During World Health Worker Week, representatives from Seed Global Health, Providence St. Joseph Health, Swedish Medical Services, and Mangochi District Hospital held a global webinar to discuss the opportunities and challenges of partnering to support and strengthen the health workforce. With a focus on collaborative work in the Mangochi District of Malawi, the conversation discusses various elements of global partnerships and their ability to make a long-term impact in low-resource environments. The following blog post represents a transcript of that webinar.
Carrie Schonwald 0:00
Hello and welcome. I’m your host, Carrie Schonwald, Manager for International Educational Exchanges with the Global and Domestic Engagement team at Providence. Since 2012, our department has partnered to make a global health impact through service that honors the leadership, expertise, and goals of communities around the world. We currently partner with programs in Guatemala, Mexico, and Malawi, by leveraging both the talents and material resources of the Providence system.
We are committed to bi-directional work that begins to break down the systemic health and resource inequities that are the global legacy of colonialism. For this reason, among many others, we were excited to have the opportunity to join a partnership in 2017 that included Seed Global Health, the University of Malawi School of Medicine, and the Swedish Family Medicine residency program with the primary goals of strengthening access to care and increasing the quality of health services.
This partnership has been training and educating, Malawi family medicine specialists since 2015. Within this program, there are immersive learning and teaching opportunities in Malawi for family medicine residents from the Providence system. And in the US from allowing registers or residents.
Learners teach, and teachers learn from one another in ways that are personal, professional, and profound. Today we will learn more about the bi-directional impacts of this partnership, as well as a bit about what life looks like on the ground at the Mangochi District Hospital.
I will introduce Dr. Modai Mnenula, Faculty at Mangochi District Hospital. He will be joining us today in a pre-recorded video to ensure that the technical issues do not get in the way of our opportunity to learn from him. He is the second graduate of the University of Malawi’s master of Family Medicine degree and is currently the Deputy Head of the Family Medicine Department in Mangochi. Providence and Swedish were fortunate to host Dr. Mnenula, in 2017, when he attended our six-week Family Medicine immersion program called the global family medicine Collaboratory. So Dr. Mnenula will participate in today’s discussion by sharing what he sees as the value of primary care in Malawi.
Dr. Modai Mnenula 3:32
Now we only have four central hospitals in the country. It is really difficult. Most patients access care in these central hospitals and Family Medicine bridges the gap. In Mangochi, we have more specialized care for patients. It is cost-effective, because we don’t have to expend as many resources to send patients to central facilities, as well because there is a component of preventive medicine in our Family Medicine program. If you had to compare curative and preventive, preventive is usually cheaper. So that’s what also makes Family Medicine important in our country.
Carrie Schonwald 5:42
Thank you. The next speaker I will introduce is Jacob Nettleton, who is a family physician at the HealthPoint community health centers in Seattle. He has also been a physician educator for the last four years with Seed Global Health in Malawi and supports Family Medicine development for current and future Malawian clinicians and partners with Dr. Anna McDonald to manage the Global Health residency rotation.
Dr. Nettleton, will you please paint a health picture of Malawi for us, as well as tell us a bit about the background of the Malawi partnership, and about your and Dr. MacDonald’s roles within it?
Dr. Jacob Nettleton 7:42
It’s wonderful to be here today. As it pertains to health, Malawi is a country that continues to make improvements but also struggles quite a bit with a lot of the metrics by which we judge health and healthcare systems, whether it be life expectancy, maternal and child mortality, or excess morbidity and mortality from a range of conditions. But that’s of course in comparison with countries that have not had to deal with the legacies of colonialism and economic imperialism.
But things are changing. We have non-communicable diseases like diabetes and hypertension and the increased morbidity and mortality that go along with those. These will further test people’s health and healthcare systems over the coming decades. And despite having a fantastic College of Medicine and other health workforce schools within Malawi, the health care workforce continues to be stretched thin.
Doctors are mostly in the central hospitals, and most Malawians are born and live their lives in the rural district setting. It was recognized that the rural district hospital setting is fertile ground for elevating quality and equity within health care hence family medicine.
