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Health Improvement Project : a new model of healthcare delivery

MIKE SPENCER CHAPMAN, FIONA GREVILLE-HEYGATE, RAMSAY SINGER, JONATHAN REES, RUARAIDH MACDONAGH

The effectiveness of aid programmes in delivering improvements on the ground in resource-poor countries is often questioned. In this article the authors describe a project involving the direct, semi-autonomous running of two hospitals in Zanzibar and highlight the successes they have achieved. Figure 1. The paediatric ward at Kivunge Hospital prior to and after renovation by HIPZ

anzibar is a semi-autonomous region of HEALTH IMPROVEMENT PROJECT ZTanzania, consisting of an archipelago ZANZIBAR of islands off the coast of mainland Africa. Health Improvement Project Zanzibar The estimated population of 1.3 million (HIPZ) is a UK-registered charity inhabit two of the largest islands, established in 2006 by Mr Ruaraidh and Pemba, where the combined doctor- MacDonagh, a consultant urological to-patient ratio is around 1:20 000 (as surgeon based in the UK. Having compared to 1:360 in the UK). Healthcare previously worked in Zanzibar, Mr provision is designed as a three-tiered MacDonagh was approached by the structure of primary, secondary and tertiary Principal Secretary for Zanzibar’s Ministry care. Primary care is provided by 134 basic of Health for assistance in the delivery of Primary Healthcare Units (PHCUs), which healthcare in Makunduchi Hospital: Mike Spencer Chapman, Core Medical are distributed evenly around the two main a 36-bed hospital with a catchment Trainee, Barts Health NHS Trust, London; islands to ensure that all the population area population of around 50 000 in HIPZ Trustee; Fiona Greville-Heygate, have a centre within five kilometres. On the rural south of Unguja, which had Core Psychiatry Trainee, Royal United Unguja, secondary care is provided by two fallen into a state of virtual disuse. In Hospital, Bath; Ramsay Singer, NIHR hospitals: Makunduchi and Kivunge. Tertiary 2007 this led to a 10-year agreement, Academic Clinical Fellow in Clinical care is provided by the largest hospital on giving HIPZ management responsibility Oncology, Maidstone Hospital, Kent; the archipelago, Mnazi Mmoja, located in the for Makunduchi Hospital, with the Jonathan Rees, GP, Backwell and capital . In practice, prior to 2006, aim of improving healthcare services Nailsea Medical Group, North Somerset; the hospitals were so dysfunctional that the and systems in the hospital and the HIPZ Trustee; Ruaraidh MacDonagh, secondary care tier was provided almost wider region. Consultant Urological Surgeon, Taunton exclusively by Mnazi Mmoja. This led to and Somerset NHS Trust, Somerset; overcrowding, inadequate staffing, and long In 2012, following the success of Founder and Chairman of HIPZ patient journeys. HIPZ’s involvement at Makunduchi, the

