrets. “My transfer project will provide curricula specifically tailored to the requirements of the reproductive-health system.” Ngata’s plan is ambitious. She wants it to reach every hospital ward in Kenya. If it succeeds, the concept could be extended to other areas.

Political grassroots

Health-service efficiency can also be boosted by empowering those in need. That is what Salome Saria from Tanzania wants to do. As soon as she gets home, she intends to conduct a survey among paraplegics. With the results, she hopes to make the government more aware of the problems of the disabled. Back home, she works for the Tanzanian Training Centre for Orthopaedic Technologists (TATCOT), which is the biggest training institute of its kind in Africa. Saria is already counting the days till she returns to Tanzania. When she flies back at the end of July, her family, her 15-year-old son Denis and a great deal of work will be waiting for her.

“Far too little is done for the disabled in Tanzania,” Saria says. Those who cannot get around on their own have no chance of taking part in social life. Wheelchairs like those made by TATCOT technologists since 2002 restore a measure of mobility.

Saria’s study will also provide hints for making better wheelchairs. At present, there is no serial production. TATCOT turns out around 30 customised units a year. Recipients do not need to pay for them; they are a by-product of orthopaedic technologist training. But hardly anyone in Tanzania could afford a wheelchair anyway. Costing around € 3,000 each, they are well beyond most people's financial reach. “The government contributes next to nothing.” Now, Saria intends to conduct a systematic study of wheelchair users’ experiences to improve the design.

What the Tanzanian health-care specialist particularly likes in Germany is that even trains and buses are designed so that wheelchair users can easily get on and off. She is also impressed by the fact that parking spaces are reserved for the disabled: “We need laws like that in Tanzania.” One big problem, she says, is that disabled people quickly feel stigmatised. So society needs to do all it can to avoid giving the disabled a negative sense of being different. “We are still a long way from that stage in Tanzania. Sometimes, disabled children are actually locked away for years.” But Saria sees a ray of hope. A member of the TATCOT staff, paralysed himself after an accident, has recently been elected to parliament.

Different conditions

Of course, the situation in Germany cannot be compared directly with that in African countries. Kenyan physician Salome Ngata is aware that the health-care system in Germany is far better equipped. At Hamburg’s Eppendorf University Hospital, for example, there are days when only two children are born – in a department with six doctors. “At a hospital back home, as many as 20 to 30 children may be born on one day – with only two doctors and maybe six midwives in reach."

The two participants of the course in Germany are particularly impressed by the way the health system is organised, health-care accounts settled, and purchasing operations conducted. But they see a downside to the widespread use of computer systems. “When you ask how stocks of pharmaceutical supplies are monitored, for example, you are told it is done by computer. Those who operate the software know what they need to enter, but they often don't know how the system works,” the Kenyan doctor explains. For her, that makes things more difficult. She wants to understand the systems – and it is not always easy to find the right person to answer a certain question in a huge university hospital.

Among other things, she has been finding out about how hospitals charge health insurances. She has learned that, since 2004, all accounts have been settled on the basis of flat-rate fees. Hospitals do not bill insurers for each individual service, but only for the entire cost of treating each patient, including hospitalisation, catering, any preoperative treatment and/or after-care provided. “When you ask about the criteria applied in the individual categories, you get no answer. That is because doctors only need to enter the diagnosis on a computer. The category the service falls into is worked out by software.” Nonetheless, Ngata will be taking home lots of ideas.

What the two East African participants have found particularly useful is the theoretical part of the course. In four-and-a-half months, they have acquired specialised knowledge in strategic management, process management, bookkeeping, human resources and quality management.

But the hands-on experience also matters. In the quiet Bonn suburb of Bad Godesberg, Tanzanian orthopaedic specialist Saria has already had a chance to look into a hospital’s departments for administration, documentation and purchasing. The German staff has also gained from the experience: “You see things in a new perspective,” a colleague says. “It takes a lot of compassion to travel so far only for the sake of training.”

The current InWEnt course is the second one of its kind. The third one will start this year. Saria says she is convinced that the situation in her country can be improved. “Everyone who learns something new has to put it into practice – and pass on their experience to others.” But she also knows that sustainable progress will depend on more than personal commitment. The funds for health-care must increase. In 2004, per-capita health spending in Kenya was only $ 86; in Tanzania, it was $ 29 – including what patients paid themselves.