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Evans School of Public Policy & Governance

Category: IPPHL

Alumni Perspective on IPPHL Impact

Recently, we caught up with IPPHL alumni Dr. Cordelia Katureebe Mboijana (Cohort 1) and Dr. John Bosco (Cohort 4) to discuss their experiences as fellows of the program and the lessons they have carried with them since graduating. This conversation was a special treat as Dr. Mboijana and Dr. Bosco have known each other for over ten years. They both worked with the Ministry of Health – Uganda under the HIV Control Program during which time Cordelia served as John’s supervisor and mentor.

Dr. Cordelia Katureebe Mboijana is a Medical Doctor and HIV Specialist with the Ministry of Health in Uganda and has been coordinating HIV care and treatment at a national level in Uganda for the past six years. Dr. Mboijana has 17 years of experience as an HIV Specialist. She was part of IPPHL’s inaugural cohort.

Dr. John Bosco is a Public Health and a Monitoring and Evaluation specialist with ICAP at Columbia University on the HIV Coverage, Quality, and Impact Network project (CQUIN). Dr. Bosco serves as the Technical Lead on the differentiated HIV testing services for the 21 countries that are supported by the CQUIN Network and is based in Nairobi Kenya. John was a Cohort 4 fellow.

The Malaria Elimination Program in Cabo Verde

Adilson De Pina is the Head of Malaria Elimination Program in Cabo Verde’s Ministry of Health, and an alumnus of IPPHL’s Cohort 5.  

We sat to talk about Cabo Verde’s malaria elimination program, and discussed the measures being taken to sustain the country’s progress. Providing free access to malaria resources such as tests, prevention education, etc., are some of the steps that were taken and are still being taken to guarantee malaria elimination. 

Adilson shares his vision for Cabo Verde to remain malaria-free and details some of the initiatives he is currently spearheading to achieve this goal. He also talked about the possibility of the disease being reintroduced due to globalization, as Cape Verde is growing into a hub for many visitors. Efforts to counter this possibility include receiving malaria prevention resources at their point of entry, emphasizing the importance of getting tested, and providing free malaria testing and treatment for everyone. 

Besides working to ensure Cape Verde maintains their malaria-free status, Adilson is also working on an international partnership with other organizations to secure a grant proposal that reinforces their malaria surveillance activities. His team also hopes that this grant application will allow them to conduct scientific research to further explain why and how Cape Verde has zero malaria cases and learn how to sustain their efforts. 

Adilson worked with national and international stakeholders such as the WHO, the Global Fund, National Malaria Program, the National Institute of Public Health, etc., to attain this feat. He talked about the ease of working together to balance each party’s interest because they all had the same goal in mind, to eliminate malaria in Cape Verde. One difficulty he mentioned was the difference in tools and resources between international stakeholders and national stakeholders. They overcame this by adapting their data and results to the levels of their stakeholders to bridge the gap. 

Adilson’s advice for people coming into the field of public health, especially young people, is for them to be patient and wait to seize their opportunity when it is presented. In the meantime, they should take advantage of the vast resources they have at their disposal which will enable them to contribute a lot more once they get into the field. He also talks about the importance of leaving a mark, trying to improve from day to day, having a clear head, and staying humble. 

Anti-Microbial Resistance as a Global Health Threat

Dr. Abiodun Egwuenu, C5, is a PhD researcher at Humboldt University of Berlin/Charité in Germany. She is a trained medical doctor and field epidemiologist from Nigeria, with a primary focus on Antimicrobial Resistance (AMR). Before her PhD, she served as the Antimicrobial Resistance Program Coordinator for the Nigeria CDC.

In our discussion, Dr. Abiodun highlighted AMR as a global health threat due to the increasing ineffectiveness of many drugs. Nigeria faces rising drug-resistant infections and high mortality rates. She emphasized the importance of diagnostic testing to detect AMR, especially in Sub-Saharan Africa, where resistant bacterial infections are prevalent. Her project aimed to improve diagnostic testing for resistant infections in Nigeria.

Dr. Abiodun described AMR as a “faceless” problem, unlike HIV or Tuberculosis, requiring a collaborative approach across various stakeholders and organizations, including national ministries, the WHO, the Flemming Fund, the World Bank, and the National Insurance Agency. She navigated stakeholder interests by fostering a collaborative environment, emphasizing action plans, and clear communication.

