Yale Global Health Leadership Institute

Shirin Ahmed, Program Manager, GHLI

As I sat at a restaurant not far from the White House discussing Ethiopian (and Pakistani) politics and bonding over honey wine with my friends from the Ethiopian Ministry of Foreign Affairs (MFA), it struck me how issues of regional security and organizational capacity are quite similar across borders.

I was at the end of spending two weeks with delegates from Ethiopia who were visiting the United States as part of Yale GHLI Strategic Thinking in Foreign Affairs Symposium followed by a tour in DC to meet with leaders on Capitol Hill, at think tanks and the State Department. I felt so welcomed by the group— they even gave me an Ethiopian name, Shelemat, a prize or reward in Amharic.

During our time in DC, I was pleased to see the enthusiasm on both ends, reinforced by mutual commitments to resolving regional conflicts, fostering business development and strengthening US-Ethiopia relations. But I also sensed a concern from the Ethiopian side about its “image” in the US, often misrepresented by western interest groups and now exacerbated by Ebola. However, it was encouraging to hear that despite these perceptions, as noted by someone from the US Chamber of Commerce, Ethiopia stands at the “cusp” of economic growth and it is only a matter of time that the country would become a major player for US investments.

One individual at the Foreign Services Institute asked me what Yale was doing with the group -- a question I asked myself at the beginning of the program. But I get it—building and strengthening. I had seen those words in writing in our Symposium brochure, but I truly understand it now. The learning at Yale coupled with relationship building in DC may be the jumpstart for the MFA to advance its foreign policy agenda.

With each passing day, I have new Ethiopian followers on twitter and Shelemat continues to receive thank you messages from the MFA.

Dawit Tatek, GHLI Program Manager for the Ethiopia Hospital Management Initiative (EHMI) became interested in public health after seeing people unnecessarily die from preventable diseases. “The problems I saw were more common among residents who lived far from health facilities. Seeing positive results from health programs in improving equity in access to health service was the turning point in my career as public health professional.”

Dawit completed his undergraduate training in Medical Laboratory Technology and Clinical Nursing at the University of Gondar, Ethiopia. After working at the Gondar hospital for six years, he joined the Clinton Health Access Initiative to work in the Ethiopian Millennium Rural Initiative program, and was appointed primary health care unit coordinator. He worked in remote areas to improve implementation of the health extension program, increase HIV counseling and testing, and increase delivery of services. In 2011, Dawit joined GHLI and has been working with EHMI, managing two Master’s of Hospital Administration programs in Ethiopia while acquiring a Master’s Degree in General Public Health.

One of the aspects of GHLI that Dawit enjoys most is the use of critical thinking and an evidence-based approach. He commends GHLI for applying scientific problem solving techniques to improve quality in hospital and healthcare management.

“I find it extremely rewarding to help transform hospitals managers into confidant and outstanding leaders through the MHA program. It is very satisfying to receive good feedback on the program and know that I have helped.”

But Dawit's job is not without its challenges. Working with stakeholders who may not always understand the urgency of the problem can lead to inefficiency in job performance, and students are not always willing to learn and change as quickly as the program demands. However, despite these challenges, Dawit hopes to assume more leadership responsibilities and become involved in strategy management processes. He also hopes to pursue a Ph.D. in health economics and health policy in the near future.

GHLI program manager Nikole Allen first became interested in global development as a freshman in high school. Nikole realized that, “access to education, health and economic opportunities provided to most Americans is not universal.” She became actively involved in Operation Days’ Work, a USAID-led youth development program.The program empowers students to promote international awareness and support educational initiatives in lower income countries. Nikole’s work with the program focused on funding a grant to refurbish a secondary school in rural Ethiopia. With piqued interest in the global health field, she selected a major in international studies at the Western Oregon University.

While pursuing her Master’s of Public Health through the Peace Corps Master International program at the University of Washington she was reconnected to Ethiopia, where she worked as a community HIV/AIDS advisor. Later, she joined the Clinton Health Access Initiative’s Ethiopian Hospital Management Initiative and began working with the Ministry of Health to help hospitals interpret key performance methods -- including the measurement of patient and staff satisfaction, the uptake of patient satisfaction best practices and the implementation of the World Health Organization Surgical Safety Checklist.

