Beryl Pilkington: Knowledge for Change: From Research to Reality

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Beryl Pilkington, RN, PhD, School of Nursing, Faculty of Health, York University in Toronto, presented at AMREF's Coffeehouse Speaker Series on global development on the intersection of health and development with specific focus on the community level in the Dadaab refugee camps. The coffeehouse speaker series looks at international development and global health, specifically focusing on Africa.

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  • June 19, 6pm at Centre for Social Innovation, Annex, ING Presentation Room - main floor at the back, 720 Bathurst Street (2 blocks south of Bloor)The African Medical & Research Foundation (AMREF) Coffeehouse Speakers Series on Global Development&Canadian Coalition for Global Health Research (CCGHR)
  • 1st bullet: Sudan, Thai-Burma border and many more.The refugees are living in cramped and seriously deprived conditions that threaten their health and well being.2nd bullet: Dadaab situation.3rd bullet:Considering, the Ottawa Charter for Health Promotion (1986) identified the following as prerequisites for health:peace,shelter,education,food,income,a stable eco-system,sustainable resources,social justice, and equity.SEE MAP, showing location of Dadaab - next slide
  • There are 5 refugee camps at Dadaab. Health services in the camps are overcrowded and underequipped. E.g., in one of the camps (Hagadera), two health units serve the needs of 78,000 people – quadruple the minimum emergency standard of 1 unit per 10,000 people. Moreover, humanitarian aide funding shortfalls will worsen the situation.While on this slide, introduce video: Developing a Model to Improve Access to PHC for RefugeesCreated to showcase a “big idea” concerning a “global health challenge. ” It was part of an application to Grand Challenges Canada (not successful but still pursuing)Speaks to the issues of limited access to the requisites for health and limited access to health care within the camps.SHOW VIDE0
  • HEALTH ISSUES. 1) High morbidity & mortality 2) Reliance on international NGOsE.g.: UNHCR, UNICEFMedicines sans FrontieresRed Cross, Red CrescentInternational Rescue Committee (IRC) in KenyaCARELutheran World Federation (LWF)National Council of Churches Kenya (NCCK)Mainly crisis oriented - respond to emergencies3) VOLUNTEER HEALTH WORKERS assist with service provision:Trained by the IRC on basic principles in health**AMREF is developing new training curriculum for Dadaab/IRC community health workers**Act as nursing assistants, reproductive health workers, work at laboratory/pharmaceutical distribution sites; run the health posts.Proactive in building community awareness and incorporating traditional/religious traditions into health promotion and/or challenging unhealthy practices in the community though health promotion.But: HWs are mostly menWhile training is provided, there is currently no credential (hence, non-portable) and they get little if any pay.
  • NEEDED: consistent access to primary health care. What is it?Essential health care; based on practical, scientifically sound, and socially acceptablemethod and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination (WHO & UNICEF, 1978).PHC encompasses:1. education for the identification and prevention/control of prevailing health challenges2. proper food supplies and nutrition; adequate supply of safe water and basic sanitation3. maternal and child care, including family planning4. immunization against the major infectious diseases5. prevention and control of locally endemic diseases6. appropriate treatment of common diseases using appropriate technology7. promotion of mental, emotional and spiritual health8. provision of essential drugs (WHO & UNICEF, 1978).
  • In 2011, BHER project conducted feasibility study in which community researchers consulted residents of the camps in focus groups and targeted interviews about perceived needs for higher education.NEXT SLIDE will BRIEFLY EXPLAIN BHER
  • All BHER offerings will be “stackable” and “portable”In addition to teacher eductation, students can choose to specialize in one of 5-6 areas.Community Health Professional Degree ConceptProposed CHP program would build on teacher training curriculum. Health curriculum would draw from: Moi U - community health curriculumYork U’s new Global Health BA/BSc program
  • 1) Why not Medicine and Nursing? Thesewere among higher education programs that camp residents in the BHER feasibility study said they needed and wanted. In most developed countries, physicians and nurses would be the major providers of primary health care. However, there are feasibility issues with providing professional education in a refugee context.1) Health professionals regulate education within their state jurisdiction and it would be a lengthy process to get approval for any new program.2) Education requires access to training facilities and resources that are not available in refugee camps2) Utilization of CHWs in PHC: They have participated in the provision of primary health care all over the world for decades.Evidence that they can add significantly to efforts to improve the health of the population, particularly where there is a shortage of motivated and capable health professionals (GHWA & WHO, 2010)3) Do CHWs need a university degree?No. They are not a ‘regulated health profession’ and thus, education & training varies widely, from several weeks to a university degree (developed countries).VALUE ADDED: degree would prepare a health worker capable of an expanded role and more employability beyond the camps. That is why we choose the title “Community Health Professional,” in recognition of the ‘expanded role’
  • Study conducted by GHWA & WHO (2010)Aim: to identify CHWs programs with positive impact on Millennium Development Goals (MDGs) related to health: reduce child mortality; improve maternal health; combat HIV/AIDS, malaria, and other diseases;Global systematic review of MDG interventions, plus eight in-depth country case studies in Sub-Saharan Africa (Ethiopia Mozambique and Uganda), South East Asia (Bangladesh, Pakistan and Thailand) and Latin America (Brazil and Haiti). Looked at typology of CHWs, selection, training, supervision, standards for evaluation and certification, deployment patterns, in-service training, performance, and impact assessment. Impact indicators included those related to maternal and child health, HIV/AIDS, TB and malaria, mental health, and non-communicable diseases.In addition, draft recommendations were developed for recruitment, training and supervision criteria for CHWs programs to address the health MDGs, for further regional and global consultation among stakeholders, and for their eventual adaptation in varied contexts.
  • The key findings are very relevant to development of the proposed program.
  • We need to consider how to integrate these findings in the development of the proposed program.
  • 1) Security:If insecurity arises, national staff and international staff most times leave the camps, leaving health posts and hospitals to be run by incentive workers who have basic training only. CHP degree would build capacity building amongst refugees working in health care so that they would be better equipped to continue providing care when unsupervised by nurses/doctors.2) Incentive trainingIncentive training is only recognized in the location where it is provided. It is NOT nationally recognizedCHP degree would allow for mobility of health workers, opportunity for employment beyond the camps, including in their home countries, when they are able to return3) Gender inequity.Recruitment for female incentive staff is very difficult due to structural issues that leave girls/women without adequate education to fulfill entrance requirements. BHER programs are structured to ensure access for girls/women; funding requires a proportion of students MUST be female
  • Based on our previous study and existing knowledge about CHWs, my colleagues and I believe that a CPH degree program is needed. What partners? International Rescue Committee (IRC), Red Cross, AMREF2) What should the program look like? What are the priority health problems in the refugee camps and how could CHPs be utilized to help address these?How many students in the BHER program would potentially pursue the specialization? Capacity of camps/host country to provide employment?What are the specific on-line and on-site teaching and learning requirements? What teaching equipment and supervised practicum opportunities are needed?3) How can the CHP role can be integrated into existing healthcare structures and systems in the refugee camps and the host country (Kenya)?potential mechanisms for employment, supervision, and continuing education; mechanisms for referral for secondary and tertiary care?
  • Beryl Pilkington: Knowledge for Change: From Research to Reality

