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Transcript of the podcast: Training health care providers to treat SAM in hospitals in Mali

Author: ENN
Year: 2017
Resource type: Other

Listen to this podcast in French. Read this transcript in French.

AY: Hello dear listeners, welcome to this podcast of ENN Field Exchange 55. I am Ambarka Hassan Youssoufane, GSN West Africa Regional Specialist and ENN Center. Today I am with Doctor Kanta Malam Issa, General Coordinator of the NGO ALIMA, The Alliance for International Medical Action, in Mali since 2015.

Good morning, doctor!

KMI: Hello Ambarka.

AY: What are the objectives of the NGO ALIMA, and what is its relationship with GCAP NGOs in Mali?

KMI: ALIMA's mission is to implement innovative medical practices in countries with recurring public health problems such as malnutrition and malaria. Of course, we must also respond to epidemics and emergencies - conflicts, wars, and natural disasters - and help the vulnerable populations impacted by them. ALIMA also aims to facilitate exchanges related to medical innovation and research. Those exchanges allow us to show UNICEF and other humanitarian organisations potentially effective practices that they can use in their work caring for communities and populations. Our main goal is to work with leaders in countries where public health problems recur. We're therefore working with what we call a platform of national NGOs. ALIMA works in multiple countries, chiefly in the Sahel.

AY: You recently wrote an article, which will appear in Field Exchange 55, about the Severe Acute Malnutrition Training Centre, or URENI School, in the Intensive Nutritional Recovery Unit in in Dioïla, Mali. Can you briefly explain the concept of the URENI School?

KMI: There are two words in "URENI School": what we call URENI, which refers to management of severe acute malnutrition in hospitals. URENI is the French acronym for Intensive Nutritional Recovery Unit, so it's really an inpatient unit that treats severe acute malnutrition with medical complications. And a school is a place for education and on-the-job training. In Mali, we've seen a range of situations and experiences. We knew we had to find a place that could offer practical training for healthcare providers, doctors and nurses, so that they're able to care for hospitalized patients. It all started with the observation that all the countries affected by malnutrition have national protocols to address it. Nonetheless, in all of those countries, and Mali in particular, there are serious problems caring for malnourished patients in hospitals. That was the starting point for our work, so we want to ensure that providers are better equipped to provide practical care. I emphasize the word "practical."

AY: And when was this approach implemented in Mali, and how is it funded?

KMI: The approach was adopted in Mali in August 2015, and is still in place today, so two years. And it was launched by our partners, including UNICEF and ???, the primary funders of nutrition programs in Mali.

AY: Could you briefly describe the training at the URENI School?

KMI: Training consists of a three-week course, and we bring in health care providers from several health districts in Mali for each course. So, it targets all health districts in Mali, and is not specific to one region. We focus specifically on the districts that lack partners, which was the initial idea. Each class comes to the centre for the three-week course. Classes consist of doctors and nurses, typically three people each from an average 3 to 4 districts. According to our contract, we have as many as 12 people in training at the URENI School in Dioïla. There are about 65 districts in Mali and we're targeting all of them. Our top priority is targeting districts without partners to help with malnutrition care.

AY: So, you could say that your training targets health centres that do not receive institutional support from NGOs?

KMI: No, we're targeting all health districts, and the health care providers who have been caring for malnourished patients before they come the URENI School. All we can do is create a training timetable. We can't provide training all districts in Mali – there are so many, more than 60. Our timeframe only allows us to prioritize districts with the greatest need.

AY: Approximately how many people have you trained to date?

KMI: We have been able to train approximately 260 healthcare workers at the URENIs, roughly 60 doctors and 200 nurses. This group represents about 40 health districts.

AY: Apart from the URENI School approach, what other training or capacity-building strategies for addressing malnutrition are in place in Mali?

KMI: There are already several training channels for health care providers who treat malnutrition. For example, the Malian Ministry of Health and the Nutrition Division offer training on the national protocol. Other organisations offering training include technical partners such as UNICEF, which is the leader in treating severe acute malnutrition. Of course, other partners and NGOs offer training, but it remains theoretical and doesn't specifically address the national malnutrition care protocol.