Since joining the GHLI team, Nikole has led research and training programs in the United Kingdom, Tanzania and Rwanda. GHLI has provided her with the opportunity to collaborate with a variety of groups in different health systems. She particularly enjoys learning about each group’s challenges and providing them with the guidance and support to generate strategies to address those problems.

“The GHLI leadership programs are incredibly valuable because they offer country participants the ability to learn outside of their regular environment and reflect on their challenges.”

“I appreciate that GHLI recognizes that health system challenges exist everywhere, so we have domestic projects and partners in high income countries as well,” said Nikole. “I’m looking forward to continuing to explore the intersection of public health and development across the globe.”

Photo Credit: Thi Nhat Le

Zahirah McNatt, GHLI Director, Leadership Education and Practice

As part of the Senior Leadership Program (SLP), I recently worked with delegates from Cambodia, Laos, Myanmar, Philippines, and Viet Nam in Phnom Penh, Cambodia to address strengthening the enabling environments for persons with disabilities. Each team brought with them a national problem - high staff turnover, too few rehabilitation professionals, poor access to physical rehabilitation centers and limited knowledge among people with disabilities about their legal rights.

For this program, all written materials were translated into four languages and we had simultaneous interpretation during lectures and group activities. For five days, we explored problem solving, leadership and management, good governance and the United Nations Convention on the Rights of People with Disabilities (UNCRPD).

The trip was an awe-inspiring opportunity to encourage collaboration among several stakeholders. We had representatives from national disabled people’s organizations, government ministries, parents, teachers and physical rehabilitation facilities. The diversity created dynamic teams and allowed for cross-country dialogue about better integrating disability rights efforts in Southeast Asia.

The SLP created a safe space for discussion on how to operationalize the aspirations of the UNCRPD. Many countries stall once ratifying such agreements and are unable to make the dreams reality. These five nations have the potential to implement practical solutions that increase accessibility and diminish discrimination against people with disabilities.

While there are many difficult stories about children who use wheelchairs being unable to get to school or people with visual impairment being denied the right to vote - I remain hopeful. I am personally motivated by the role models present in the Program itself - women and men with and without disabilities who have chosen to champion the rights of others. I left Phnom Penh struck by the power of our unified voices and further committed to encouraging and demanding justice and equality for all.

Erika Linnander, GHLI Senior Technical Officer

Unplanned hospital readmissions are estimated to cost more than $17 billion each year for Medicare alone. Across the country, hospital executives, clinicians, policymakers, and researchers search for the best ways to reduce unplanned hospital readmissions. Hospitals are intently focused on this issue, and are joining quality improvement networks and programs to guide their efforts. A dizzying array of tools and best practices are available, but which approaches are in fact tied to reduced readmission rates?

Researchers at Yale’s Global Health Leadership Institute continue to study which strategies work best for providing quality patient care and reducing hospital readmissions. Between 2010 and 2012, they found significant increases in the use of nine frequently recommended strategies among hospitals participating in the State Action on Avoidable Rehospitalization initiative or the Hospital-to-Home Campaign.

The latest evidence appearing in the May 2015 issue of the Journal of Internal Medicine shows that hospitals that incorporated any combination of three or more of these strategies which focused on changes to hospital culture and administration, saw significantly larger reductions in risk-standardized readmission than those hospitals that took up fewer strategies. After adjusting for hospital size and location, hospitals that implemented several strategies reduced their readmissions rates by 0.4 percentage points more than hospitals that implemented fewer strategies. Scaled nationally, this improvement could save the Medicare $400 million annually.

The study findings showed rather than a single recipe, many different combinations of strategies led to similar reductions in readmission rates.

What can health care professionals make of these results? First, there is no silver bullet. None of the nine strategies alone accounted for sizable reductions in readmission rates. Second, the successful hospitals were implementing at least three new strategies to reduce readmissions. Because readmissions have multiple root causes, a bundle of strategies is likely needed. Different hospitals used different means for achieving results. Last, change is hard. Despite their enrollment in major quality improvement initiatives, 70% of the hospitals surveyed had taken up fewer than three strategies during the course of the study.

As a child, I watched people with acute and chronic illnesses coming to the health station located hundreds of meters from our home. My father was a health assistant in charge of a rural government clinic and spent most of the days working in the clinic. He was sometimes called for emergency services during the night and had to travel to remote rural villages when epidemics occurred. My exposure and interest in public health was a part of my life as long as I can remember.