She also developed a national diagnostic stewardship toolkit for AMR and applied the theory of change framework learned in IPPHL to train staff in Abuja. This improved blood culture requests, particularly for sepsis, which is often complicated by AMR.

Regarding public health disparities, Dr. Abiodun pointed out that children, especially newborns, are at higher risk of AMR infections due to their undeveloped immune systems. Investing in prevention strategies, such as education, is crucial to mitigate this risk.

Improving Immunization Coverage in Ga South District, Ghana.

Afua Twumasi (Cohort 4) is the District Director of Health Services in Ghana, bringing 24 years of experience in the health sector. With 11 years dedicated to clinical care and 13 years to public health, she has a comprehensive understanding of both fields. Afua has served as a district director for 12 years, working across six different districts, demonstrating her leadership and commitment to improving health services in her community.

Q: Can you please give us a brief overview of the current project you’re working on and what you wanted to achieve?

A: My district, the Ga South Municipality, is the second largest district in the Greater Accra region of Ghana. It is also the second largest populated district with low health indicators. My project was to improve health indicators, especially maternal child health indicators within a year, by 20%. The interventions started in 2023. The indicators that have still not improved are Antenatal Care Coverage and Percentage skilled delivery. The emphasis was to improve immunization coverage since there were low immunization rates.

Q: What was the problem?

A: In addressing our organization’s challenges, we identified a critical issue in human resource management: the team was fragmented, and roles were unclear, hindering the effectiveness of our management and health service delivery. To tackle this, we conducted a comprehensive evaluation of the geographic distribution and functionality of our resources, aiming to enhance both management and service delivery. Our solution involved strategic steps such as a thorough Resource Positioning and Assessment to identify critical gaps, followed by Staff Reshuffling based on experience, skills, and knowledge, and implementing targeted Training and Capacity Building to foster a resilient workforce. Collaboration and community engagement were pivotal to our approach. We formed partnerships with private facilities to extend our reach, implemented domiciliary care for children who missed vaccinations, and used Geographic Information Systems (GIS) to analyze health facility distribution and address accessibility issues. By fostering a collaborative work environment and considering risk factors, we ensured regular mop-up operations for vaccinations. This comprehensive approach led to significant improvements in health outcomes and accessibility, creating a cohesive team capable of overcoming challenges and increasing healthcare coverage and efficiency.

Q: What impact do you hope that the Health System Strengthening Project will create?

A: The program aims to create a transformative impact by fostering leadership and improving health service delivery. Through our efforts, I hope to see a team that excels independently, no longer requiring constant oversight. The enhancement of leadership skills has instilled confidence in the team, enabling them to deliver effectively. The work climate has evolved into a collaborative and supportive environment where every team member feels valued. Field supervision has shifted to a more supportive and coaching based approach, resulting in increased motivation and productivity. Witnessing individuals who previously displayed a laissez-faire attitude now actively engage and produce tangible results is particularly rewarding.

 

Q: What types of skills and knowledge did you find to be the most useful in addressing the situation?

A: Adaptive leadership was crucial in overcoming resistance to change in the public sector, fostering a culture open to change and flexibility. This approach allowed us to manage resistance and stay adaptable to emerging challenges. Our strategy also emphasized monitoring and evaluation, focusing on assumptions and risks to proactively solve problems and implement solutions effectively. Together, adaptive leadership and rigorous monitoring and evaluation significantly enhanced our program’s effectiveness and adaptability, improving outcomes and creating a resilient, dynamic work environment.

Q: What are some of the organizations or stakeholders that you worked with and how did you balance all of them?

A: Different organizations interest In this area, the main stakeholders were staff, mothers, caregivers, community leaders, and religious bodies, whose engagement was crucial due to their influence on women’s participation in health programs. Our team spent five months building local staff capacity to engage stakeholders effectively, organizing community health management committee meetings with leaders to gain support for initiatives like setting up outreach points in community spaces. Engagement was tailored to each community’s context, with sub municipal heads focusing on grassroots engagement and higher-level officials handling broader coordination. We used GIS to identify areas with low immunization coverage, especially in new, rural, and peri-urban settlements, expanding from four to seven sub municipals and improving road accessibility to deliver vaccines. Our program aimed to enhance leadership skills, foster community engagement, and reduce health disparities by ensuring equitable access to health services.

