Babich, Lauren P. MPH; Bicknell, William J. MD, MPH; Culpepper, Larry MD, MPH; Jack, Brian W. MD
Teaching and research at Boston University (BU) have long been enhanced by a strong social mission and commitment to service. BU has formed long-term university–community partnerships to improve both education and medical services in the Boston community. In 1989, BU assumed the management of the troubled school system in Chelsea, Massachusetts.1 In 1996, the Boston University Medical Center Hospital merged with Boston City Hospital to form Boston Medical Center (BMC), to provide high-quality medical care to some of Boston’s poorest,2 and the Department of Family Medicine is at the forefront of bringing the clinical services of BMC into the city’s neighborhoods. But BU’s dedication to service extends beyond the city borders. Since its inception in 1869, BU has had an international mission. For at least the last 30 years, BU has been attracting international students, typically from more than 100 countries in any given year, and usually about 15% of the university’s total student body. In the health arena, the university had a large program in West Africa in the 1970s. From the late 1970s until the early 1990s, BU and Suez Canal University collaborated in the development of a community-oriented, problem-based medical school and family medicine residency training program. In the mid 1980s, the Center for International Health was established, and this later became the basis for the Department of International Health in the School of Public Health. It is now the largest department by all measures in the School of Public Health. From the mid-1980s to the present, more than 2,000 students from over 120 countries have participated in certificate and degree programs in the School of Public Health. From the School of Medicine, particularly the Department of Family Medicine, and the School of Public Health, major service delivery, operation, and policy-oriented research programs have been carried out in the former Soviet Union, Middle East, South and Southeast Asia, the Pacific Islands, the Caribbean, and sub-Saharan Africa. The university’s strategic plan pledges its commitment to “internationalize [its] students, faculty, and studies and to carefully and strategically extend the BU presence in select countries around the world.”3
The BU–Lesotho Connection
In August 2003, BU made an institutional commitment to work with the African country of Lesotho to tackle the human capital implications of the HIV/AIDS epidemic. Completely surrounded by South Africa, and with a population of 2 million, Lesotho suffers the world’s third-highest adult HIV prevalence rate, about 24%.4 Lesotho is a stable, peaceful, parliamentary democracy whose people are united into one ethnic group, the Basotho.5 Education is highly valued, and the literacy rate among women is 94%, the highest in sub-Saharan Africa. There is one major university, the National University of Lesotho, with several other postsecondary technical institutes. There is no medical school in the country, and the majority of Basotho medical students attend one of six medical schools in South Africa with financial support from the government of Lesotho. Both official languages, English and Sesotho, are taught in schools. The roads, telephone system, and physical infrastructure are good, and corruption is low. However, Lesotho is one of the 50 poorest countries in the world6; 58% of the population falls below the national poverty line, which is an income of $32 per month.7,8 The great majority of households gain their livelihoods from subsistence farming and migrant labor, with a large portion of the adult male workforce employed in South Africa, many in the mines.5
There are 72 health centers, nine district hospitals, a national referral hospital, a mental hospital, and a leprosarium operated by the Ministry of Health and Social Welfare. There are an additional 73 health centers and seven district hospitals operated by the Christian Health Association of Lesotho under a memorandum of understanding with the government of Lesotho, which provides 60% to 75% of the operating costs. Patients requiring tertiary care are referred to Bloemfontein, South Africa. There are also a number of small, private practices, but very few provide inpatient services. For the delivery of primary care services, Lesotho’s health system relies most heavily on nurses and nursing assistants, who are largely trained at one of four nursing schools in the country.
Geography and epidemiology make the country vulnerable to losing valuable members of society from both the attrition of its workforce to South Africa and the high death rates of its productive population from HIV/AIDS. BU’s commitment to address these issues grew out of a conversation in November 2002 between a BU faculty member and the Lesotho minister of health and social welfare regarding a long-term approach to the problem of assuring the availability of a workforce with sufficient education and training as the epidemic comes under control. On the Minister’s request, a small team from the BU School of Public Health worked closely with the government of Lesotho to identify the country’s priority needs. All parties agreed on three priorities: preserving the lives of Lesotho’s citizens, building the capacity of the country’s workforce, and maximizing the efficiency of Lesotho’s existing systems and resources.
