Dr Norberta Washaya APFP Fellow in general paediatrics 2015 - 2019

The African Paediatric Fellowship Programme

Department of Paediatrics and Child Health, University of Cape Town

Annual report: January – December 2018

Building a workforce for specialist child

health for Africa, in Africa

“Training in general paediatrics at Red Cross has exposed me to some of the best medical minds in the world. This in turn has led me to aim for the best, not only

in my training, but for my future goals and for my country”.

Dr Norbertta Washaya, Zimbabwe

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About the APFP The APFP builds paediatric clinical workforce, research and training capacity across sub-Saharan Africa. Established in 2008, the programme is an initiative of the Department of Paediatrics and Child Health at the University of Cape Town, and more recently has expanded to the Universities of Kwazulu-Natal and Witwatersrand. Working in close partnership with hospitals and training institutions across Africa, we equip doctors and rehabilitation therapists with the specialist/subspecialist skill sets they need to optimise patient care, lead on new service developments, and build an evidence-base for paediatric healthcare in low-resource settings. From this, we work with referral institutions to build in-country training capacity – catalysing the sustained development of a new workforce to advance child health in Africa.

This report focusses on the activities of the APFP at the University of Cape Town in 2018.

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APFP (UCT) in numbers (2007-2018)

98 paediatricians trained

in 22 sub-specialties

from 14 African countries

6 paediatric rehabilitation therapists graduated

98% of alumni work in Africa

>75% of alumni work in public facilities

150+ peer reviewed publications

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2018 saw 23 fellows continue their training with the APFP (UCT), and 21 new enrolments joining the programme during the course of the year. Eleven fellows passed their subspecialty exams from the Colleges of Medicine of South Africa, and 14 completed their post-graduate degrees. This brings the total number of APFP specialists to 104.

In particular, we are proud of our contribution to the development of specialist paediatric healthcare capacity in Kenya, Ghana, Malawi and Uganda, where a total of 50 APFP alumni have returned to work.

This year has also seen the continued development of relationships with key partner institutions in Kenya, Ghana, Zimbabwe, Uganda, Zambia, Malawi and Tanzania. In each instance, we were proud to engage with the services and activities driven by our alumni at their home centres, and are excited to explore opportunities to better monitor and support these developments.

Together they are backbone of a new network of paediatric specialists committed to the development of specialist child healthcare in Africa.

SUMMARY OF OUR WORK IN 2018

“‘I’m looking forward to the next steps specifically building a Paediatric Pulmonology service at University of Nairobi/Kenyatta National Hospital together with [alumnus] Prof. Obimbo. I’m very excited and see numerous opportunities to improve respiratory health in Kenya working in conjunction with the team of adult and paediatric Pulmonologists back home. Of course, we are still very few Paediatric Pulmonologists in the country and I look forward to more colleagues getting the opportunity to train within APFP so that we can build a critical mass.” Diana Marangu, Kenya, Paediatric Pulmonology Fellow, 2016-2018

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GOAL 1Building partnerships with hospitals and training institutions across Africa

Actively engage partner hospitals and training institutions to ensure that training is optimal for country needs, and support fellows who have returned to develop their services at home.

The APFP continues to engage partner institutions to jointly plan their training activity. We also remain in frequent contact with APFP Alumni - many of whom are keen to collaborate with the APFP as they work to build local service capacity and identify/support future trainees. To this end, 2018 saw us hold meetings with partner institutions from six countries. See page 4 for detail.

OVERVIEW OF PROGRAMME ACTIVITIES 2018

Supporting a national drive to enhance neonatal care in Zimbabwe, APFP fellows teamed up with the Zimbabwean Paediatric Association (PAZ) to facilitate an educational conference aimed at improving the quality of care that premature babies receive in tertiary health centres. Delivered over four days in September 2018, APFP neonatal consultants and Zimbabwean fellows led a series of activities focused on: neonatal resuscitation, the well and the sick pre-term baby, policy and governance. More than 80 participants attended the event, including paediatricians and neonatal nurses from both government and private practice. The meeting was well-received and highly informative – culminating in the identification of a list of issues health workers can address to improve neonatal survival/care, to be taken forward by PAZ.

Not only a positive practical step towards improving neonatal health services in Zimbabwe, the event was also an exciting example of how collaborative efforts between APFP staff, alumni and fellows-in-training can support relationships with partner institutions in the region.