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Ministry of Health requested that HIPZ Identifying realistic, tailored successes. These have included renovation undertake a similar 10-year project at healthcare solutions of staff accommodation, staff training, Kivunge Hospital in the north: a larger, HIPZ aims to improve healthcare through introduction of the hospital manager role 72-bed hospital with a catchment area micro-managing health systems at a local to strengthen leadership and discipline, and population of around 200 000. HIPZ level. This strategy allows us to work in building staff morale and pride by providing now manages the only two hospitals a constructive partnership with staff to an improved work environment that is clean, outside of the capital, providing primary identify already well-functioning projects, has better equipment and offers new services. and secondary care to an area with a troubleshooting ‘on the ground’ issues, and Initially, HIPZ also provided a supplement combined population of around 250 000. understanding the various complexities of to employees’ salaries to encourage failing healthcare projects. engagement with the improvement process; THE HIPZ MODEL this is now transitioning to a performance- International development organisations Providing volunteer doctors from the UK, based approach. have tried many diverse approaches who work with Zanzibari staff on a daily to healthcare improvement in resource- basis, allows us to observe, listen and learn Partnerships with other health poor countries.1 HIPZ has an innovative about area-specific issues. A ‘one-size-fits- development organisations model to achieve this goal in Zanzibar. all’ approach to improving healthcare in A multitude of health development Some key elements of this approach are low-income countries is simply not effective organisations have a presence in summarised below. across the wide range of economic and Zanzibar, each with its own priorities cultural settings. The close relationship and need for donor accountability. There A formal partnership with the between our leadership team and the team is risk of poor co-ordination between Ministry of Health on the ground enables a targeted approach: organisations, and few have an ongoing A Memorandum of Understanding (MoU) we are selective and specific about the presence on the ground to ensure the was created, giving HIPZ management areas that we support, and ensure that we long-term success of projects. Within responsibility for each of the two hospitals, follow through on all projects we undertake. our hospitals we are well placed to help in collaboration with the Ministry of Health This results in clinically important, high- with these issues, and have had several Zanzibar, for a period of 10 years. impact improvements for relatively modest successful partnerships with other financial investment. development organisations including the The agreement outlined the roles and United Nations International Children’s provisions apportioned to the two Ensuring long-term clinical and Emergency Fund (UNICEF), the United partners. The Ministry of Health would financial sustainability Nations Population Fund (UNFPA) and continue to provide staff, salaries and A core element of HIPZ’s strategy is to Rotary International. basic services, such as certain medications incorporate long-term sustainability into and equipment. HIPZ would support and all projects and healthcare initiatives. NOTABLE ACHIEVEMENTS develop the day-to-day management Fundamental to this has been the Soon after taking on the management of the hospital, provide clinical support identification of key members of staff of Makunduchi Hospital, HIPZ initiated a through volunteer UK doctors, supervise and the support of their personal and monthly collection of data relating to the and fund renovations and building professional development. As per the usage of hospital services, compiled by the projects, and develop systems to deliver MoU, Makunduchi and Kivunge Hospitals hospital manager. As well as allowing the a reliable and consistent health service. will return to a fully locally-delivered early identification of problems and key areas Although generally working within healthcare service at the end of the for development, this has demonstrated a Government regulations, HIPZ funding 10-year period of the agreement. number of successes (Box 1). is spent directly on service improvement and does not go via the Government, thus Maximising the potential of local staff Data from 2009–2014 showed a dramatic ensuring accountability and a degree Having talented, motivated staff in key increase in the use of hospital inpatient of autonomy. clinical, administrative and managerial services. Monthly hospital admission rates positions is instrumental in implementing increased by 193%. Since the establishment In short, the Government has handed improvements and will be essential in of comprehensive emergency obstetric care over the running of a hospital to an NGO maintaining sustainability in a Zanzibari- and general improvements to maternity for a protracted period with the aim of led healthcare service. Consequently, the services, a 116% increase has been seen in improving services. As far as we know, this implementation of measures to improve the number of mothers delivering in arrangement is unique. staff performance has been key to HIPZ’s hospital. Other maternity services, such

