#9 Summer 2017

African healthcare: How mind shifts can move mountains

The journey towards eliminating HIV in Africa by 2030 requires a different approach and the Spark Health partnership between the UCT Graduate School of Business and Johnson & Johnson is modelling just this – proving that significant changes in service delivery can be achieved by changing the way healthcare professionals think about the challenges they face.

The announcement by US President Donald Trump that foreign aid for HIV/AIDS will be slashed has caused an outcry from stakeholders and healthcare professionals worried about the impact on HIV/AIDS care, prevention and treatment in Africa, but a small project at the UCT Graduate School of Business (GSB) is showing that it is possible to achieve big impacts with limited resources.

According to UNAIDS, South Africa has the highest prevalence of HIV globally, with 19% of the adult population carrying the virus in 2015. Around 6.8 million people are estimated to live with the virus in South Africa alone. The country spends R23 billion per year on fighting it, but still it has the largest number of HIV/AIDS infected individuals in the world.

While there has been significant progress made in combatting the scourge on the continent, we now find ourselves at a fork in the road. Strategic choices on the way forward will determine sustained gains against HIV infections or see the unravelling of the progress made thus far. In other words, similar to a marathon where the last mile is the hardest and thus requires the athlete to dig deeper into his/her inner strength (as opposed to simply leveraging physical strength), the journey towards eliminating HIV by 2030 requires a different approach.

What is called for now is not just more funding or aid – but a new way of thinking. The silo approach to service delivery needs to be transformed into a more integrated one, with shared experiences, and both vertical and horizontal communication lubricating joint efforts, where problems are reframed as challenges. This may sound idealistic, but there is evidence that simply changing the way nurses, doctors and healthcare workers think about the challenges they face can have a monumental impact. HIV/AIDS transmission rates can be reduced comprehensively – without spending much more on equipment, medicines or staff.

This is the inspirational story of the small group of people at Spark Health – an organisation of just nine people that has had a major impact on service delivery in the HIV/AIDS sector in nine African countries including South Africa, Zimbabwe, Malawi, Kenya and Nigeria.

Spark Health is a partnership between the UCT GSB and Johnson & Johnson, but it was never going to be a standard training intervention. While the transfer of new leadership and management principles and practices is core, the initiative has a more ambitious agenda: to reframe the way healthcare professionals think about their work and empower them to devise new solutions.

Specifically, they want to find new ways to reduce mother to child transmission of HIV in Africa – the most common way in which children are infected with the virus and a major focus area of the World Health Organisation (WHO) in combating the disease.

A pilot programme was initiated in the Kingdom of Lesotho in 2011-12 partnering with the Ministry of Health, USAID and EGPAF and involving about 139 (79 directly trained by Spark Health and another 60 integrated by those who had been trained) managers and healthcare professionals at district level, all over the country.

At the end of the year-long programme, there was an improvement in all seven identified key indicator areas – with a 7.6% increase in pregnant women attending antenatal visits and an 8% increase in women receiving anti-retroviral drugs or prophylaxis. Safe and controlled births in healthcare facilities (as opposed to home births) improved by 6.7%.

Participants provided extremely positive feedback. The new way of thinking helped transform simple work groups into well-functioning teams that had a shared vision. Critically, data integrity became everyone’s business and not just the domain of health information systems professionals.The intervention also prompted a critical policy change by the Ministry of Health on pharmaceutical delivery in Lesotho, which had a direct impact on the availability of medicines and improved service delivery.

Following these results, Spark Health was asked to run more programmes at district level in the Eastern Cape in South Africa and a programme is currently under way in KwaZulu-Natal.

The results from the 2012-2013 Eastern Cape initiative were even more impressive. There was an increase in pregnant women attending antenatal classes, a 17.7% increase in women who were initiated on HAART (highly active anti-retroviral therapy), and a 36% increase in pregnant women who were re-tested for HIV. Stock availability of medicines at two depots increased by 76%, making a huge improvement in service delivery to patients in the area.

It is worth noting that Spark Health achieved these results with a limited budget and funding. The question of how such a small team could make such a big difference lies in the core principles of the Spark Health programme – which is to empower health officials, to give them new tools and to encourage them to share these with others and to let this information spread virally.

Instead of looking at what healthcare officials don’t have (resources, time), they are encouraged to look at what they do have (parts of the health system that are functioning well, available assets) to develop creative and innovative solutions and promote teamwork and better communication. Building relationships and opening channels of communication is vital for better efficiency and productivity at clinics, hospitals and pharmacies.

With their new management and leadership skills, these officials then set about finding ways to overcome the challenges they were facing, resulting in strengthened health systems and improved outcomes. What is key to the Spark Health approach is the recognition that training alone will not yield the desired health outcomes. As such, more emphasis is placed on intensive, on-the-job mentoring to assist the healthcare professionals to transform skills into practice, and practice into performance, and then performance into health outcomes.

The Spark Health programme begins with an intense week-long workshop at the end of which participants leave with an action plan. Thereafter, there is about a year or two of intensive mentoring, day-to-day communication as well as quarterly review meetings and feedback sessions to see how teams are getting on with their plan.

One of the big advantages of the Spark Health programme is the further co-opting (integration) of other individuals to the programme by participants who have successfully attended the workshop. They then share their new expertise and knowledge with colleagues, effectively training them in the same way of thinking and integrating them into the process.

This integration causes a ripple effect of knowledge, empowerment and increased productivity and sees the expansion of a new way of thinking and acting, widening the reach of the programme and increasing its effectiveness.

The Eastern Cape programme run in 2012-13 saw 123 people initially participating and a further 56 people integrated into the process afterwards, resulting in a total of 179 professionals able to draw on the resources of the programme through mentorship, support and review sessions.

What the Spark Health initiative has shown is the power of a transformed mind to unlock people’s intentions and ignite their passion and drive. By empowering professionals in the healthcare system to effect change – the change actually happens: lower infection rates, improved maternal and newborn health, strengthened health systems and better medicine availability.

It is clear that more investment is needed in the fight against HIV/AIDS – but this is not necessarily limited to financial resources. It is the targeted development of individuals on the front lines of the war against HIV/AIDS that will produce improved and sustained health outcomes. Healthcare professionals are the most important asset in the healthcare system; assisting them to develop a different culture that is characterised by strong, well-functioning teams with a shared vision and asset-based rather than needs-based thinking, is key to achieving more and improved health outcomes with less resources.

It is possible to eliminate HIV in Africa by 2030, but as our healthcare professionals head towards that finishing line, exhausted, thirsty and running on empty, a shift is required to enable them to persevere and find ways of coping with the added pressure and pain. When we stop thinking about how tough it is and look toward what is possible, we see that our objective can be reached.

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