So in terms of this partnership, you know, it started in 2013-2014 between Dr. Martha Makwero of the Malawi College of Medicine, one of the first family physicians in Malawi, and Dr. Elizabeth Hutchinson, who faculty in the Swedish residency program and who was a Seed Global Health educator in Malawi at that time. They dreamed of a bi-directional partnership.
Since then, there’s been an ever-growing formality of partnership between Seed Global Health, Providence, and Swedish, as well as the College of Medicine. Dr. McDonald and I each worked two years full-time at Mangochi District Hospital, and now we work part-time or part of the time there each year and then part of the time in Seattle. We teach and train Family Medicine postgraduate trainees as well as medical students, serving as faculty with the College of Medicine, supervising and mentoring visiting residents as well as helping coordinate and participate in the activities when the Malawian trainees come to the US in terms of education and scholarship.
Carrie Schonwald 11:12
Thank you, Dr. Nettleton. Our next speaker is Mr. Chris Maddocks, the Managing Director of Partnerships and External Affairs at Seed Global Health, where he oversees the development and communication functions as well as supporting strategic partnerships such as the one we are talking about today.
Chris Maddocks 11:48
Thank you. I am so excited and honored to be here on this panel. I will start by introducing Seed Global Health. We were founded in 2011 by Dr. Vanessa Kerry, and currently have programs in five countries; Uganda, Zambia, Sierra Leone, the kingdom of Eswatini, and of course, Malawi.
At over 20 sites across these countries, Seed Global Health has helped to train more than 20,000 doctors, nurses, and midwives. In each of these countries, our work is focused on helping to address the critical shortages of health workers. According to the World Health Organization, there is a global shortage of skilled health workers, estimated to grow to 18 million by the year 2030. This represents a significant inequity in resources, which is the backbone and fundamental to health delivery. In Africa, where 16% of the global population lives, these shortages are most acute.
In the program as that we’re discussing today, our partnership in Mangochi is a unique one. It is modeled on this theory of bi-directional partnership. This is a really meaningful spirit of our work and how it’s designed. Seed Global Health does not have a “one-size-fits-all” or prescriptive model for how we help build the health workforce. We seek to co-create programs with the local leaders, the governments, the stakeholders in the countries where we work. We want to ensure that any efforts that we’re doing with clinicians or caregivers are fully integrated into the needs of the country. Ensuring that we’re supporting local leaders and champions who can continue this work, you know, effectively, picking up the banner for what we have introduced.
In Malawi, there are three core focuses in the country. Our goals are to strengthen mental health services in a country where nearly 40% of patients present with a mental health disorder of some sort. Additionally, Maternal and Child Health, given the country’s very challenging, maternal and child health metrics, is both a national priority and a local priority for our stakeholders. And then finally, as it pertains to this partnership in particular, the area of primary care and community health. Malawi is a primarily rural country over 80% of the population lives outside of urban centers, meaning that it’s critically important to build a health workforce that is agile, flexible, and distributed at the district level facilities or lower and village health facilities.
So to enable that kind of support for the health system, we adopt a three-pronged approach to our program. First, we develop a suite of health professional education tools to improve the breadth and depth of educational inputs that exist in the country. Second, we support clinical mentorship, being at the bedside with residents and trainees, so that not only are they moving through a training program with that kind of knowledge and understanding but they’ve also had the benefit of mentorship and that kind of showing and learning at the bedside.
The final piece of our work ensuring this health system’s capacity is married to a strong policy foundation. If we don’t see government and public policy, moving with these investments, and helping ensure that the seeds that we’re planting, have a chance to fall onto fertile ground and can take root. We need to make sure that Ministries of Health, Ministries of Finance, multilateral and development partners are also working with the countries to ensure that these investments can take hold.
In the context of COVID, it feels strange to be a year into this experience. I would say some things haven’t changed and I think that’s really important to notice that for countries that do have these shortages of the health workforce. The need for trained and skilled health professionals doesn’t change because of a pandemic; babies are still being born, bones are still being broken, critical care is still needed.