After completing my high school education, I enrolled in the Addis Ababa Centralized School of Nursing. I was assigned to the rural health center Arsi, Robe where I started my professional career as a qualified nurse. There I diagnosed and treated patients, provided maternal and child health services, and vaccinated children at the health center and outreach posts. I was often expected to perform those duties without a supervisor - which challenged me while also giving me the opportunity to make decisions, be confident and broaden my education and experience.

After four years at the rural health center I was transferred to a regional hospital in Arsi, Assela where I worked in several departments and managed a nurses division. I then relocated to Addis Ababa, Ethiopia where I joined the Black Lion Specialized Referral Hospital and served for 15 years in diverse positions. During that time, I also advanced my education and received a B.S. degree in nursing and M.H.A. in Health Care Administration.

I joined the GHLI HEPCAPS Project in November 2013. I appreciate and enjoy the strategic thinking of the program, which aims to strengthen health systems in African countries, mainly through capacity building, training and research. As part of the HEPCAPS team, I work to strengthen primary health care units within the larger health sector in Ethiopia. The time motion study for HEPCAPS and PHCU demonstration project by GHLI are the most rewarding aspects of my work. This project helps us understand how health extension workers in Ethiopia spend their time, and my role includes collecting, monitoring and reviewing this data. The biggest challenge is bringing the people and the stakeholders I work with on board to implement the strategy.

As my work progresses, I hope to continue to improve health systems at the grassroots level and to also develop my skills by working on projects with people from which I can continue to learn and grow.

Rex Wong, Director, GHLI, Health Management and Leadership

Being a manager of global health programs in Africa for more than a decade, I receive many inquiries from young, energetic, people who want to join the world of global health. Apparently I am “living their dreams.” I see equally as many people who were just as passionate only to realize that this work may actually be just that … a dream.

New groups continuously come to this country ready to make a difference. While they enter with good intentions, reality often leads to frustration and, within a year, I see many of them pack their bags and leave vowing “never again.”

Global health can be deceivingly glamorous and brutally demoralizing. During one of my first presentations recommending strategic plans and ideas to the Ethiopian government and hospitals, the stunned faces and you-are-out-of-your-mind looks told me it was not going to be easy. I tried regardless. This year, as I spoke to master in hospital administration students in Ethiopia, the responses I received could not be more different. Not only have the students heard of the systems we’ve taught all these years, many have even implemented them. As a global health worker, I could not have asked for better reward.

Sometimes it’s hard to believe we make any progress, not to mention impact. But I don’t fail to see the improvements we have made - a toilet in the hospital being fixed or a cashier being relocated to a more convenient place for patients. Every now and then, I receive unexpected appreciation from a staff or a patient and that would make it all worth it. We cannot give them more salary or promotions, but we offer glimpses of better future.

Nobody ever said it would be easy or that change would be drastic. Many of us may not stay in a country long enough to see the results, but know all efforts are valuable and we are making a difference.

Drew Weil, 2015 GHLI U.K. Fellow

You don’t have to go far to find a British citizen that is proud to receive health care through the National Health Service. It is one of the country’s sparkling achievements and a system that people from every social class and demographic endear.

My fascination for how the U.K. can care for literally every member of their society so well was what drove me to this GHLI fellowship working for the 12weeks with the East & North Hertfordshire NHS Trust. And subsequently, I wanted to understand what can we learn and apply to improve our own U.S. healthcare system.

My work here is largely focused on improving the care and services provided for frail and elderly people. I believe that the way a country and health system cares for their most vulnerable populations is a good test of its conviction to humanity and civility. In this Trust, there are many stakeholders eager to work towards and progress forward with this aim.

However, with a more diverse stakeholder group, also comes opportunities for redundancies and inefficient work processes. I am able to work with each of these groups – which include community health care providers, social service leaders, NHS commissioners, hospital administrators, physicians, government representatives, and others – to find a common approach to improving care and healing that is provided. I’m excited and feel a sense of accomplishment when I can apply concepts I’ve learned in my Health Care Management coursework and past work experiences. Whether it is interpreting data, discussing the economics of the NHS, or watching the hospital operations in real-time, it is an amazing feeling to see the pieces begin to come together.

Although the weather is typically grey and overcast, the people have been warm and cheerful. It is an inspiring group of people to work with, and it makes it very easy to wake up, be motivated and want to contribute-to and improve their community! “Cheers!”