    1. 1. .Beryl Pilkington, RN, PhDSchool of Nursing, Faculty of HealthYork University
    2. 2. The issue: In the Global South, there are currentlyover 15 million people caught in refugeesituations for protracted periods Dadaab, Kenya: about half a millionrefugees, many living here for > 10years Living conditions pose severe healthchallenges
    3. 3. Health Issues High morbidity and mortality due topreventable conditions(e.g., diarrhea, communicablediseases, malaria, childbirthcomplications, malnutrition) Reliance on international NGOs Insecurity in camps severely hampers healthservice delivery Volunteer health workers
    4. 4. Needed: ‘Primary Health Care’ What is primary health care (PHC)*? Essential health care; Based on practical, scientifically sound, andsocially acceptable method and technology; Universally accessible to all in the communitythrough their full participation; at an affordablecost; Geared toward self-reliance and self-determination*WHO & UNICEF (1978)
    5. 5. Needed: Higher Education inHealth Need for health education identified in afeasibility study conducted by BorderlessHigher Education for Refugees (BHER)project**Dippo, D., Orgocka, A., & Giles, W. (2013).Reaching Higher: The Provision of Higher Educationfor Long-Term Refugees in the DadaabCamps, Kenya.Available: http://crs.yorku.ca/bher
    6. 6. BHER Partners & Aims Partners: Canada: York U, U British Columbia, WUSC Kenya: Wendle Trust Kenya, Kenyatta U, Moi U, AfricaVirtual University Aims:1. Improve the equitable delivery of quality education inrefugee camps and adjacent local communities throughuniversity training opportunities which will prepare anew generation of male and female teachers;2. Create targeted, continuing opportunities for young menand women in university programs that will enhancetheir employability through portablecertificates, diplomas and degrees;3. Build the capacity of Kenyan academic institutionsthat already offer onsite/on-line university degreeprograms to vulnerable and marginalized groups.
    7. 7. Why Higher Education forCHWs? Why not focus, instead, on education forphysicians and/or nurses? Utilization of CHWs in PHC: Evidence that they can add significantly toefforts to improve the health of thepopulation, particularly where there is ashortage of motivated and capable healthprofessionals (GHWA & WHO, 2010) But do CHWs need universityeducation?
    8. 8. What is Known about Utilizationof CHWs in Health Care? Global Health Workforce Alliance (GHWA)commissioned a study as part of itsmandate to implement solutions to theglobal health workforce crisis. The resultantreport: Global Experience of Community HealthWorkers for Delivery of Health RelatedMillennium Development Goals: A SystematicReview, Country Case Studies, andRecommendations for Integration into NationalHealth Systems (GHWA & WHO, 2010)
    9. 9. Key Findings:1) CHWs should be coherently inserted in thewider health system, and should be explicitlyincluded within the HRH strategic planning atcountry and local level;2) Village health committees shouldcontribute to participatory selection processesof CHWs;3) Pre-service training curriculum shouldinclude scientific knowledge about preventiveand basic curative care;
    10. 10. Key Findings…4) CHWs should continually assesscommunity health needs anddemographics;5) CHWs should have established referralprotocols with formal health services andsocial service agencies;6) CHWs should benefit from regular andcontinuous supportive supervision andmonitoring.
    11. 11. Priority Areas for FurtherResearch* cost-effectiveness, effectiveness of paid vsvolunteer workers, quality & effectiveness ofservices, whether CHWs promote equity andaccess, role of CHWs in HIV/AIDS prevention& care, sustainability of interventionsprovided, #s of CHWs required according tovolume of work* Findings address training, but not highereducation Also, role of CHWs in refugee context notaddressed*(GHWA & WHO, 2010)
    12. 12. Community HealthProfessional:A Response to ContextualIssues Security Recognition of training Gender inequity
    13. 13. Challenges & Questions Besides Moi U, what other partners inKenya should be involved in developing thenew CHP program? What should the CPH program look like? Curriculum, # of students, teaching-learningresources & facilities? How can the CHP role can be integratedinto existing healthcare? employment, supervision, and continuingeducation opportunities; referral mechanism?

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