CASE STUDY: IMPROVING NEONATAL CARE IN ZIMBABWE

The facilitation team: APFP neonatology consultants, alumni and fellows from UCT and Wits

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Partner country Purpose and Outcome

The APFP hosted Dr Wedu Ndebele, the new Head of Department from Mpilo Central Teaching Hospital and the National University of Science and Technology in Bulawayo. This created an important opportunity to further our partnerships with Zimbabwean training institutions and facilities - laying groundwork for APFP to support the expansion of general and specialist paediatricians in Zimbabwe. We are also proud to have collaborated with the Zimbabwean Paediatric Association to strengthen quality of care for premature babies in Zimbabwe [see case study].

The Kenya Paediatric Association Annual Scientific Conference provided an invaluable opportunity to work with APFP alumni, and support the facilitation of Paediatric Nephrology, Neonatology and Paediatric Epilepsy Training courses for conference participants. A workshop with East African alumni also helped identify the potential benefits of national/regional sub-specialty groups – an activity sparking the formation of the Kenyan Paediatric Nephrology Association (led by a group of APFP alumni).

A visit by Cardiology and Neonatology supervisors to APFP alumni in Lusaka highlighted urgent need to train more in-country specialists (including anesthetists and clinical technologists). In-line with this, October 2018 saw the APFP host Dr John Masuku, Head of the Paediatrics Department at the University of Zambia Children’s Hospital and President of the Zambian Paediatric Association. Dr Masuku outlined Zambia’s plans to build its paediatric training capacity, and formally requested APFP’s support. We will continue to work with Dr Masuku and colleagues to support the development of such opportunities.

APFP Director Prof. Jo Wilmshurst visited partners in Ghana to support APFP alumnus Dr Charles Hammond with the delivery of the country’s first Paediatric Epilepsy Training courses. Prof Wilmshurst also spent time at the Komfo Anokye Teaching Hospital. During this time she facilitated an alumni workshop to explore new opportunities, post-training activities, monitoring and support - an activity that has led to the formation of Ghana’s first formal ‘Alumni Group’.

Meetings with Muhimbili University Health and Allied Sciences Teaching Hospital highlighted the challenge of family commitments and cost when it comes to leaving home for long-term training with the APFP - a situation that particularly affects women (~70% of the University’s Paediatric Department). We are working to explore solutions to these challenges, and have further meetings planned for 2019. Whilst in Tanzania, we also supported the delivery of two Paediatric Epilepsy Training courses organised by APFP alumnus, Dr Edward Kija. More than eighty qualified paediatricians and registrars in-training attended the event.

September 2018 saw a multi-disciplinary team visit Uganda to support physiotherapy graduate Dr Idah Sendagala and to run a two-day training workshop on paediatric rehabilitation. Attended by 100 health workers (including rehabilitation therapists and paediatricians from the public and private sector), outcomes included a decision from health workers to set-up multi-disciplinary clinics in their home settings, as well as enthusiasm to implement practical learnings – particularly those linked to the treatment of premature newborns and children born with cerebral palsy.

Zimbabwe

Kenya

Zambia

Ghana

Tanzania

Uganda

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2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018Re-enrollments 4 3 4 7 7 10 19 20 20 28 23New enrollments 5 2 6 6 9 10 18 8 15 19 13 21Exited 1 3 5 3 9 7 9 7 15 11 18 16

0

5

10

15

20

25

30

35

40

45

50

2018 saw the APFP host a record number of trainees, with 44 doctors and rehabilitation therapists enrolled from across Africa, including:

• 41 medical fellows - 8 for General Paediatrics training- 33 for sub-specialist training in a total of 18 paediatric sub-disciplines

• 3 paediatric physiotherapists.

16 fellows completed their training with us in 2018, with 28 continuing to train with APFP in 2019.

GOAL 2Train African Paediatric Medical and Rehabilitation Professionals

Deliver specialist and sub-specialist paediatric training to strategically selected African health professionals to strengthen multidisciplinary paediatric health care in the African region.

A UNIQUE TRAINING MODELIn addition to standard clinical training, APFP fellows are offered additional support in the form of: • One-on-one mentorship to support their clinical exam preparations.• Funded participation in a range of skills-training workshops relevant to their specialty. • A workshop in professional communication skills.• Access to course materials from the UCT Health Sciences Masters module: Health & Leadership.• Support to participate in relevant local/international conferences – assisting in the development of key presentation skills, exposing them to their broader subdiscipline, and assisting them with connecting to colleagues from beyond the immediate UCT environment. • A facilitated reflective essay process undertaken over the full duration of their training – the aim of which is to guide supervisors on trainee needs and goals, and to assist fellows in shaping their training for optimal application on return home.