Geoff Soybel, 2015 GHLI Fellow

The prevalence of childhood obesity in Puerto Rico has been estimated to be as high as nearly 30%. This statistic demonstrates that the youth of the island territory are less fit than their counterparts in some of the unhealthiest areas of the United States. This harsh reality is not lost on locals.

Being in Puerto Rico as a GHLI Fellow, I now see how the eastern Caribbean island, and many organizations, both public and private, are taking steps to alleviate the health burden. The problem is that most efforts are conducted independently, and there are very few mechanisms in place to evaluate their effectiveness. Childhood overweight and obesity initiatives are so disjointed, in fact, that some offices at the same organization are unaware of their coworkers’ contributions to the cause.

This is where GHLI’s Puerto Rico delegation can help. In order to maximize health promotion results, or determine if they are working at all, the delegation understands that local stakeholders must come together. Without unifying efforts toward the same goal, it is impossible to know what accomplishments, if any, have been achieved. In many ways, the work that we’re doing with GHLI is focused on removing our proverbial blindfold, so our path to Puerto Rican childhood health is clearly visible.

My time here in Puerto Rico has been wonderful! The sunny weather is ideal, and my office is situated in the Medical Sciences Building of San Juan’s Centro Medico, which is only a five minute train ride from my lodging, so dealing with the frustrations of a morning commute is a non-issue.

Dr. Capriles, one of our delegation members, brought me to sample the delicious local fare of bacalaitos and alcapurria (salted cod fritters and deep-fried, meat-filled dough). The trip was both enjoyable and educational, as it became clear that the island’s food tradition is one of many factors we must consider to successfully approach local childhood overweight and obesity prevention.

Modupeore Shenbanjo, 2015 GHLI UK Fellow

Before becoming a graduate student at Yale, I worked as a research assistant in adolescent medicine where I observed multidisciplinary teams caring for patients struggling with eating disorders, drug addictions and teen pregnancy. I often heard in my classes at Yale about how the National Health Services (NHS) provides equitable health care at the point of service. And, now I’m able to see firsthand how the East and North Hertfordshire NHS Trust ensures that no one “falls through the cracks” of health care.

In my role as a GHLI Fellow, I have been able to interact with the trust management, divisional directors, general managers, service coordinators as well as consulting physicians to assess surgical theatre efficiency such as investigating reasons for late start times for the first patient of day and blockages to quick turnovers in between patients.

Through various conversations within the trust, it is evident that not only health professionals, but also the general public are proud of their health system and are determined to ensure they continue to meet the expectations of their citizens.

While observing a surgical procedure, I was impressed at how nurses as well as clinical support workers ensured that each surgery had all the necessary equipment and anticipated possible complications. I also noted that even in a specialty as busy as surgery, senior staff members understood the value of good management and leadership to ensure the needs of each staff member is met and to ensure they create an environment that continues to support learning.

I have been able to utilize my past research skills, as well as my knowledge gained from my courses in order to collaborate with consultants and investigate the root causes leading to surgical starts and cancelations. It’s been an exciting, informative journey thus far.

Sequoia Leuba, 2015 GHLI Fellow

Diabetes in Barbados? Not something I had ever thought about before this year. But, when I applied to be a GHLI Fellow, I learned an estimated one in five Barbadian adults has diabetes, and more than 40% of beds in the island’s largest hospital are occupied with diabetic patients. Now I am in Barbados – helping leaders from diverse backgrounds develop and implement a strategy to address this problem.

While several successful programs have been implemented, the fragmented care is unable to address the growing diabetic population. I travelled around the island learning first-hand about the strengths and weaknesses of each program, implementation successes and challenges, and how the program structure could be incorporated in an expanded island-wide approach. After many lively discussions, the Barbados delegation plans to implement a system redesign in public and private primary care clinics. To support this endeavor, I will spend part of the summer evaluating the current state of diabetes and its care in Barbados.

In addition to working, exploring Barbados has led to great adventures. A short excursion to see a delegation member play piano at a local restaurant ended up being an unanticipated undertaking, as going from the restaurant to the boat club where the party was moving involved walking in the drizzle to the boardwalk, and traveling on a dinghy, to a sailboat, to a leaking kayak, to wading in the beach, all in a maxi skirt that kept ripping. Arriving drenched, I was exhilarated – a feeling I consistently have, whether working with a magnificent team or having remarkable experiences.