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rise in the incidence of cardiovascular Box 1. HIPZ achievements at Makunduchi/Kivunge Hospitals disease in Africa. A BMJ editorial in 2005 reported that cardiovascular disease ‘has reached near epidemic proportions in l Supporting staff to gain recognisable qualifications Africa’, with the WHO reporting in 2002 l Daily teaching and supervision, with incentives for self-directed learning that almost 10% of deaths were due to l Renovating wards, theatres and staff accommodation cardiovascular disease, with hypertension l Building of primary healthcare units to improve primary healthcare in the most prevalent underlying cause.2 conjunction with the current hospital This figure will only have increased in l Provision of a free ambulance pick-up service for women in labour the last decade, as lifestyles continue l Reliable supply chains for delivery of essential medicines and recognising to change. importance of hospital stores in managing stock-taking l Computer training and training in data collection and administration The management of hypertension was, l Free ultrasound and blood transfusion service for pregnant women therefore, identified as a key priority in l Establishment of an accident and emergency room improving health outcomes. However, l Expanding bus service links to allow remote villages to access healthcare there is a striking lack of robust data l Regular radio slot for health education and promoting hospital services on the prevalence of hypertension in Zanzibar. Unpublished research, based as antenatal clinics, also showed an increase by the Government. In the place of on a survey of 2639 adults aged 25–64, in attendance of 160%. doctors, clinical services are provided found a prevalence of 33% (based primarily by clinical officers: a mid-level on WHO definition of hypertension The roots of these successes are clinical position that is unique to as >140mmHg systolic or >90mmHg multifactorial, but are in part attributable East Africa. However, even they are diastolic). The overall prevalence of to the renovation of dilapidated wards in short supply throughout the island, moderate to severe hypertension (Figure 1) and the improved provision of leading to low staffing levels in many (>160 systolic or >100 diastolic) was essential services through the development areas. Guidance and teaching is imperative also high at 16%, and extremely high of a reliable supply of medication and to support these individuals who, in the over 45-year-old population at equipment. This, in turn, has led to increased after only three years of study, are 34%. A basic hypertension clinic was in trust and confidence from the local immediately thrust into senior clinical operation at Makunduchi Hospital prior community, who previously travelled long positions. Changes are occurring, however, to improvements by HIPZ. An audit in distances to go to the tertiary hospital in the with the first cohort of medical students 2013 showed that median systolic blood capital rather than attend locally. graduating from Zanzibar University pressure was 170mmHg, with 39% of last year. patients having a systolic >180mmHg The monitoring of physiological (Figure 3). This was in a cohort of patients observations in inpatients was Development of services supposedly treated for hypertension and another basic but challenging area for Integral to the development of outpatient improvement. Observations were rarely services has been the building of PHCUs, checked or acted upon appropriately. Prior completed in Makunduchi in 2009 and in to HIPZ, the hospital had little functioning Kivunge in 2014 (Figure 2). Prior to this, equipment to measure blood pressure or there were almost no routine or specialist oxygen saturations, and no oxygen therapy clinics available. Patients attending was available. Through regular teaching outpatient appointments did so within and daily supervision of clinical officers on the inpatient environment. The PHCU at ward rounds, the proportion of patients Makunduchi Hospital now sees over 3000 having daily observations has increased patients a month. Once fully operational, from less than 10% to over 85%. the Kivunge PHCU is expected to see 6000 patients per month. KEY CHALLENGES Figure 2. The Primary Healthcare Unit Staffing levels and experience Cardiovascular disease recently built by HIPZ at Kivunge Hospital. Makunduchi and Kivunge Hospitals Increasing urbanisation and exposure to The unit is expecting to see over 6000 are not allocated any qualified doctors a range of risk factors has led to a huge patients per month

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care to nurse-led outpatient clinics in the 60 Systolic hospitals. Three general nurses undertook a six-month education programme (based Diastolic on WHO MhGAP guidelines3) to train as psychiatric nurses. The lead psychiatric 40 nurse at Makunduchi Hospital now delivers a fortnightly clinic, seeing around 80 patients per month. New referrals are growing rapidly, including from the main 20