This helps us to make sure that APFP fellows are given the best-possible foundation to support a successful transition from training to the practical reality of practicing their specialty in their home settings.

Who have we trained? Specialties to date

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7

4

12

7

10

12

6

11

6

2

3

1

10

2

15

1

2

4

1

1

4

4

Urology

Paediatric Surgery

Paediatric Rheumatology

Paediatric Pulmonology

Paediatric Physiotherapy

Paediatric Neurology

Paediatric Nephrology

Paediatric Infectious Diseases

Paediatric Gastroenterology

Paediatric Critical Care

Paediatric Cardiology

Paediatric Allergology

Neurosurgery

Neonatology

Medical Genetics

General Paediatrics

ENT

Emergency Paediatrics

Developmental Paediatrics

Child & Adolescent Psychiatry

Cardiothoracic Surgery

Anaesthesia

African Hospitalist

Annual APFP entry and exit totals, 2007 – 2018

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GOAL 3 Expand African clinical research output

Provide research support to fellows to expand research output during and after training, to strengthen the clinical evidence base in Africa.

All APFP fellows are assigned an established research mentor. This helps to build student knowledge in research design, methodology, ethics, sampling and data analysis, with fellows also encouraged to undertake additional courses in this area. As of 2017, all sub-specialty fellows are required to complete a dissertation component of their Masters’ degrees – the intention being that these are published upon completion. With this requirement now well established, we are pleased to start seeing the fruition of fellows’ work, with activity in 2018 including:

• Participation of almost every enrolled fellow in at least one of >20 scientific conferences.

• Research presentations at 15 local conferences/symposia and at seven international conferences.

• 12 APFP alumni and two current fellows were involved in Kenyan Paediatric Association conference planning - presenting in pre- congress symposiums and supporting conference coordination.

• All three awards at the UCT Department of Paediatrics Research Day were presented to APFP fellows:

- Dr Jocelyn Dame, Ghana (Infectious Diseases)- Dr Sandra Kwarteng Owusu, Ghana (Pulmonology) - Dr Sa-eeda Chippendale, South Africa (Hospitalist).

• More than 150 publications authored by APFP fellows to date.

2018 APFP graduate Precious Madzimbe is the first specialist paediatric physiotherapist in Zimbabwe, having returned to join general paediatrician and APFP alumnus Dr Thabani Thatha at Mpilo Hospital. Together with other fellows in training, they are part of a strategic plan to bolster and expand paediatric services at the United Bulawayo Group of Hospitals.

Dr Sandra Owusu, paediatric pulmonology fellow 2016-2018.

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GOAL 4 Assist with establishing training nodes in the regionWork with selected partner institutions to assist their training programme development, as a step towards establishing more independent and/or joint clinical paediatric training nodes in future.

This relies on the development of a critical mass of specialist expertise at partner centres, as well as engagement with national education/training systems for curriculum development and accreditation – as such it will remain a ‘work in progress’ for many years to come.

By way of example, 2018 has seen our training partnership with the Malawian College of Medicine / Queen Elizabeth Central Hospital take an important ‘next-step’, with the welcome of the first cohort of Malawian general paediatric trainees trained in Blantyre for their final 15 months of training in Cape Town. The first of its kind in-country, this programme represents the culmination of 10 years focused partnership development and support and is an important step towards improving national training capacity across the region.

In addition to specialty training, we are also actively supporting alumni to establish and facilitate short training courses for the region. These courses provide invaluable practical clinical skills to a broad range of health professionals on the continent.

PEDIATRIC EPILEPSY TRAINING (PET): Epilepsy is a common, high-burden health condition in Africa. We have been actively rolling out PET courses in collaboration with APFP alumni, the British Paediatric Neurology Association and the International League Against Epilepsy. The number of health practitioners who have undertaken the training with us in the last three years is approaching 800 following the delivery of repeated courses in Kenya, Ghana, Tanzania, Uganda and South Africa. Since the courses were first rolled out in South Africa in 2016, the African faculty has doubled to 70 following a second ‘train the trainer’ course in 2018 in Kenya.