Wendy-Ann Wattie, Ministry of Health, Trinidad and Tobago

Alcohol is the most widely used, accessible drug in Trinidad and Tobago. It is a risk factor for many non-communicable diseases (NCDs), but is also associated with a myriad of other health and social problems, including the spread of sexually transmitted diseases, violence, accidents, injuries and road fatalities. A group from T&T, comprised of five country participants from the Ministry of Health and the University of the West Indies, recently convened at Yale for the GHLI Forum for Change to discuss the issue of alcohol use and abuse. While we had planned to discuss the relationship between alcohol and NCDs, the team agreed that the damaging impact of alcohol consumption superseded exclusive focus on NCDs and that a more comprehensive strategy was necessary to tackle this problem.

We found the Forum to be a creative, thought-provoking environment at which we could collaborate with not only Yale faculty but also with our Eastern Caribbean colleagues in attendance focusing on their own specific NCD issues. Dr. Rohan Maharaj, principal investigator, ECHORN: Trinidad and Tobago, helped our group involve senior officials and successfully motivate the team. Our strategy discussions and development evolved from early conversations on the complimentary role of followers to leaders and embracing and tackling implementation challenges; to problem solving tactics such as identifying a champion and developing a National Policy on Alcohol, that we hope to implement over the next few months/years.

There were a few unforeseen events that we had to overcome, like skyping our absent T&T countryman to maximize participation benefits and getting prompt health care for our fallen Barbados counterpart, but it was met with an energetic and effective response. After dinners with faculty and staff and an outing at a local orchard, there were clear personal and familial contributions of GHLI and ECHORN members that signaled their humility, grace, sincerity and infectious commitment to achieving the shared purpose of global health.

Chanel Marin , 2015 GHLI Fellow

Colombia has been immersed in an armed conflict for over 50 years. The underpinnings of the conflict have evolved over time, but its consequences have remained the same: mass displacement, violence, and death. The impact of exposure to violence on children in Colombia continues to grow as one of their biggest public health challenges.

I am currently in Bogota, Colombia working as a GHLI fellow with Fundacion Saldarriaga Concha on a project to strengthen resiliency and peacebuilding in children under age five affected by the armed conflict. GHLI is working with the foundation to evaluate the impact of this intervention and my role is to develop, refine, and carry out focus groups and interviews with child caregivers, teachers, and government stakeholders. I work daily with a group of dedicated colleagues who bring me on field visits to witness how the intervention is being implemented.

The visits were an incredible opportunity to meet the children impacted by the intervention. On one occasion I ate lunch with the children and assisted in their play and nap time. They were happy, energetic, and very curious about the new adult at the center. During the visit, I interviewed mothers regarding their experiences with conflict and their children’s behaviors. These brief interactions gave me a sense of how displacement has affected large portions of the population and how this impacts young children.

As my time in Colombia draws to a close, I am grateful to have worked with such a passionate team and to have learned how an intervention is implemented from the ground up. I have experienced the incredible kindness, warmth, and spiritedness of the Colombian culture and will take that with me home.

Gianna Kinsman, 2015 GHLI Fellow

This summer, living in St. Croix studying the challenge that non-communicable diseases pose to the United States Virgin Islands, I soon observed the carbohydrate- and fat-rich local diet that often includes bread, macaroni, pate, or yams. The reality of having to ship most goods to the islands by plane means that produce, like other healthful, perishable food, expires quickly. Many of the restaurants are fast food chains that also provide high fat foods which further impacts my areas of study -- diabetes and hypertension.

Since the individual insurance mandate of the Affordable Care Act does not apply, USVI expanded Medicaid rather than establishing an insurance exchange, but nearly one third of the population remains uninsured. Even to insured citizens, health care costs can pose a significant problem. Although many educational programs about diabetes exist, efforts to implement such a program in the USVI have failed due to a lack of funding and because most citizens cannot afford repeated copays to attend classes. During my time in the USVI as a GHLI Fellow, I hope to help the delegation rectify challenges such as this and other NCD issues.

While working with Frederiksted Health Care and Governor Juan F. Luis Hospital & Medical Center, I collected data on patients with diabetes and hypertension, and also interviewed providers about existing options for management of diabetes and hypertension on the islands. From these interviews, I learned about past community-level programs to educate patients on diabetes management, the burgeoning development of a unified electronic health record, and initiatives to improve overall patient health and the patient-provider relationship, such as brown-bag medication reviews.