For countries that have these critical shortages of health workers, they cannot pivot on a dime and shift into COVID mode. They really have to have that backbone of health professionals that can deliver the essential primary care and respond to COVID. Assuredly our travel has been disrupted and additional screenings and health clearances – all the things that have become our new normal.
But I would say what hasn’t changed is the importance of leaning into this moment and understanding that we can’t pause primary care because of a pandemic. And thanks to wonderful professionals like Dr. McDonald and Dr. Nettleton and the team at Providence, we’ve been able to meet this moment. We have been able to continue to build that health worker pipeline, support our partners in the ground.
This is where it really matters; making sure that as we start to think about recovery or moving out of the pandemic that we haven’t lost ground in establishing these important foundations that will be so critical, both to meeting future health emergencies but also, again, dealing with the day to day.
Carrie Schonwald 20:01
Thank you, Chris. I see it as a phenomenal organization and we feel very lucky to have joined the partnership with such strong foundational infrastructure and values alignment.
Our next speaker is Anne Marie Williams, a family physician who spent four weeks in Malawi, as a second year resident in the Swedish First Hill Family Medicine Residency. She now splits her time between New Mexico and Liberia, as a global health fellow for UCSF. Dr. Williams, can you share a bit about what has most stayed with you from your four weeks and Mangochi, both personally and professionally, and also what do you believe your impact was in your time there?.
Dr. Anne Marie Williams 20:47
Thank you and it’s good to join old colleagues, having left the residency now. I think what struck me the most was just the power of teaching as a tool to strengthen systems and enforce and improve health care quality. I think that there are sort of core principles of teaching that translate across very different clinical contexts and that that makes it a good piece for residents to come in and join in that piece of the work.
For a little background, when residents go the main piece that they’re helping with is teaching and supervising medical students on their family medicine rotation. Building a differential diagnosis, a lot of that is foundational and does translate and so is a really thoughtful piece I think, for residents to help with. You actually get to really demonstrate high-quality care through encouraging curiosity and thoughtful empathy.
I learned a lot from watching doctors Nettleton and McDonald, lead and guide change through example; like suggesting ways to make really strong follow-up plans for patients when they leave the hospital, or modeling following up on labs to make sure that the medical plan is happening. Those are aspects of high-quality care. I could see how impactful that change could be without it coming as a sort of top-down, outsiders coming in and telling people what to do approach. I think those were really important things to see modeled for my own work going forward.
I think what has also stayed with me is just great humility and respect for people practicing in such low resource settings. I remember trying to diagnose or think through a possible heart attack in a place where you can’t do an EKG. It’s a complete frameshift of how you would think about that diagnosis and organize care around that. Another example is trying to teach how to provide care for someone in diabetic crisis or diabetic ketoacidosis, which in our setting relies heavily on frequent labs. To do that in a place without those labs, I think there’s a lot of risk in that. But that is the reality that people are facing and so I have just so much humility and respect for our colleagues.
Carrie Schonwald 24:08
Thank you so much, Dr. Williams. I had the great pleasure of being in Malawi when Dr. Williams was on rotation, and the photograph that you all saw of her and her colleague, presenting a didactic was very humbling for me to see how well embraced residents are on the ground, in Mangochi, and how quickly they try to adjust to all of the changes and move in partnership with those that they meet.
Dr. Nettleton, how have US residency rotations to Mangochi, and the Malawian registrar rotation in the US, supported the goals established by this partnership?
Dr. Jacob Nettleton 24:58
In terms of thinking about the American residents visiting Malawi, I think Dr. Williams hit the nail on the head. We do believe very strongly that clinicians from one setting have no business dropping into another setting that’s not their context and telling people what to do. But there are things that translate universally in terms of supporting clinical problem-solving skills.