APFP neurology alumni and PET Faculty leads for Ghana (Dr Charles Hammond), Tanzania (Dr Edward Kija) and Kenya (Dr Pauline Sarnia), with APFP Director Prof Jo Wilmshurst, Kenya 2018

CASE STUDY: KENYA The 30 paediatricians trained under the APFP in 13 subspecialties from 10 institutions across Kenya, with a further three currently in training, are putting the country on the cusp of becoming the next ‘hub’ for paediatric subspecialty training. As part of this, in 2018, our renal alumni initiated the Kenya Paediatric Nephrology Association (KePNA) which will develop cohesive clinical guidelines for the country, with medium-term plans to develop subspecialty training.

This is in addition to service-based achievements which include the establishment of the first paediatric ICU, a renal dialysis and transplant programme, and the overhaul of a neonatal service. Many of our alumni have gone on to key leadership roles in the national paediatric body, the Kenyan Paediatric Association, and are leading research for the region.

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4

6

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10

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14

16

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2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Working in Africa

Left Africa

Further study, APFPFurther study

Fellow died

GOAL 5 To retain graduates in African health services Target: 95% one-year post-exit; 90% three years post-exit

Overall: At the end of 2018, 92% (96/104) of all APFP alumni were working in Africa, of whom 74% were based at their original referring institution. Of the remaining 8, 6 are undertaking further study at the time of reporting, one has migrated overseas and another has sadly passed away. If we remove those alumni that have gone on to study, we are proud to say that 98% of APFP alumni work in Africa.

We attribute this success to our careful selection processes, extensive ongoing engagement with partner centres and collaboration in the development of their strategic training plans their strategic plans.

Where are they now? By exit year

CASE STUDY: MALAWI Our long-time partnership with Queen Elizabeth Central Hospital (QECH) in Blantyre and the Malawi College of Medicine (MCM) has produced 10 qualified paediatric specialists to date, with more in the pipeline: 5 fellows completed their full General Paediatric training at UCT, with a further 8 currently undertaking joint MCM-UCT training. In addition, 5 Malawians have undertaken subspecialty training in Paediatric Gastroenterology, Critical Care, Neonatology, Paediatric Oncology and Surgery at UCT: at present this level of subspecialty training is not yet available in Malawi. This multi-disciplinary team is key to mobilising the College’s plan to continue building capacity for Paediatrics training in-country. With this work in development we continue to welcome trainees from Malawi who wish to gain sub-specialist qualifications with the APFP. In the interim, returning APFP fellows are already making their mark:

• Dr Kondwani Kawaza has transformed the neonatal service at QECH, introducing kangaroo care, and bubble CPAP, among other service developments. He has also stepped into the role of Coordinator for Research and Staff Education and is a principal investigator for the WHO multi-country study ‘Immediate Kangaroo Mother Care’ – an initiative focused on implementing low-cost CPAP for neonates across the region.

• Dr George Chagaluka trained in Haematology- Oncology and returned from South Africa

to lead the QECH’s established Oncology service. Previously run by a retiring British doctor, George is the first Malawian to step into the role.

• Dr Rachel Mlotha-Mitole completed her training in 2018, and is excited to be the first specialist bringing paediatric gastrointestinal skills to Malawi. The burden of gastrointestinal disease and nutrition-related illness in Malawi’s children is high, and Rachel has returned home with clear plans for the future. We have no doubt she will make her mark as a leading specialist in gastro-intestinal disease.

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2018 has been a successful year – although it has not been without its challenges. These relate to:

APFP operational team capacity: The immense growth in the programme over the past few years, with increased trainee enrollments, a growing body of alumni, and the start of training sites at the Universities of the Witwatersrand and KwaZulu-Natal, has put our small operations team under strain. We are immensely proud of all that this team has achieved over the period, but also recognise the urgent need to strengthen its core capacity in order streamline its systems, strengthen its M&E processes, and increase its impact – all of which will enable us to more effectively improve Africa’s capacity for the delivery of specialist paediatric healthcare. Extensive delays to the recruitment process for a new Programme Manager and the resignation of the Programme Coordinator in the latter half of 2018 exacerbated challenges. However, we are pleased report that the role of Programme Manager was filled in January 2019, and a new Programme Coordinator recruited in March 2019. This has significantly increased team capacity, with a full review of team roles currently underway. From this we will look to adjust the core team of the APFP so that we can direct our capacity towards long-term growth.