BU began its commitment in Lesotho by implementing several small, targeted interventions that were essential to building meaningful relationships, establishing trust, and gaining a deeper understanding of the country and its challenges.9 These smaller interventions eventually led to a large country program now registered locally as the Lesotho–Boston Health Alliance. The initiation of the program required a substantial initial institutional investment without any promise of payback, which allowed BU to begin work in Lesotho while searching for additional funds. The projects completed to date are summarized in detail in Table 1. BU began by introducing the Problem Solving for Better Health methodology to selected Basotho leaders from the health sector, government ministries, schools, nongovernmental organizations, faith-based organizations, community-based organizations, the private sector, and communities, to develop skills in identifying problems, breaking them into manageable pieces, proposing solutions that can be implemented using resources currently available, and creating an action plan that is then implemented during a period of four to six months and that aims to achieve measurable outcomes. With support from USAID’s Higher Education for Development program, BU went on to establish a partnership with Lesotho’s only teacher-training college to open a clinic at the Lesotho College of Education (LCE) in Maseru that provides primary care and HIV/AIDS services to the campus community. BU has also assisted in training Basotho community health workers and developing systems of support to bring counseling and testing services to the communities as part of Lesotho’s national Know Your Status campaign, with the support of funding from USAID. The influx of outside resources to support more targeted interventions only highlighted the underlying limitations of Lesotho’s human resources and systems.
The overwhelming need for more providers of good primary care services prompted the involvement of BMC’s Department of Family Medicine in mid-2004. Funding from the U.S. Department of State allowed BU to begin exploring the best way to strengthen the quality and accessibility of affordable and sustainable primary care, increase the nation’s capacity to respond to the burgeoning medical care demands of the HIV/AIDS epidemic, and improve the recruitment and retention of nurses and physicians. As the problems with physician and nurse retention were explored further, the health systems issues became more apparent, and by mid-2005, the BU School of Management joined in the effort.
A clear strategy to address the need for primary care providers began to form out of a combination of workshops and mutual exchanges of carefully selected health professionals between Lesotho and BU. This led to securing initial funding from the W.K. Kellogg Foundation to develop a long-term strategy for improving primary care services. In turn, this planning phase led directly to a five-year grant from the W.K. Kellogg Foundation to the Lesotho Ministry of Health and Social Welfare and BMC to support sustainable strengthening of district hospitals and their associated health centers by increasing the return and retention of Basotho physicians and nurses in Lesotho. Specific components of this plan were initiating a family medicine residency program based in Lesotho, instituting sustainable continuing medical and nursing education programs, transforming two pilot district hospitals in the Leribe and Berea districts into vibrant, sustainable, well-utilized hospitals providing services of good quality in support of primary care, and laying the groundwork for transforming other district hospitals in Lesotho.
This five-year program emphasizes the importance of strengthening both clinical and management aspects of district health services in an integrated and carefully coordinated manner. The BU Department of Family Medicine is working closely with the University of the Free State in Bloemfontein to develop a four-year postgraduate training program in Lesotho aimed at building a supply of Basotho physicians who are able to deliver with excellence the full range of services, including pediatric, adult, and geriatric medicine (both acute and chronic care), obstetrics, basic surgery, mental health, management of HIV, AIDS, and TB, and selected aspects of management and public health, needed at district hospitals in Lesotho. At the same time, faculty from the School of Public Health and the School of Management are working to improve the practice environment, by bringing about necessary national change, improving district hospital services, and strengthening the district health management teams responsible for coordinating the delivery of community care, so the newly trained physicians can use the skills they have learned. As problems are addressed at the district level, national policies essential to supporting district hospitals and clinicians will be identified and put in place.
It is expected that the program will recruit Basotho currently in training outside the country, because a high-quality postgraduate specialty training program will be very attractive. An improved practice environment will be the key to retention when the residents finish their training. This reengineered environment will allow the newly trained physicians to use the skills they have learned and will provide a competitive salary and benefits package for these well-trained physicians to remain in the country. The training will be designed to ensure that each resident completing the four-year training program has the skills and the requisite knowledge and attitudes to be an effective district physician in Lesotho, and it will encompass aspects of medicine, surgery, pediatrics, obstetrics–gynecology, psychiatry, public health, and management. Each graduate must be a clinician manager with a public health and community orientation. The first group of six residents is targeted to start training in January 2008. Continuing education programs for current physicians and nurses will be integrated with the specialty training program and have already begun. The government of Lesotho has already committed to fund the faculty positions required to operate the program after donor support ends for the positions in 2010, and the program graduates will be paid more under the classification as specialists, thus ensuring sustainability and an incentive for physicians to complete the program.
A complete baseline assessment of hospitals in the Leribe and Berea districts was conducted in September to December 2006 and will be conducted again in mid-2009 and the end of 2011. Comparison of the assessments will evaluate changes in use of district health services, key measures of quality, patient, and provider satisfaction, and turnover rates for physicians and nurses. True success of the program will be measured by a steady recruitment of residents into the program, retention of graduating residents in Lesotho, and dissemination of successful management-improvement strategies from the Leribe and Berea districts into the other districts of Lesotho. The hope is that the best and most relevant aspects of this program will ultimately be disseminated throughout the southern African region.
Since August 2003, BU and BMC have sent 15 faculty and staff, 40 students and residents, and two alumni, representing three separate BU schools and four departments of BMC. They have participated as technical support for grant-funded activities, clinical volunteers, or contributors to extension activities. Each category of participant has contributed significantly to firmly establishing a visible and widespread presence in Lesotho.
Grant-funded programs have provided valuable opportunities for faculty, staff, and students of BU. For several of the faculty, the Lesotho program served as their introduction to international work. Most faculty and staff who have made working visits to Lesotho have become interested in making a more long-term commitment to supporting the Lesotho program. In October 2005, a returning faculty member initiated a Lesotho interest group for BU and BMC that continues to meet monthly. Grant-funded activities have also offered internships on a regular basis to graduate students of the School of Public Health and, more recently, the School of Management. Students provide critical support to the program and gain valuable experience in the field. Several students have received job offers as a direct result of their work in Lesotho, including one who is now working full-time managing the program and one working regularly as a nurse consultant.
The first resident from BMC’s Department of Family Medicine completed a two-month rotation at Lesotho’s Maluti Adventist Hospital in February and March 2004. Since that time, more than 30 residents from the Department of Family Medicine, the Department of Pediatrics, the Department of Internal Medicine, and the Department of Emergency Medicine have completed voluntary clinical rotations in Lesotho. The Department of Pediatrics has supplied nearly one full-time equivalent resident since January 2006, which has contributed greatly to the improvement of pediatric services at Maluti Hospital. The regular presence of senior residents and faculty has also given several medical students the opportunity to experience medicine in a low-resource setting.
The success of BU’s program in Lesotho has raised further interest among those who have participated in the program. A returning student raised support from Free the Children. A returning alumna has raised more than $75,000 to support programs providing essential health services for orphans and vulnerable children in Lesotho through her nonprofit organization, SHARED, Inc. The wife of a faculty member and professor at Brandeis University received a Fulbright scholarship to work long-term on curriculum development at LCE, and she started a literacy program. Recently, several faculty and staff started a nonprofit organization, Global Primary Care, to raise contributions from interested individuals to support the needs identified during implementation of grant-funded activities.
Now that the schools of public health, medicine, and management have a well-established and long-term program in place, BU is preparing to expand involvement in the Lesotho program to other schools and departments throughout the university. To date, the Goldman School of Dental Medicine, the School of Education, the School of Social Work, the School of Law, the College of Health and Rehabilitation Sciences, and the Department of Anthropology have expressed interest in supporting development in Lesotho. In addition, the Departments of Ophthalmology and Obstetrics at BMC are exploring opportunities for clinical rotations in Lesotho.
This program is about much more than a university carrying out its civic duties. The partnership between BU and Lesotho has proven to be mutually beneficial to both country and university. Lesotho offers unique opportunities for new research and experiential learning. In exchange, BU is able to support Lesotho in a way that is holistic and responsive to the needs identified by the country’s leadership.
Lesotho’s social, cultural, economic, political, and environmental aspects offer abundant opportunities for research and learning in all sectors. These opportunities are valuable as practical experiences for students at BU and also contribute to faculty development and satisfaction. Experiential learning opportunities such as these are especially important in medicine. Medical students and residents experience medical care in low-resource settings, improve their cultural competency, and gain exposure to diseases that are rare in the developed world. The number of American students studying abroad has increased by 170% since 1994.10 In 2004, 22.3% of graduating American medical students completed an international elective, compared with 5.9% in 1978.11 As demand grows for international educational experiences, international programs become increasingly important for recruitment. And an international program that offers continuity is certainly meaningful for the student and more valuable for the country. In addition, those students participating in an international elective are more likely to choose to work in an underserved area or a primary care setting, where the need is greatest.12
University participation in assisting developing countries usually occurs as an offer of specific expert skills of a specific university or medical center department (i.e., Tulane University’s expertise in monitoring and evaluation, Columbia University’s expertise in prevention of mother to child transmission, Baylor University’s expertise in the treatment of pediatric AIDS). All of BU’s work has been determined by country needs, and this has included actively responding to requests from the Lesotho Ministry of Health and Social Welfare for advice and technical support. Since August 2005, BU has provided advice and guidance to the Ministry of Health and Social Welfare on research involving human subjects and to the Ministry of Health and Social Welfare, the Ministry of Finance and Development Planning, and the International Finance Corporation on the content of services and the training role of the new national referral hospital. In addition, BU has developed an interactive model and derivative policy analysis that shows the relationship between the growing burden of clinical AIDS, the cost of antiretroviral drugs, and the funds known to be available to purchase drugs, has provided the minister of finance and development planning with an analysis of health insurance options for civil servants, and has reviewed the draft agreement between the Ministry of Health and Social Welfare and the Christian Health Association of Lesotho at the request of the principal secretary of the Ministry of Health and Social Welfare. This technical support demonstrated BU’s commitment to supporting the government of Lesotho according to its needs, and it further cemented the partnership.
BU’s broad commitment has proven to be an exceptionally effective approach to addressing the challenges to providing health care in Lesotho. BU works to address those areas identified by the government as priority and to remain flexible as priorities change or as new problems arise. This provides the country with a continuous partner offering a wide range of expertise across multiple sectors.
Areas for Further Development
Working at a broad, systems level requires interactions across and between several different government ministries and careful collaboration with numerous players. Negotiating the various aspects of such a comprehensive initiative and developing an effective team take considerable time and a real commitment to making sure all the pieces work together for the maximum benefit of the program. Maintaining regular and complete communication, particularly over long distance, with limited use of e-mail correspondence, has been particular challenging, and it takes extra effort to make sure that all parties are fully informed. In addition, as new partners join in addressing the challenges, it is challenging to ensure that all programs are done in collaboration and that they are complementary rather than implemented in isolation and redundant.
Designing a program with the intention that the government can continue its operation after donor support ceases is also challenging. Especially in a country with a weak economy, it is essential to consider the resources that are actually available and the level of administration that can be realistically maintained without external assistance. Although an approach that offers instant results creates fewer barriers to implementation, the partners in this program have chosen a conservative approach to ensure sustainability and long-term success.
Finally, BU’s commitment to addressing the needs identified by the government of Lesotho has required a great deal of flexibility and ability to adapt our team and skills to the changing circumstances. As more and more people have come to Lesotho offering skills and experiences that are very specific and targeted at particular issues, it has been important for participants to be able and willing to step aside and focus our attention and efforts on some unaddressed area requiring additional support and assistance. Many international partners in Lesotho are focusing on important aspects of systems improvement (e.g., pharmacy, laboratory, prevention of mother-to-child transmission) that have to be carefully coordinated within the context of BU’s efforts to transform district health services.
BU’s commitment to work with Lesotho as it tackles the human capital implications of the AIDS epidemic has been clearly demonstrated through the involvement of more than 50 individuals from two campuses and three schools during a four-year period. In turn, Lesotho has provided BU’s faculty and students with an environment for extensive learning and research opportunities. The initial commitment has developed into a mutual partnership with benefits to country and university alike. By combining the expertise from various schools and departments to focus on a single country, a university can significantly advance international development, strengthen its service mission, enrich teaching, and provide new opportunities for research.