I appreciate Dr. Williams bringing up the modeling Family Medicine because that’s one thing. There are only a few family physicians in Malawi and the vision with the College of Medicine and the Ministry of Health is to vastly grow that number as a solution for rural district medicine. It is important for medical students to see trainees and more family physicians, teaching and being proud of the discipline that they’re in, and explaining their own kind of career and clinical care and educational experiences. I think that’s very valuable for medical students. It also serves as an introduction to clinical system strengthening and clinical education for the visiting American residents such that it serves almost like a pipeline. In Dr. Williams’ case and certainly, for me, I was in the residency rotation when I was a resident, before becoming a full-time Seed Global Health Educator myself.
This is also a bi-directional partnership. In 2017 and 2019, the Malawian postgraduate trainees spent six weeks in Providence and Swedish-sponsored Family Medicine immersion experience in Seattle. By all accounts, this was quite enriching in the areas of clinical education, especially in areas that were identified by the Malawian trainees in areas that we have educational opportunities which are not necessarily available to them. For example, in the area of Geriatrics.
And then also education and comparable health systems, being immersed and observing and participating in the health system here in Seattle and having supported them in taking their next step towards leadership in primary health, healthcare, and global health. They also take a leadership course in the University of Washington in global health leadership.
And then finally in scholarship. As you see in the picture that’s being presented this last week, both groups, 2017 and 2019, participated in the American Academy of Family Physicians’ Global Health Summit, collaborating in presenting sessions and workshops. And then this last time, both the AAFP global health summit, as well as the WONCA world rural family medicine conference, which was a great experience.
I do think these experiences serve to meet the objectives of the different partners including the Family Medicine trainees with an aim towards systems’ improvement in the pipeline of physician educators, cross-cultural and cross-systems collaboration, as well as strengthening Mangochi District Hospital specifically as a hub of clinical excellence and clinical education in the rural district setting.
Carrie Schonwald 28:43
Thank you Dr. Nettleton, and with those with a keen eye, you will have noted, Dr. Modai Mnenulawho that in the first picture in 2017, and Dr. Anne Marie Williams and the second.
These are phenomenal events that allow for a tremendous amount of bilateral, bi-directional, collegial sharing and in the case of the Collaboratory, it was actually trilateral in the first one because we also had three Guatemalan physicians as well as the Malawian physicians all working very closely with the American residents so it’s a very powerful program.
To summarize the words of Dr. Mnenula in speaking about the Collaboratory experience, the end result is that each learner, each teacher winds up being both because they are bringing their different contexts and they are deeply complimentary, there are very different strengths and challenges encountered in each of our systems, and that winds up being the great strength of this partnership and partnerships like it. Those differences are the grist for the mill of bi-directional learning.
Chris Maddocks, working within global health, can you tell us a bit about how this partnership and work in Mangochi is distinct from some of the broader Seed context?
Chris Maddocks 32:19
The word that keeps coming up is bi-directional. I think one of the things that are truly unique about Mangochi is, again, not only are we building a cohort and a pipeline of family medicine practitioners: U.S. residents are coming through, are then practicing in the US, but also building that pipeline in the Malawian context.
Ultimately, what we’re seeking to build together with our colleagues in Mangochi is the backbone of a health system that can be replicated across the 28 districts of Malawi. It is the kind of expansive opportunity that has been started here in Mangochi to show a model of deep partnership and bi-directional learning that can then be modeled and replicated across the 28 districts.
Mangochi is one of a number of places in Malawi where Seed Global health works and it’s the kind of an exemplar and site that we believe is highly replicable and that we look forward to in this partnership with Providence and the College of Medicine. Seeing that take shape, and then expand to other sites, so that our impact is not just in this one very important district, but it’s something that we are able to then scale up is part of the backbone of the health system, writ large.
Carrie Schonwald 34:11
Wonderful, thank you so much, Chris. Dr. Williams, as you reflect on your own clinical work here in the US and the work in Mangochi, and now Liberia, can you help us understand how these experiences intersect?
Dr. Anne Marie Williams 34:33
I think that providing healthcare anywhere for a population that is different from you or that you’re not from is a lifelong learning experience and each time you enter into a new place you’re kind of continuing to build on those skills.
A lot of it is actually unlearning certain sets of skills that make us successful in school or in training or in academic medicine of kind of being a go-getter and getting stuff done and coming in really strong with a lot of energy and ideas and that is often not the best thing to do in most of these settings and I think that’s true in different communities in the US as well.
