HOPE works in more than 35 countries worldwide. Please enjoy our blog as we document the successes and challenges of our work to provide Health Opportunities for People Everywhere.
PART 1: Beyond Geographic Barriers
Suchi Gaur, Ph.D., HOPE’s Communication Specialist in Southeast Asia, visited outlying regions of Nepal where Project HOPE is working to improve health for mothers and children in the most challenging geographic conditions. This is the first in a three-part blog series about her experiences.
When most people spoke of Nepal prior to 2015, they referred to the beautiful landscapes, Buddhist shrines, Mount Everest. But after the April 2015 earthquake, people began to look at Nepal differently. The earthquake exposed existing issues in the regional corners of Nepal and also brought new problems, particularly regarding access to health care services and resources.
Health indicators are poor in rural Nepal, compared to national and district data, especially in the remote Makwanpur area, where access to health care is especially challenging. Project HOPE’s SPARSH-M program for maternal and child health operates in five Village Development Committees (VDCs) of this district, within the marginalized and disadvantaged Chepang and Tamang communities. The program is funded by the Center for Disaster Philanthropy and Project HOPE, and implemented in collaboration with the Nepal Public Health Foundation.
During my recent visit to the program site in Makwanpur’s Raksirang block area, I got an opportunity to not only meet and train the local field team at Hetauda, Makwanpur, but also travel across to Raksirang and interact with the team as they engaged with mothers and adolescent girls, strengthening the health program at the very basic, ground level.
Early morning, as we drove to the local village, we crossed a semi-dry riverbed for a few miles to reach the Raksirang VDC. With untimely rain and water filling up the cervices of the riverbed, our travel turned difficult. While the team discussed going back to the local office or going towards the VDC, I looked around and realized that this region can be completely cut off from the mainland during the monsoon season. The fact that this is one of the most inaccessible and marginalized areas of the country made me think about a complexity of issues regarding community mobilization, the presence or absence of local governance and support, the presence or absence of health facilities and sustainability factors associated with every single health activity implemented in the region.
I observed how this community struggled with traveling all the way from different villages situated on different hills to use these services and imagined how hard it would be for a pregnant woman to walk down to meet the health care provider.
I observed how this community struggled with traveling
all the way from different villages situated on different hills
to use these services and imagined how hard it would be for
a pregnant woman to walk down to meet the health care provider.
Eventually, we managed to reach the entry point for the VDC. With a steep walk to the main area, and no designated walk-way, we managed to reach a flat area, which was the center for all services in the VDC. A quiet, unhygienic and unplanned place, I realized how difficult it must be for the people living on different hills and villages to get to this location to access basic health services.
With SPARSH-M, one of the key objectives has been to improve access and utilization of maternal, neonatal, child health, nutrition services and hygiene practices. I observed how this community struggled with traveling all the way from different villages situated on different hills to use these services and immediately imagined how hard it would be for a pregnant woman to walk down to meet the health care provider.
I am proud that HOPE’s SPARSH-M program is working to address this major challenge in maternal and neonatal health in this remote region, including ensuring that health services are available in every VDC, in an accessible way: training health staff, providing a mobile skilled birth attendant as well as a social mobilizer to act as an immediate help in times of stress.
Training of Trainers Creates Cascade Effect of Knowledge and Skill
Eden Ahmed Mdluli, M.P.H, PMP, Project HOPE’s Senior Program Officer, RMNCH (Reproductive, Maternal, Newborn and Child Health), recently accompanied a team of experts for a National Training of Trainers on Essential Newborn Care in Sierra Leone.
In April of this year, I traveled to Sierra Leone for 12 days to support three volunteers and one consultant who are expert trainers in the field of newborn care including Dr. George Little, a renowned neonatologist and Fellow at the American Academy of Pediatrics; Dr. Yemah Bockarie, a Sierra Leonean pediatrician who works at Cape Coast Teaching Hospital in Ghana; and Beryl Brooks, our 2016 Volunteer of the Year).
Sierra Leone has the highest maternal mortality ratio in the world.
Newborn mortality and stillborn rates are alarmingly high.
Eighty percent of all newborn deaths in Sierra Leone are caused by preterm birth, intra-partum related causes and newborn sepsis.