Q: What steps are necessary to implement human resource strengthening programs on a national scale, like the one described?

A: To implement a national human resource strengthening program, government commitment is crucial, along with scientific validation to provide evidence-based results for policy changes. Efficient use of resources is essential, emphasizing effective leadership and team management. Capacity building through on-site training and mentorship ensures practical learning, while pilot programs in selected areas help identify best practices. Disseminating pilot results builds confidence and support and focusing on leadership training fosters strong leaders. Aligning the program with existing policies ensures credibility and effectiveness, leading to improved healthcare outcomes and a more resilient health system.

 

Q: Anything else that you want to highlight?

A: In my experience working in six districts, including serving as a sub-municipal head, I’ve learned that solving public health problems hinges more on effective leadership than on significant funding. Strong leadership skills, crucial at all levels, can transform limited resources into impressive results, while poor leadership can squander even substantial funds. Building cohesive, motivated teams has been key to success, as dedicated leaders empower their teams to excel by fostering belief in their potential. Though not scientifically tested, my practical experiences consistently show that leadership and team dynamics are core issues in public health, leading to lasting positive outcomes.

Deploying CHWs to Decrease Severe Acute Malnutrition in South Africa

From 2016 to 2021, the public health department in Limpopo Province, South Africa built a community health worker program that reduced the fatality rate in cases of severe acute malnutrition in children in their first 1000 days from 21.5% to 7.5%. Severe acute malnutrition (SAM) is a major issue across Sub-Saharan Africa and is associated with 30.9% of South Africa’s audited under-five children deaths.

Mr. Daddy Matthews, Deputy Director of Nutrition Services for the Department of Health in Limpopo, South Africa, recognized that Community Health Workers (CHWs) were an underutilized resource in the fight to combat neonatal and child malnutrition. The 1,226 CHW’s in Limpopo Province, primarily tasked with performing HIV/AIDs-related activities, were inadequately trained, not regarded as departmental personnel because they were managed by NGOs, and insufficiently compensated with only a small stipend.

Mr. Matthews recognized an opportunity to both address the high rates of malnutrition and to improve the morale and skills of CHWs in Limpopo Province. First, Mr. Matthews and his team developed an integrated framework to guide their work, the Limpopo Neonatal, Maternal, and Child Health Nutrition Framework. Using this framework, they trained CHWs and NGOs on infant and young child feeding, malnutrition detection, and management of foodborne illnesses. They established teams, known as “children’s clubs,” that were trained in essential skills, including identifying severe acute malnutrition using mid-upper arm circumference (MUAC) tapes, recognizing pregnant women, detecting children with vitamin deficiencies, and connecting mothers with South Africa’s child’s grant. To incentivize performance and boost motivation, Mr. Matthews and his team introduced a competitive element, where teams earned points based on their community outreach success and were awarded prizes. CHWs received formal recognition as Department of Health personnel, receive direct payment and have access to departmental resources. Since implementing this framework, case fatality rates due to Severe Acute Malnutrition have plummeted.

To develop and implement this new framework, Mr. Matthews drew on a number of skills gained through IPPHL, including implementation analysis using theory of change, stakeholder engagement and collaboration, behavioral incentives for program design, and performance assessment to monitor progress and adjust program strategy.

Improving Access to Mental Health Services for Children and Adolescents in South Africa.

Dr. Eva Mulutsi (IPPHL Cohort 3) is the Chief Clinical Psychologist and Head of Mental Health Services for Tshwane District Health Services in Gauteng, South Africa. Her responsibilities include overseeing mental health services, establishing and reviewing implementation programs, developing referral pathways and standard operating procedures, and ensuring the provision of adequate, accessible, and quality mental health services in the district. In an interview with IPPHL, she talks about improving access to mental health services to children and adolescents in her district in South Africa.

Q: Could you please give us a brief overview of your current project and what it seeks to achieve?
A: My current project focuses on improving access to mental health services for children and adolescents in my district. Mental health issues are prevalent across all populations and
genders, significantly impacting quality of life and contributing to 30% of the global disease burden. Lower socioeconomic status is strongly linked to higher rates of mental disorders due
to its negative effects on literacy, employment, and productivity. The COVID-19 pandemic and natural disasters have only exacerbated these challenges.
In South Africa, 16.5% of the population suffers from mental disorders, and about 20% of children and adolescents are affected. There is a significant treatment gap globally, with 75% of those needing treatment for common mental disorders not receiving it. In South Africa, this gap is around 90%. Our district, with a population of about a million, has only 10 beds available for children suspected of having mental disorders, which is woefully inadequate. My project seeks to improve access to affordable mental health services, addressing the frustration and
limitations of the current system.