But it’s really hard to unlearn those skills and then build different, more collaborative ones.
So I think that these experiences just continue to build on each other and strengthen people working in health equity who can come in partnership and solidarity centered. And I think also that these different settings have all really reinforced a passion for health care quality improvement in me and I think that is kind of the next forefront of global health work.
There are a lot of structures and infrastructure and resources that have been put into building systems up. But those systems are really only as strong as the quality of care they’re providing. And that is, I think, the next step of making sure that the training is really emphasizing high-quality care and I’ve seen that in each place I’ve gone.
Carrie Schonwald 36:29
Thank you for that perspective, Dr. Williams. Such vastly different settings but of course it’s still, medical care, and it’s still with doctors taking care of patients, thank you for sharing that.
Dr. Jacob Nettleton, I am going to direct this question to you, if we have time I will get the perspective of our other speakers: what are the ways that this partnership does and does not yet move toward global health equity in Malawi?
Dr. Jacob Nettleton 36:59
So I think there are some ways it does in some ways that we can continue to improve on, in ways that it does, you know, we’ve been emphasizing this bi-directional aspect of it, which I think is really vital.
When faculty members from the US are working in Malawi, they are full-time faculty, rather than just dropping in for short periods for the most part. And, the emphasis on elevating the College of Medicine in the Ministry of Health objectives as Chris alluded to, and then actually using resources to, fight against how resources usually flow in the world to support exposure and global health leadership and scholarship for our partners in the Malawian setting.
And then attempting as much as we can to be explicit about avoiding the pitfalls of other global health programming and interventions, and in our resident exchange that includes pre-travel orientations, debriefs and supervision to avoid the drain on the host and local resources and having some of the different difficult conversations to get through the weeds and some of these issues.
This is all work in progress, and it’s not exactly balanced; far more American residents come to visit Malawi than vice versa. That’s partially because the Malawian training program is in its early stages and so there haven’t been that many Malawian family medicine postgraduate trainees yet.
But, as Chris alluded to, the vision of the Ministry of Health is to have family physicians in all of the 28 districts, and so that’s a lot of trainees and a lot of opportunity for further collaboration. And then our hope is of course that over time and over generations the human resources for health development will start to put a dent in the kind of superstructural forces that reinforce power and resource differentials, but those forces obviously are strong and so in those regards, it’s an uphill battle.
Carrie Schonwald 39:12
So we don’t have time for our other panelists to answer the same question, although I know they spend a great deal of time thinking about the answers to these questions, and to this question, in particular, we are going to try one final video from Dr. Mnenula as he shares his vision for primary care in Malawi, for the future.
Dr. Modai Mnenula 39:40
I want to ensure that people living in their communities have the link to a specialized doctor, in this case, family physicians, because a lot of things are happening at the community level. And what we see at the hospital is just the tip of an iceberg.
Carrie Schonwald 40:00
I recently learned of a movement within the field of global health to change the term capacity building to capacity sharing. Language, as we know, is powerful. A shift in language represents a shift in perspective, and ultimately a shift in practices, policies, and funding.
I hope that you will all have learned today the ways that this partnership keeps evolving to share capacity with one another, all with the primary goal of strengthening and growing Malawi’s primary care provider pipeline.
Thank you to all of my colleagues who carved out time today to share your work with our audience. Additional thanks to the College of Medicine and Seed Global Health for making this partnership possible, and including Swedish and Providence in your journey toward primary health care access to all Malawians. Above all I would like to thank all of the Malawian clinicians and learners who embrace the opportunity for robust educational exchange, allowing for this bi-directional journey.
And finally, thanks to all of our guests for joining today and for staying with us, and to everyone for listening and sending in your questions. We will try to answer those in blog form, post forum. To learn more about our initiatives, programs, services, and ways to give, or if you’re looking for medical care, please visit providence.org And make sure to follow us on social media at Providence Health System for LinkedIn, Facebook, and Instagram, and under Providence on Twitter.