This dire situation was exacerbated by the Ebola Virus Disease outbreak, which led to the death of 221 health care workers further complicating access to services.
Project HOPE is working in close collaboration and coordination with officials from the Ministry of Health and Sanitation (MOHS), United Nations agencies, District Health Management Teams, other NGOs and local councils to strengthen Sierra Leone’s health system to provide quality care for women, newborns and adolescents.
The team of expert trainers and staff traveled to Sierra Leone upon the request of MOHS to train 30 national master trainers in Essential Newborn Care. They subsequently supervised the 30 master trainers train 250 district trainers in four districts including in Freetown and Bo – all within a period of less than three weeks. The training followed the American Academy of Pediatrics and WHO guidelines and materials such as Helping Babies Breathe and Essential Care for Every Baby. It emphasized mastery of neonatal resuscitation skills and taught other trainers how to teach using interactive simulations and demonstrations.
The Project HOPE team greatly assisted the Ministry and partners in improving materials for the training of trainers as well as the subsequent cascade of training to service providers at the peripheral or primary health units.
Under the MOHS plan and guidance, the trained district trainers will pass on their training to labor and delivery staff at the peripheral units. This is the cascade effect – where lifesaving knowledge is successively passed along from the trained national master trainers to district level trainers who will later train non-hospital level MNCH providers.
This training is expected to greatly improve lifesaving care for each newborn through:
Improved routine and essential care
identification of danger signs requiring referral to a higher level facility
and defining the steps needed to make referrals
It is clear there is a desire for expert training in newborn care among the health care workings in Sierra Leone. Participants were very engaged and came to all four days of the training, even though it was the start of the Easter holiday weekend. Many of the participants were already experienced trainers so their comfort with the role of the trainer was apparent. By and large, they seemed enthusiastic about the new model of training using our small group, highly interactive approach. Because availability of training mannequins (NeoNatalies) was not always adequate to support the number of trainees, Project HOPE provided additional NeoNatalies at each training site. Mastery of neonatal resuscitation skills was emphasized, as well as the skill of leaving the cord intact for one to three minutes. Adequate documentation of a newborn’s condition and documentation during referral for higher care was reinforced. A lack of essential commodities were noted in all of the District Trainings including Injection Vitamin K, Tetracycline Eye Ointment and Ampicillin.
There were many robust discussions after each session on cultural practices that affected essential newborn care activities including breastfeeding and cord care. MOHS plans to cascade this training to the primary health care providers in the coming months using the 250 trained trainers in settings such as health care centers and maternal and child health posts.
After the government’s commitment to the training, supportive supervision and mentorship follow up is essential to be successful. While many health professionals benefitted from The Essential Newborn Care training, this was only the first training of trainers that need to happen to improve the outcome of care.
It was through a chance call from a colleague in Ghana that I first got to know about Project HOPE. My friend Jacqueline had volunteered for work in Sierra Leone, and was due to return for another stint but something had come up and she was looking for someone to replace her. Sierra Leone is my home country, and though I had left Freetown 14 years ago, with bittersweet memories of a serene childhood and searing images of a brutal civil conflict my heart surged at the idea of an opportunity to go back. Project HOPE was collaborating closely with UNICEF and the country’s Ministry of Health to roll out essential newborn care training across the country. Sierra Leone had suffered the gruesome hit of an unprecedented Ebola outbreak that had stripped the health sector of resources and manpower. Project HOPE’s instrumental role was to help in this badly needed restructuring of health services and support short and long term training needs.
Though I had left Freetown 14 years ago, with bittersweet memories of a serene childhood and searing images of a brutal civil conflict,
my heart surged at the idea of an opportunity to go back.
I work as a Pediatrician in a resource-limited teaching hospital in Cape Coast, Ghana. We have volunteers come in several times a year, but here I was, now having an opportunity to reverse the trend, to be a volunteer to others, and uniquely, to my country of birth. I was thrilled to give back with Project HOPE as the platform to channel my expertise.