Q: What impact do you hope to achieve?
A: The project has already fostered improved communication and collaboration among multidisciplinary health teams at all levels of care, from clinics to tertiary hospitals. Specialists can now directly communicate with primary health professionals, ensuring that children receive appropriate treatment even at lower levels of care. Key outcomes include enhanced referral pathways and systems, clarifying which children require further care and which can be treated locally. The project also aims to develop standard operating procedures for the care and rehabilitation of children with mental health issues, making services more accessible at the primary care level. Additionally, it seeks to decentralize mental health services and improve collaboration with other stakeholders, such as the Departments of Education and Social Development. This ensures that children identified in schools, by police, or in courts receive proper referrals and treatment. Ultimately, the project aims to increase public education and awareness about child and adolescent mental health, enabling communities to better identify and refer children with suspected mental illnesses.

Q: What type of skills and knowledge did you find to be the most useful in addressing the situation?
A: The most useful skills and knowledge I found in addressing the situation include a deep understanding of policies and legislation, effective communication and collaboration, diversity management, and thorough monitoring and evaluation. Understanding the country’s policies and legislative provisions on child and adolescent mental health is crucial for guiding systems and procedures while identifying gaps and recommending practical solutions. Effective communication and collaboration are essential for building
and maintaining relationships with colleagues and external partners, such as the Departments of Education and the police, while diversity management motivates stakeholders to contribute their best in intersectoral collaboration. Finally, monitoring and evaluation systems ensure continuous improvement, allowing for regular revisions and reviews to meet project targets and timelines successful.

Q: What are some of the organizations or stakeholders you’ve worked with, and how did you balance all of them?
A: I’ve worked with a multidisciplinary task team within the Department of Health, including doctors, nurses, psychiatrists, pediatricians, psychologists, registered counselors, and admin officials. Beyond the Department of Health, stakeholders include education, social development, the National Prosecuting Authority, the South African Police Services, and civil society organizations representing mental health user groups. Balancing these diverse interests requires a strategic approach, emphasizing effective communication, conflict management, and active listening to maintain stakeholder engagement and cooperation to advance the project, I utilized tools and frameworks from the International Public Policy and Health Leadership (IPPHL) program, which helped me understand the prevalence of mental illness and service gaps. By analyzing the local context including cultural, political, and socio-economic factors—I identified gaps in content and processes like referral procedures and operating guidelines. The World Health Organization (WHO) pyramid framework further revealed the need for better collaboration and resource allocation, as primary healthcare services are limited. The project aims to standardize procedures, enhance intersectoral collaboration, and improve the overall impact of mental health services for children and adolescents in South Africa.

Q: Do you have any advice for others looking to be leaders in public health, especially women?
A: My advice is to have a clear vision and goals, knowing exactly what you need to achieve and the changes you wish to make. Follow your own path and remember that your work is for the benefit of others, not personal gain. As health professionals, it’s crucial to prioritize the wellbeing of the people we serve.
Stay confident, motivated, open to seeking more information, and be honest if you miss something. Being yourself will help you develop and learn. Increase your visibility within your organization, as your recommendations need approval from higher-ups. For female leaders, capitalize on inherent qualities like empathy, nurturing, and passion to create a supportive environment for stakeholders.

Q: Is there anything else you’d like to talk about or highlight?
A: There has been progress in perceptions of mental health. Previously, people associated mental health with extreme cases, like those visibly distressed in public. However, especially after COVID-19 and natural disasters, there’s a growing understanding that common mental disorders affect everyone. Experiences like stress, grief, and low mood are now recognized as affecting one’s performance and functioning. Public awareness has increased, with prominent figures, like soccer and cricket players, openly discussing their mental health struggles. This has helped reduce stigma and discrimination, although these issues persist. Government efforts are crucial in providing accessible services, as increased awareness leads to more people seeking help. To address the demand, South Africa has employed registered counselors—graduates with degrees in psychology who provide initial psychological services in the community and refer cases as needed. This initiative ensures that mental health services are available at the community level.