Afya Bora: An Approach to Global Health Leadership

1. Afya Bora: An Approach to Global Health Leadership Aliza Monroe-Wise, MD, MSc Carey Farquhar, MD, MPH

2. Overview • Afya Bora: The Concept, Participants, Timeline, and Activities • Structure • 3 week modules • Attachment sites • Mentorship • My experiences • Attachment site • Activities • GO Health Project

3. Afya Bora: The Concept • 4 US Academic Institutions partnered with 4 African Institutions • UW - University of Nairobi (Kenya) • UCSF - Makerere University (Uganda) • UPenn - University of Botswana • Johns Hopkins - Muhimbili University (Tanzania) • Participants chosen from 85 applicants in medicine, nursing, and public health

4. Afya Bora: The Participants • 23 Fellows selected • 7 Kenya, 4 Tanzania, 4 Uganda, 4 Botswana, 4 US • Multidisciplinary group • 10 Medical post-graduates and post-residency physicians • 13 Graduate nurses • 9 with public health degrees (2 PhD; 6 MPH) • 7 men and 16 women

5. Attachment I (~3 months) Afya Bora: Timeline and Activities January 7-28 January 31-April 28

6. Overview • Afya Bora: The Concept, Participants, Timeline, and Activities • Structure • 3 week modules • Attachment sites • Mentorship • My experiences • Attachment site • Activities • GO Health Project

7. Module 1: Leadership Skills • Leadership attributes • Definitions of leadership • Leaders vs. Managers • Strategic thinking • Thinking vs. Planning • SWOT analysis • Consensus building • Modalities, steps • Mentorship • Mentoring vs. training vs. coaching • The learning contract model • Roles, benefits

8. Module 2: Implementation Science & Health Systems • Stakeholder and policy analysis • Polio eradication case • Measuring impact and effectiveness (surveillance, metrics) • Operations research • Qualitative Health Systems Research • Sex worker case • Cost effectiveness and economic analysis • Motor vehicle injury prevention case • Social marketing • Group Case Discussion

9. Module 3: Project Management & Research Coordination • Federal and international ethics regulations • Examples and cases from US, Kenya, etc • Budget and financial management • Case: how to develop a budget • Personnel management • Case: the SHARE project • Subject recruitment and retention • Data Management • Creating questionnaires and databases

10. Attachment I (~3 months) Afya Bora: Timeline and Activities January 7-28 January 31-April 28

11. Attachment Sites • Kenya: MoH, AMREF, Kenyatta Hospital, Kenya Medical Research Institute • Uganda: Joint Clinical Research Center, MoH • Botswana: University of Botswana, i-TECH, Botswana-USA CDC • Tanzania: Ben Williams HIV/AIDS Found, AMREF,

12. Mentoring • 1-day workshop for Mentoring Teams within first 2 weeks, includes fellows • As needed meetings with Attachment Site Mentor • Weekly meetings with Primary Mentor • Semi-monthly meetings with Country Lead and Fellows in-country • Monthly meetings with Mentoring Team • Project report and evaluation due last day of rotation

13. Overview • Afya Bora: The Concept, Participants, Timeline, and Activities • Structure • 3 week modules • Attachment sites • Mentorship • My experiences • Attachment site • Activities • GO Health Project

14. Attachment Site: AMREF • Founded in 1950s by British Doctors • Emphasis on flights to remote areas • International organization with operations in 29 African countries, as well as offices in UK and USA • Vision: Better health for Africa • Strategic foci: • Community partnering for better health • Health systems and policy research • Capacity Building

15. AMREF: Kenya • HIV/AIDS integrative approach • Sanitation and basic services • Maternal and child health • Nursing clinical skills courses • Community health worker training • Work in remote rural areas, and urban slums

16. Kibera • Urban slum with ~2.5 million residents; 60% of Nairobi population (gov’t estimate 170,000) • ?Largest slum in Africa • 2 water pipes, 20% electricity, no sewage

17. AMREF: Kibera • Full care clinic in Kibera • Maternal health care • Pediatric clinic • Adult clinic • HIV testing/care • TB clinic • Laboratory • Social work • Pharmacy

18. AMREF: Kibera • HIV counseling and testing program • Over 3,800 HIV-positive patients have enrolled to date • Almost 2000 on ARVs • 823 defaulters identified (no return to clinic in >90 days) • Tracking in progress

19. Activities • Evaluation of clinical practice by Clinical Officers in the adult medicine clinic • HIV testing, counseling, group information session, enrollment, follow-up • Evaluation of procedures in laboratory • HIV rapid tests, CD4 count, malaria blood smears, stool O&P, UA • Evaluation of tracking activities performed by the clinic Social Worker • HIV “social assessment,” tracking defaulters

20. Activities • Review of HIV/ART database • Large longitudinal database from all HIV positive patients in the clinic • Preliminary literature review • Several studies published regarding HIV positive cohort in Kibera slum • Attendance at meetings of ART program staff and clinical providers

21. Project: Goals & Hopes • Afya Bora Fellowship • Learn GH leadership skills • Gain valuable GH experience with international organization • AMREF Management • Data analysis of existing data • Journal publication • AMREF Kibera Employees • Improve working conditions in clinic • Serve as advocate & liaison with management • Personal Goals

22. Project Overview • Quantitative Data analysis • Evaluation of overall project retention • Timing between visits • Factors affecting time between visits • Value Stream Mapping • Steps taken in clinic visits • Value in individual steps analyzed • Time in Motion Analysis • Timing of steps taken in clinic

23. Preliminary Data Analysis

24. Major Bottlenecks Eligible for Program CD4 Testing Retention >90 days 3848 HIV+ 3108 81% 3031 98% 2361 78% 2025 86% 1940 96% 1117 58% #Extra If Eliminated 270 320 823

26. Time and Motion Analysis • One observer watches all patients coming to the clinic • Records of wait times at each step taken in clinic • Overall bottleneck steps can be evaluated • Can be used in conjunction with value stream mapping