The preparatory phase of team work leading up to the field work was fantastic. I was joining three American volunteers to spend up to three weeks in Sierra Leone as part of a team of expert trainers. The great part was that I didn’t have to ponder about what to expect in respect to climatic predictions and cultural perceptions. I didn’t have to acclimatize to the sweltering tropical heat or take anti-malarial prophylactic drugs. I didn’t have to worry about cultural “shocks” to process or dialectal dilemmas to cope with. What took me aback however was the quantum of tangible help that was needed in the health sector. In a country where the doctor : patient ratio is 0.02 physicians / 1000 population, and the country is still painfully reeling from the loss of many lives of health workers to the deadly Ebola virus, the subtle gains made in improving neonatal mortality had been rapidly lost. The fragile health system, now fractured by the devastating consequences of the outbreak, means there is little logistical support for neonatal and pediatric care. A visit to the Ola During Children’s Hospital, the only children’s hospital in Freetown, revealed how resources were stretched to beyond maximal limits in the provision of child care.
The doctor : patient ratio is 0.02 physicians / 1000 population,
and the country is still painfully reeling from the loss of many lives
of health workers to the deadly Ebola virus; the subtle gains made in
improving neonatal mortality had been rapidly lost.
The hands-on training experience was intense but provided new knowledge and skills and soon the thirty master trainers we had taken through the essential newborn care package in Freetown, were ready to roll out to the various regions in the country with a target to train one hundred and fifty district trainers. These trainers would then roll out the training package to the peripheral health units nation-wide. I accompanied one of the training groups to Makeni in the north of the country, and supervised the roll out of training to districts in the northern sector. Throughout, I was struck by the resilience and enthusiasm of all the Sierra Leonean health workers I came across during the training program. I could sense their passion to turn the tide and master the skills they had learned so they could teach others, and I could feel their innate gratitude to those who give of their time and talent to invest in their health needs. But more gratifyingly, I could sense the defiance among the participants and a desire to beat the odds and make every newborn’s life count. Indeed, that became our slogan through the training. Make every newborn’s life count. In what many have described as one of the worst places for a woman to give birth, Project HOPE was igniting flames of hope within the inner core of these health workers. Thanks to them, many Sierra Leonean babies would see the rising sun.
In what many have described as one of the worst places
for a woman to give birth, Project HOPE was igniting flames of hope
within the inner core of these health workers.
Thanks to them, many Sierra Leonean babies would see the rising sun.
It’s been a long time since I felt as satisfied as I did after the training. The catalyst call I had accepted a few months earlier from Jacqueline was now having its life-transforming effect. It had been almost 20 days non-stop on my feet. My tired limbs were aching and felt like giving way. My eyelids were begging to close. My body was profoundly exhausted. But my spirit was upbeat. Through the long journey back to the capital, I was unfazed by the scars of the Ebola outbreak I saw through the many villages we drove by. Project HOPE was planting seeds of hope. And it was unfolding right in front of my eyes.
Jacqueline Myers is an advanced practice nurse practitioner in an emergency department in Chicago and also teaches graduate courses at DePaul University. She recently returned after serving as a Project HOPE volunteer, lecturing at Sanda University in Shanghai.
I have been a practicing registered nurse for ten years and a nurse practitioner for the past three years. In additional to my clinical work, I volunteer with Big Brothers, Big Sisters in Chicago and enjoy the time I spend with the youth that I mentor in that program.
In February, I went on a trip to Lebanon with the Syrian American Medical Society. During this trip I provided medical care to refugees.
My most recent trip was to Shanghai. This was my first Project HOPE mission, but I want to participate in others.
As a Project HOPE volunteer in Shanghai, I met with small groups of students for conversations to help improve their English skills, including medical terminology. In addition, I was in the Renji Hospital observing students in the clinical setting. Based on all these experiences, I was able to submit a report comparing and contrasting Western vs. Eastern nursing programs. I found that nursing students in the U.S. and China receive a high quality of education; there are more similarities than differences in the way the nursing schools in both countries prepare nursing students. The differences seem to be based primarily in fundamental differences in our healthcare systems.
I also gave lectures on “Nursing in America” to the Sanda students in Shanghai. These lectures included information about American health insurance, a history of advanced practice nursing in the U.S., and what it’s like to work as an emergency department registered nurse in the U.S.
Because I enjoy teaching, working with the students in Shanghai helped me to remember why I wanted to be a nurse in the first place.
The students were great, very similar to American students. They were optimistic and ready to learn.They also had a wide range of questions, from American nurse salaries, to dealing with death in the hospital, to what my natural hair color is!