I said at the start of this show that we wanted to implement a very practical component, to show the emphasis on practice in hospitals. And that's a substantial topic, but URENI students have three weeks of hands-on training, and almost all of them achieve their training goals.

AY: Listening to you, it seems that you designed the training course to be practical. Would you say that this training, this URENI School approach is an improvement over the typical training and capacity building activities available to Malian health care providers previously?

KMI: Yes, we believe that the malnutrition care training that students receive at the URENI School adds great value to their theoretical training. The problem with the other approach is that the training was short, no more than a week, and was vague. But this three-week course devotes more time to training providers, and focuses on the worst problems. Providers will see the most malnourished patients in hospitals, and the sickest ones, who are at risk of dying. So, to prevent these patients from dying, we must focus on inpatient treatment of malnourished children. This is what distinguishes the URENI School program from other training.

AY: Can we talk about risk of overlap between the different training and capacity-building strategies in Mali? If, yes, is there is some coordination in the selection of participants for training?

KMI: No, not at all, there is no overlap. Rather, there is continuity in the training of providers, though the levels are different. And most of the training that people get here is fairly general and about the national protocol, whereas URENI training addresses inpatient care specifically. So, there is no overlap, but rather, the various training programs complement each other, which is quite important.

As for how we select trainees, we use a timetable that we've set in advance, consulting with all the partners involved in this process. The chief partners are the Nutrition Division, and thus the Malian Ministry of Health, and of course our partner UNICEF, which also a funder. So, this timetable is very effective, and we know in advance the districts where staff need training. We inform those beneficiary districts that they should select the personnel to come to the URENI School: 1-2 doctors and 2-4 nurses each time, depending on availability. But we all insist – ALIMA, UNICEF, and the Nutrition Division – that the providers who come for training must be dedicated to URENI, and will work directly with URENI units after completing training. Or they must be paediatric staff. In some districts, it's often difficult to separate URENI, care of patients with severe acute malnutrition and complications, from general paediatrics. Either way, the district benefits if their general paediatric staff come for training.

AY: Would you say that ALIMA coordinates with health centres to select the right health care providers to receive training?

KMI: Oh yes, absolutely. They're the ones that approve us – we only have the information that X district should be coming through next month. It's up to the district to identify the providers who should attend, and the process is transparent to everyone.

AY: Earlier you discussed the context in which ALIMA implemented this approach. Were you inspired by another program that was implemented elsewhere?

I said in my introduction that one of ALIMA's goals is innovation. The URENI School wasn't inspired by a model elsewhere, as far as I know. It came from our experiences, the different observations that we've made in various contexts, but more specifically in Mali. So, the idea really came our constant concern for ALIMA's ability to innovate each time we're faced with major problems – to say, "OK, what should we do?" So, when that we had the idea for the URENI School, it wasn't something that we had seen elsewhere. It's really very unique to ALIMA.

AY: So, we can say the innovation was to adapt on the ground?

KMI: Exactly.

AY: Has ALIMA used the URENI School as a model for another context or country?

KMI: We started to do that two years ago. There's a great, very visible commitment to ALIMA's work in Mali, but that commitment is growing and spreading to other countries with different circumstances. People started to show an interested, but I think that there's already a certain number of countries who are starting show interest, too. I think Chad is one of them, and I think that Nigeria is considering the idea more and more, too. Yes, it's progressing well in Mali to start, so we're asking, will this be the only training centre? Will there be others? I don't yet know how to answer that, but at any rate, there's definitely a commitment to this training centre.

AY: As someone who participated in creating the centre in Mali, what specific contexts do you think are necessary, or could necessitate the creation of a centre like this to provide training nationally?

KMI: In Mali, the context is the prevalence of malnutrition, and the public health problem of nutrition amid the poverty of human resources, in number and in quality. These are the factors that led us to address malnutrition, but always – always worrying about how to make our response viable, and integrating it into health care facilities. Those were the factors that led us to conceive a permanent training centre. And therefore, these are the essential factors that motivated us to create the URENI School. I think it's quite appropriate to create similar centres in many other countries in the Sahel with heavy burdens of malnutrition.