Number of patients psychiatric hospital in Stone Town. The service is a reflection of the wider HIPZ model – identification of a local problem, fostering the talent of local staff and 0 working closely with the Ministry of Health and other development partners. >240 60–7070–8080–9090–100 140–50 100–110110–120120–130130–140 150–160160–170170–180180–190190–200200–210210–220220–230230–240 Blood pressure FUTURE DIRECTIONS HIPZ is currently in a challenging phase Figure 3. Range of blood pressures in Makunduchi outpatient clinic 2013; 39% of patients of the hospitals’ development. Three had a systolic blood pressure over 180mmHg years remain of the agreed 10-year lease of Makunduchi Hospital, meaning that indicates the likely scale of the problem in over 85% of patients are now treated in the phase of handing back care to the the untreated population. accordance with HIPZ guidelines. Government is fast approaching. With so many developments achieved and Improved primary care facilities at the Women’s and children’s services some still underway, the consolidation of hospital enabled the development of Developing integrated women’s and existing improvements and ensuring their specialist hypertension clinics. Various children’s services has led to an increase long-term sustainability is now the key factors had to be considered: identification in women accessing healthcare. Since challenge at this site. As previous examples and training of suitable staff; designing pro opening the PHCU in Makunduchi, illustrate, there are still many areas in formas with tailored guidance for clinical tailored clinics and screening programmes which patient care could be improved. officers; sourcing a regular and affordable have been created, increasing the number As is central to the HIPZ model, the path supply of antihypertensive medications; of children receiving vaccinations and forward must be decided collaboratively involving Shehas (local leaders) to ensure growth monitoring. With the Kivunge with local staff and address the issues community understanding of the changes; PHCU building approaching completion, specific to this region. Being embedded and measures to improve health education these developments are being mirrored at locally, HIPZ is perfectly placed to of both clinic patients and the local this site. understand these issues and to provide population as a whole. workable solutions. Mental health services The weekly hypertension clinic in Zanzibar has one psychiatrist covering Lessons learnt at Makunduchi Hospital Makunduchi now treats up to 350 patients a population of 1.3 million over two are being applied to the improvement per month. A recent audit showed that islands. This leaves a huge unmet need of process at Kivunge. However, even between patients with mood disorders, psychosis, these two sites on a small island, different BLOG child and adolescent mental health approaches are often required. This further What do you think is the best problems, and epilepsy (traditionally emphasises the importance of grassroots way of improving healthcare within the remit of psychiatry in involvement and understanding in in the developing world? Go ). HIPZ has collaborated with effective health system development work. to the Trends website to read the Zanzibari Ministry of Health and a an accompanying blog by team of Norwegian psychiatrists from The HIPZ project has the potential for Jonathan Rees and have your say: Haukeland University Hospital in Bergen, further successes by extending the www.trendsinmenshealth.com/blog in a project to widen access to psychiatric knowledge gained through the work in our care. This has decentralised psychiatric hospitals, not only to other centres on the

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Zanzibar archipelago, but possibly further increasingly been recognised by influential REFERENCES afield. The ultimate impact of this work will bodies to be an effective model of aid to 1. Moon S, Omole O. Development assistance only be known in time. But this model, or which global health partners should aspire. for health: Critiques and proposals for an adapted version of it, applied to meet Again, from the BMJ: change. Centre on Global Health Security the specific needs of a setting elsewhere, Working Group Papers. London: Chatham could provide valuable assistance to other ‘International aid genuinely earmarked House, 2013. regions in need of drastic improvements to for eradicating poverty must be taken 2. Kadiri S. Tackling cardiovascular disease in their healthcare systems. out of the hands of the politicians and Africa. BMJ 2005;331:711–2. bureaucracies of both donor and recipient 3. World Health Organisation. MhGAP CONCLUSION countries. Such funds should be controlled intervention guide for mental, neurological Since 2006, HIPZ has transformed the by independent and accountable agencies and substance use disorders in non-specialized healthcare system in Zanzibar, delivering which have knowledge of the existing needs health settings. World Health Organisation, 4 medical care to over 250 000 people who and have direct access to those in need’. 2010. (http://www.who.int/mental_health/ previously had almost no access to even publications/mhGAP_intervention_guide/en/; the most basic healthcare. This has been Declaration of interests accessed 11 August 2015). achieved on a low budget, consistent with Mike Spencer Chapman and Jonathan Rees 4. Ncayiyana DJ. Combating poverty: the aim of long-term sustainability. The are trustees of HIPZ. Ruaraidh MacDonagh the charade of development aid. BMJ innovative approach adopted by HIPZ has is Founder and Chairman of HIPZ. 2007;335:1272–3.

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