When most people think of refugees, they think of tent cities on the African savannahs, the communities of Cambodians and Burmese that sprung up on the Thai border, or the cramped shacks of Gaza.
But at a time when war, fraying national borders, and even the early impacts of climate change are triggering human exoduses into neighboring countries, there is a new challenge that the world must understand and confront.
It’s the plight of urban refugees. In fact, about 66 percent of the world’s refugees don’t live in camps, they live among us, often in places where the host community is almost as poor as the refugees themselves. Unfortunately, national governments and international aid agencies are not yet really able to work effectively in these mixed urban settings.
The deepening refugee crises around the world will be on many of our minds on World Refugee Day on June 20. The issue is becoming so acute, that governments, relief agencies and NGOs are now having to place it at the center of all their policy making on humanitarian and aid issues.
The situation is especially acute in the Middle East. The extraordinary humanitarian crisis sparked by the civil war in Syria, and Iraq before that, has seen hundreds of thousands of people flee the fighting, seeking refuge in neighboring nations and Europe.
The news media offers extensive coverage of the camps that have sprung up in Jordan — a country that already carried a huge burden after taking in refugees from the Middle East conflicts of previous generations, but not many people know that only 10 percent of the Syrian refugees who fled to Jordan live in those vast camps. The rest of them are spread across towns and cities.
This is a reality that creates complex challenges for NGOs, the UN, and host governments when they think about how to help refugees. It is also a situation that threatens to create resentment towards refugees from the communities in which they settle.
Think about it for a moment. Refugee organizations often concentrate more on the well-being of refugees than their host communities. For example, the UN High Commissioner for Refugees is mandated to fund refugee relief, but not host community development. This could mean providing vaccines to refugees and not the impoverished local community, fostering resentment, reinforcing segregation, and in some cases sparking violence.
We are just beginning to recognize the emergence of such humanitarian dilemmas that come with changing patterns of refugee migration and settlement. However, we have not yet adapted to what will be a difficult challenge in the years to come.
When I started working with refugees, after shelving my previous career as a civil engineer following some time observing the acute humanitarian suffering unleashed in Sierra Leone by a terrible civil war, I would have assumed most refugees spend only a short time in a camp — six months perhaps or maybe a year.
I was shocked when I found out that all refugees stay in exile for many years, with some of them remaining in exile for more than 20 years (Somali refugees in Kenya, Burmese refugees in Thailand), and those that stay in urban areas tend to stay in exile for even longer and that means of course that not only are host nations struggling to deal with new refugees, they must cope with new generations of refugees who are born in host nations.
Today there are about 65 million refugees or displaced people around the world — 10 million of whom are what we call “statelessly displaced” — jargon for those unfortunates who have no rights, are badly in need of help, and now lack citizenship. Making matters worse, many urban refugees fall into this category.
The biggest refugee crisis right now is in Syria and its surrounding nations. The war has raged for almost six years and is nowhere near resolution. It has killed around 400,000 people so far and created 4.8 million refugees and 6.8 million internally displaced people.
Of the 4.8 million refugees more than a million have made it to Lebanon, 680,000 to Jordan and another 2.6 million are now in Turkey. There are numerous challenges to helping the refugees who live in camps, but we have worked in refugee camps before with success. However, the more diffuse distribution of Syrian refugees spread around towns and cities in neighboring countries creates a problem we are not yet well equipped to deal with efficiently. That’s because if funding is earmarked to deal with refugees, that money cannot be spent on host communities. And if foreign aid is intended to be spent on host communities, it cannot therefore be used to provide care to refugees.
In practice, in places like Jordan and Lebanon, this breeds tensions between refugees and people who live in communities that have taken them in. Before long, this is going to become a very sensitive political issue in the countries involved. That’s why we are going to have to start thinking out of the box. In these communities we should examine the challenge of expanding health care capacity for the local population and care for refugees as a singular challenge.
We owe it to these countries to do something to help. Leaders, policy makers, implementers, funders and academics need to rethink how we balance the healthcare needs of the refugee and host communities. This problem is only going to get more serious and will cause further misery for refugees who already have grim prospects, if the world doesn’t act soon.
For more on Rabih Torbay's insights on how to address the plight of urban refugees, listen to his interview on the Global Health Checkup Podcast:
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