Professional Registration: Obtaining professional clearance and registration for in-coming fellows who have received their degrees and are practicing outside of South Africa can be a time-consuming process – one that is often inefficient and opaque. Unfortunately, on occasion, delays in finalisation of paperwork can delay the enrolment of a number of trainees. In 2018, eight scheduled fellows were deferred to 2019 as result of registration challenges, and in the case of those undertaking PG Diplomas (two in Emergency Medicine and two in Paediatric Physiotherapy) saw their training postponed to 2020. We are working hard to strengthen relationships with facilitative agencies in the best way we can, so that we can keep these delays to a minimum and ensure the smooth enrolment of arriving fellows.

CHALLENGES

‘Returning home, a paediatric gastroenterologist is a great achievement. For me, a dream realised. For my community it is a story of hope as I return as their advocate for child health, friend and paediatrician!’Dr Rachel Mlotha, APFP fellow 2016-2018

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FINANCIAL REPORT

Spending in 2018 was within budget, with an underspend of R3 296 593 reflecting at year end. This is primarily due to delays with prospective trainees’ registration with the Health Professions Council of south Africa and thus postponement of their training to later than scheduled. All budget variances greater than 10% are explained in the notes below.

Please refer to the key on the financial report overleaf for number references.

1. Programme manager not appointed as planned in 2018

2. Delays in a number of fellows' arrival, largely due to registration delays, affects all costs related to Medical fellows

3. Medical protection society cover budgeted, but not required by rehabilitation therapists.

4. Delay in arrival of clinical technologist trainee to 2019, detailed in narrative report.

5. One (of two) hospitalists elected to undertake a shorter period of training.

6. Multidisciplinary rehabilitation workshop not fully budgeted

7. Cheaper than budgeted. Educator internship not undertaken in 2018.

8. Capacity issues in the programme led to postponement of many of these activities.

9. Various key items not budgeted, eg cleaning of residence rooms, telephones, meeting refreshments, etc. Allocated to sundry, and budgeted going forward in 2019.

WITH THANKS The ELMA Foundation Children's Hospital Trust Children's Hospital Foundation Vitol FoundationEquiom Trust Mauerberger FoundationHarry Crossley Family FoundationBritish Paediatric Neurology Association German Academic Exchange Service (DAAD) Peter Gilgan Foundation

TOGETHER WE CAN BUILD A WORKFORCE FOR SPECIALIST CHILD

HEALTHCARE IN AFRICA.

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Budget by Line Item (ZAR) Approved Budget FY2018

ACTUAL SPENDFY2018

(1 Jan- 31 Dec 2018)Variance % Variance

PersonnelMedical Specialist Fellowships

TuitionCollege of SA FCSA Exams - Fees and Accom.Fees for Professional Bodies and AgenciesStipendsReturn Airfares and Institutional VisitsVisa Applications and RenewalsRelocation Counselling

Child Rehabilitiation Therapists Fellowships TuitionInternational FeesHealth Professions Council of South AfricaMedical Protection SocietyStipendTravel

Paediatric Clinical Technologist FellowshipsClinical Hospitalist FellowsCongress and coursesAPFP Staff Exchange Visits to Peer InstitutionsPeer Institution Exchange Visitis to APFPProgramme DevelopmentOperating Costs

Total Project Cost

R 1 815 8808 435 528

423 340194 290370 620

6 948 200433 800

30 14035 138

R 474 104 79 464 48 540 10 580 10 900

297 78026 840

R 162 310 587 770 298 535 183 738137 191

42 265183 279

12 320 599

R 1 499 7935 915 465

480 225 112 053238 217

4 736 844314 016

18 44815 661

R 441 253 87 821 40 481 10 475

- 272 965

29 512

R - 376 764 308 847 219 472

51 28412 589

198 538

9 024 006

R 316 087 2 520 063

-56 88582 237

132 4032 211 356

119 78411 69219 477

R 32 851 -8 356 8 059

105 10 900

24 815-2 672

R 162 310 211 006 -10 312 -35 735

85 90729 676

-15 260

3 296 593

17%30%

-13%42%36%32%28%39%55%

7%-11%17%

1%100%

8%-10%

100%36%-3%

-19%63%70%-8%

27%

Expenditure Report, January – December 2018

Key

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