AY: The URENI School initiative focuses on training the staff in the field, improving the capacity of health care providers. But what is there in terms of initial healthcare provider training? Does ALIMA have a specific approach or strategy?

KMI: We don't provide the initial training of aspiring health care providers. We're just an NGO, a humanitarian NGO, so we partner with the Ministry of Public Health to respond to acute needs. Training health care providers in professional education programs isn't part of our mission. But considering the backdrop of the URENI School, we often question perspectives, and consult with our partners, such as the Ministry of Health, about how to integrate the URENI School in the future. Shouldn't we be consulting with the schools training healthcare providers, including the university and the medical school, to provide useful input to them? Wouldn't it be better to be able to review existing training courses and seek opportunities to integrate our experience into them? That raises the question of revising curricula in schools for healthcare providers and the medical school, which are training doctors and healthcare providers.

AY: Related to that question, have you had any response from Malian health care authorities?

KMI: We've never specifically asked them. I'd say that our first objective is to train health care staff so they can provide quality healthcare. The training courses, however, provide a useful framework for meetings and exchanges. There is what we call the URENI Steering Committee. We discuss all these issues during meetings of the Steering Committee. They are many people involved in the Committee. There are the officials from the Ministry of Health, but there are also paediatricians, sometimes from medical schools or health care school programs. So, these people are tasked with sending the same message, which is not that the Malian government is taking over the URENI School. But it's progressing well. If the government has the will and the means I think it becomes possible, but we shouldn't put the cart before the horse yet. We're working together to ensure that the school, which has already built a strong reputation, can continue to train healthcare providers, and achieve tangible results in the field. We must therefore follow the providers who have already been trained at the URENI School, ensuring that they implement what they've learned. We thus begin to discuss the process of how the government is taking over the URENI School. And that is not a short-term question, but a medium- or long-term one.

AY: Just now, you were speaking about a Steering Committee at the URENI School in Dioïla, which considers various issues. Is there a coordinating framework outside of the URENI School that includes other actors, such as public officials, that can address issues related to nutrition and innovation?

KMI: The Steering Committee is the forum that allows the parties to discuss issues related to the URENI School. The technical parties, such as the government, and funders such as UNICEF and ECHO are key participants in the Steering Committee. We will soon be mobilizing other funders to support us going forward, such as OFDA and the Orange Foundation. So, all of these parties will participate in Steering Committee discussions. There are other frameworks for discussing nutrition, where we share ideas and keep people up to date. Most notably, there's the Nutrition Cluster, which dates back to the first efforts to address malnutrition in Mali. The Cluster provides opportunities to discuss important issues. But I should note that the URENI School is separate from the Steering Committee. The Committee includes representatives from all of the partners, and their genuine desire to take action is palpable.

AY: Let's return to the article on the URENI School in Dioïla. You noted in a link between the security situation in Mali since 2012, and the poor capacity of the government to provide quality healthcare to the population. Can you tell us more about how the two problems are connected?

KMI: You know that in Mali, just like everywhere, any time you say that there's a crisis – a security crisis or a war – that destabilizes government institutions. So, when you say "destabilization," you're saying "non-functioning institutions." So, the healthcare system has been destabilized since the crisis in 2012. Specifically, some providers have abandoned healthcare facilities, as well as the system that supplies medicines and goods. Another issue is the destruction of infrastructure in many healthcare facilities in northern Mali. In that sense, yes, the crisis has destabilized healthcare services.

AY: Another link that you made in this article is between the rather high birth rate, the relatively high natural growth of the Malian population, and the problem of malnutrition. How do you make this connection?

KMI: Mali is one of the countries with the highest rates of population growth, with an average of 7 children per woman, which is quite high. Large families become a problem, as we know that they limit a family's socioeconomic level and household income. We can imagine that there are greater needs but fewer resources to meet them. So, this is exactly the problem Mali faces. Large families pose challenges in ensuring access to healthcare and food. These two factors alone and combined, will inevitably contribute to the deterioration of the nutritional status of populations, especially of children, who are most vulnerable.

AY: How has the URENI School impacted or changed training methods, particularly the costs of training? Has URENI affected the costs of training?