I’m enjoying my stay in the USVI and found my role as fellow rewarding as I help my delegation develop a strategy to reduce the prevalence of advanced complications of these widespread NCDs.

Brittany Stollar, 2015 GHLI Fellow

Before this summer, I had almost no knowledge of the structure, the effectiveness, or the political implications of the National Health Services -- the United Kingdom’s health care system. When I joined GHLI as an intern, that quickly changed. My first project involved researching the impact of NHS reform on the recent elections in the UK. What really made this experience special was not just that I was learning about the NHS in greater depth, but I got to hear about certain details first-hand when our UK colleagues visited the Yale campus this summer.

During the week-long Forum, I was surprised to realize how little I really knew about health care systems outside of the U.S. I knew our health care expenditure per capita was much higher than most other countries, but never truly understand to what degree and that we spend more than $2000 beyond that of our closest competitor while still having health outcomes consistently below the average of our peers. I was also shocked by how partisan the Affordable Care Act has been. Unlike in the UK, there is no agreement between the parties on any of the issues raised within the ACA.

Coming from a country that has practiced universal health care coverage since 1948, the UK delegates struggled to understand our political conflict over the ACA. I found myself struggling to understand as well. I hadn’t realized that I’d grown accustomed to debates over the basic human right of available, accessible, affordable, and acceptable health care. While the delegates learned about how to improve the NHS by looking at our system, I learned how we could improve our system by looking at the NHS. During this week, the concept of national agreement on universal health care became less of a myth and more of a feasible possibility.

Yaphet Getachew and Jennifer Mandelbaum,

2015 GHLI Fellows

We often hear parents complain that their kids spend too much time on the internet or they are too lazy to play outside. But, in Brazil, it’s not lack of desire among kids to be active, there is a far more serious reason why physical activity is a challenge – safety.

As part of our GHLI fellowship this summer, we spend time in Brazil observing the Agita São Paulo program – designed to prevent childhood obesity through physical activity. During our first week in Brazil, we visited the island of Ilhabela to learn about efforts in both elementary and middle schools to help kids be more active.

We met with representatives from the Secretary of Education and learned about the very real barriers to physical activity facing children on the island. For example, even though they’re surrounded by water, the majority of children and their parents on the island do not know how to swim. Parents worry about violent crime, causing them to keep their children indoors most hours that they are not in school. And, so the only real safe space students have to exercise is within the schools. This leads many children to spend their free time playing video games or watching television and being sedentary instead of playing sports outside with their peers. Students are typically only in school for half of the day, leaving many hours of unscheduled time, which is why the development of active after-school programs is crucial.

Given these barriers to physical activity, Ilhabela has made strides to provide outlets for physical activity in schools. For instance, the schools we visited had recently built an athletic facility, which included a basketball court and a pool. Our visit to the schools gave us a much clearer picture of the physical activity environment theses kids can access and helped us develop recommendations for Agita’s future programs. Maybe more importantly, we observed how a community bands together to tackle a major problem for its children.

Gerneiva Parkinson, 2015 GHLI Fellow

History, culture, tradition and income. When I was growing up in this beautiful twin- island, Trinidad and Tobago, these were some of the associations used when talking about rum and other alcoholic beverages. Being a former sugarcane colony, alcohol is integrated into the rich heritage of this country. As a result, alcohol consumption is very popular within the country – with that brings alcohol-related health issues.

Islanders are prone to high rates of binge drinking, and there is an alarmingly high alcohol usage among the adolescent population. Despite these issues, there is little in place to restrict or control alcohol use and subsequent abuse. As a GHLI Fellow, this summer I worked with with members from the Ministry of Health and a university to develop a national policy and action plan to control alcohol use and decrease its harmful effects on society. Daily, we pooled together research on past alcohol studies to create evidence for our policy draft. We also reached out to other government, regional and non-profit groups to spread awareness and ultimately create an alliance towards alcohol control.

Alcohol will always be a part of T&T's heritage, but we can find ways to make its use safer and more responsible. I look forward to working with this fantastic delegation for the next year, as we usher in a new policy for alcohol regulations. It has been wonderful to see the various delegates with different backgrounds and skill sets collaborating for one cause; forged from a unifying love to see our country flourish safely. With my career interests surrounding NCDs in the Caribbean region, this opportunity as a GHLI Fellow has been a unique and absolutely magnificent experience here at Yale.

GHLI research associate, Dr. