Academic Partnerships to Improve Health

Frank J. Anderson MD MPHfwja@umich.edu

Partnerships with Projects

As opposed to projects with partnerships

MDG 5

• Target 5.A:• Reduce by three quarters, between 1990

and 2015, the maternal mortality ratio• 5.1 Maternal mortality ratio

5.2 Proportion of births attended by skilled health personnel

THE CARNEGIE ACOG/RCOG POSTGRADUATE TRAINNIG PROGRAM IN GHANA

CAPACITY BUILDING

EVIDENCE BASED IMPLEMENTATION PROGRAMS REQUIRE AN OPERATING SYSTEM

Ghana Postgraduate Training Program in Obstetrics and

Gynecology • Established in 1989 with a grant from the

Carnegie foundation due to the very low repatriation rate of trainees sent abroad

• Partnership program with RCOG, ACOG, Ghana Ministry of Health and University departments of OBGYN

• Two Locations- – Korle Bu teaching hospital Accra (KBTH)– Komfo Anokye teaching hospital Kumasi (KATH)

Klufio et al American Journal of Obstetrics and Gynecology 189:3 2003

Program Outcomes• As of Summer 2011, 85 specialists have

completed the program and been certified by WACS or GCPS, and 83 have remained in country

• >50 peer reviewed research articles have been published

• Two major textbooks– Comprehensive Obstetrics in the Tropics– Comprehensive Gynecology in the Tropics

• Chairs of both OB GYN programs are graduates of the program as is the Dean at KNUST

Cumulative number/year retained graduates

Program Outcomes

• Multiple clinical and public health projects– Graduates have opened new clinics improving

access to care and employing more nurses – Graduates have trained countless

paraprofessionals– Graduates have helped develop and

implement trainings in maternal care, family planning, HIV/AIDS, cervical cancer prevention

Factors related to retention

• In October 2002, we interviewed 19/26 of the graduates

• A “graduate” – completed the assigned coursework, rotations

and other requirements of the GPTP in Obstetrics and Gynecology

– passed all the targeted qualifying exams of the West African College of Surgeons qualifying for Fellowship

Three major factors related to retention emerged

Presence of a Program

Economic feasibility of staying

Social commitment

The Ghana-Michigan Collaborative Health Alliance for

Reshaping Training, Education Research

(Ghana-Michigan CHARTER)• 2-yr grant from Bill & Melinda Gates

Foundation • GOAL: To strengthen training & deployment

of human resources for health (HRH) in Ghana

• Partners: • University of Michigan• Ghanaian Ministry of Health• University of Ghana• Kwame Nkrumah University of Science and Technology

Ghana’sHRH

Priorities

3. Education and Training

2. Data for Policy

Decision-Making

4. Research Infrastructure

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Ghana’sHRH

Priorities

3. Education and Training

2. Data for Policy

Decision-Making

4. Research Infrastructure

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Objective 1. Develop a Charter for Collaboration:

• Identify and document principles of collaboration between Michigan and Ghanaian partners that will guide our interactions

• “Right Brain” part of the project• The critical milestone for this objective is

approval of a charter addressing principles of communication, compensation, research and educational collaboration

Past Programs

• “Development Aid” is often delivered through vertical programs

• Priorities are oftentimes set by the Donor• Programs are time limited • Capacity building may be limited or short

lived• Sustainability may not be ensured

Some reasons for failure - 1

• Lack of institutional involvement– ?reflective of strategic plan

• Poor leadership/wrong leadership– Appropriate skills and authority

• Poor management structure, chain of command

• Lack of a proper work plan • Loss of interest – not a priority• “Unequal” interest in collaboration

– agreeing to partner for fear of losing an opportunityPeter Donkor Ghana-Michigan Charter

kickoff Meeting February 2009

Some reasons for failure - 2

• Inadequate resources– inadequate compensation

• Inequity in the sharing of “spoils”• Lack of transparency• Feelings of exploitation• Unrealistic expectations• Unequal partnerships • Authorship conflicts• Failed communication/inadequate information

Peter Donkor Ghana-Michigan Charter kickoff Meeting February 2009

More reasons for failure• Misunderstanding of goals• Misunderstanding of processes

– Admission requirements into programmes• Change of rules mid-stream• Local laws on expenditure

– Procurement laws in Ghana on expenditure– Delays in execution of contracts

Peter Donkor Ghana-Michigan Charter kickoff Meeting February 2009

Why G-M Charter?

• Ghana – Typically has a long shopping list of needs– Manpower, infrastructure, etc, everything!!– Poverty mindset has turned us into beggars who

are afraid to ask questions and advance our self-interest

• Michigan– ?Global reach– ?Altruism – ?Philanthropy – ?Collaborate or perish, promotion, job securityPeter Donkor Ghana-Michigan Charter kickoff

Meeting February 2009

What makes this Grant different?

• This is a learning grant – time to learn– Everyone is starting from the ground up

• Stems from a long standing relationship• Future funding possible

– Form follows funding? – OLD– Form follows country priorities and capabilities

Purpose of the Charter process• Encourage open dialogue among partners to

– ensure that Ghanaian priorities have been clearly identified– policies and procedures underpinning collaboration have been

considered.– Mechanisms of communication, such as websites and

newsletters will be established. • Develop overarching principles

– provides clarity and transparency so that the group may go forward in programmatic and research collaborations with issues of participation, compensation and authorship addressed.

• Guide the implementation of pilot projects and proposal development in the learning grant, – ensure that a broad, sustainable capacity building approach is

emerging from the process.

The Charter Document

• Adoption of the charter mark the beginning of a contemporary model for collaboration

• The charter will be a “living document” and will include the processes for institutional commitment, faculty involvement and progression, communication, faculty support, mechanisms for the approving and expanding the charter

The emphasis on the “Charter document” in the Ghana-Michigan Charter differentiates it from partnership grants that rely solely on technical interventions as the basis of combined work.

Creating a process for the creation of a “Charter Document” as the background of the project creates a platform for any number of technical interventions and so thus

makes this work applicable across campus and across disciplines

Addressing consciously the ramifications of inherent and overlooked inequities is the first step in creating an authentic collaborative international team that begins to capitalize on diversity and move into a new era of partnership based on a new paradigm for planning projects in an ever increasingly interconnected world.

Observing the Process

• A team of US and Ghanaian Social Scientist invited to observe

• Interviews with investigators and participants on both sides one year into the project

Quotes• “We in Ghana have started communicating with each other far better than

we ever did.” It’s like, we’re not even there. • “I always felt like it was hard for me to go over to the medical school at the

University of Ghana. But now, – I can just all him up, I go to his office, we have conversations. But until this project we never did that”.

• “I would like to say that this collaboration has been very useful for having brought the ministry and the major teaching institutions together. As others have said, it is something that we should use in future collaborations because ordinarily we are miles apart. So I think that has worked – the fact that we have come together in this institution. And I think that also for me the commitment of the Michigan people and the way you are focused on your objectives”

• “but from the get-go I had the sense of well-established trust, and that, come hell or high water, we were going to work together in a positive way. “

Quotes• “it is not something dictated by one person. It was developed going

back and forth, back and forth, back and forth. So it is – it’s just assured us of what we all have wanted. So, I would say it’s made things easy in the sense that everybody knows that this is what we are, using to guide our partnership.”

• “Yes, it is true that maybe in terms of resources, Party B has more physical or material, financial resources. But the other one may have some other form of resources in terms of even the raw material to work with. So I know we gain, together we also gain. So I think it is a win-win situation. Yes. Right.”

• “It’s not unusual for institutions in developed countries to – I mean, to put it very bluntly – to have a colonialist mentality, you know, when it comes to these collaborations. But I think that is not the case as far as this collaboration is concerned.”

Quotes• “laying out on the table explicit issues has been incredibly valuable and I

would never want to give the impression that—that that was anything less than critical because I think that’s been a—an—an incredible outcome of this grant is having an explicit charter for how we’re supp—how we would ideally collaborate.”

• “I think it made it easier, because I think we’d agreed on certain principles that everybody was comfortable, and they were principles like our liberality and transparency and openness and honesty and kind of fundamental principles. And so I think that we’ve used it over and over as a touchstone, and so I think it’s been continuously useful. I mean to have something to quote that we could use with other groups. I mean, we’re starting to talk in the United States and in a variety of venues about this project. “

• “ I think it’s become kind of this original declaration that’s kind of useful for us to go back to”

Quotes

• “I think that the fact that developing a charter is something – I guess I didn’t really think that developing a charter for collaboration was going to be as successful as it’s been, so I’m surprised with that. But I guess the lesson that you have to learn to be open to kind different ways of thinking about things. And I think I’ve always been open to that kind of stuff.”

 • “but I think at least kind of crystallizing the charter for collaboration

has been very helpful in thinking about – in really thinking about – what these kinds of partnerships should look like.”

Summary

• The Ghana-Michigan health partnership started with Obstetrics and Gynecology around a development goal

• Lessons from the partnership led to the CHARTER project and development of a Charter for Collaboration

• Now, multiple departments work in a number of projects to improve health partly defined by “Charter Principles”

Summary(fruit salad, not fruit punch)

• Institutional ownership of collaboration• Complete understanding of the expectations of

all partners• Determination to ensure that everyone is a

winner• The question that must always be asked: “What

is in it for me or my institution?”• The surest way to achieve an enduring and

successful collaboration is by ensuring that while you pursue your interests, you also look after the interests of the other partner.

Peter Donkor Ghana-Michigan Charter kickoff Meeting February 2009