KMI: We haven't measured costs ourselves, but we should look at the evidence: anyway, both the URENI School and hospital cost money. Each requires more human resources, time, and materials, and hospitals use more medications. People should remember that hospital care is how we prevent most deaths. Nearly 100% of patients with severe acute malnutrition and medical complications who don't receive quality care will die. So, we win by dedicating all these resources to hospitals, precisely to prevent deaths. The resources that we dedicate to training aren't expensive, and Malian officials are supporting trainees. We just enhanced the technical platform and increased the training staff to support new trainees. We assess the nurses and other health care providers who come for training. They are experienced and used to caring for and supporting severely malnourished patients.

AY: You said that this approach is supported and funded by various donors, including UNICEF and ECHO. Does ALIMA have a strategy in place to make this initiative more sustainable, do you know if there will be long-term funding?

KMI: We're discussing the question of funding. Two initial grants, from UNICEF and ECHO have just ended. However, we recently secured new funding, which will begin in August, from other donors: OFDA and other US funders, and the Orange Foundation. We are also discussing the sustainability of these new funding sources. The Steering Committee is also considering how the Malian government can include the cost of this training in the national budget. We hope that we'll be able to consider funding from the Malian government or other donors by the time the third phase of training ends. That phase will last just over 12 months.

AY: What is the role of the Ministry of Public Health in ALIMA's strategy?

KMI: The Ministry provides staff and facilities, which ALIMA didn't build itself. We're using government facilities to conduct the training. The Chief District Physician for Dioïla has been involved in training from the start. People know that we need to provide quality healthcare in order to improve outcomes. We need to invest in staff in order to lower the mortality rate of children under five. The Malian government has agreed, and has provided some staff. Moreover, government officials continue to play leading roles on the Steering Committee, creating consensus among all stakeholders to support the URENI School. The government provides a framework for URENI, which is a positive demonstration of its interest in the problem of malnutrition. I think the government is fully meeting its responsibilities. There's also the issue of contributing funds to support the URENI School, which the Malian government can now afford. The school can't be funded right away; that takes time, and requires careful consideration. Each stage in the process of setting the national health care budget requires evaluation and advocacy.

AY: The URENI School's strategy seems to be well received in Mali. Would you advise other countries to adopt similar initiatives for managing malnutrition?

KMI: Absolutely. This kind of training is a tool that can respond to fast-changing need to build improve the capacity of hospital staff. I think it's something that we can replicate in all countries where governments face grave problems responding to severe malnutrition. This is very feasible.

AY: What advice would you give to a country wishing to implement such an approach?

KMI: That people must have the will to implement it. I'd say that we can prevent needless deaths by ensuring the quality of health care providers. Everyone who responds to malnutrition must understand this. It's a question of will for stakeholders working on nutrition problems.

AY: What factors promoted success in Mali?

KMI: First, the commitment of the government. The commitment of the Ministry of Health through its Nutrition Division. Also, the commitment and availability of technical and financial partners. And of course, we at ALIMA and our partner GCAP, have a strong desire to show that it is possible to change and improve. And with the support of the partners that I have just mentioned, this has been possible.

AY: What would be a holistic and sustainable strategy for dealing with severe malnutrition?

KMI: Government suffers from significant staff turnover, so we must continue to train everyone. Even if we can train all of the Malian health care providers who work in URENI in Mali, it's cyclical, so we must continue to train new providers.

It doesn't matter where a trainee works within Mali. We can't lose what we've achieved, so the benefits endure. Trainees will always be Malian, and will remain committed, wherever they are, to the health of their compatriots. The nation doesn't lose that commitment. The other thing to consider is revising training curricula for health care providers. Integrating acute malnutrition care in the community, especially in hospitals, into training will prepare new graduates to provide quality care. These strategies can help us to address these issues of turnover in Malian health care and of providers changing jobs.

AY: Thank you very much, Mr Kanta Malam Issa, for sharing your experience with the URENI School initiative in Dioïla, Mali, with us. I wish you the best as you continue your work and I hope to speak with you again. I would also like to thank our audience for listening to this podcast. It is part of a series created by ENN to complement publication of Field Exchange 55. As always, we look forward to hearing about your experiences and your contributions to addressing nutrition issues. 

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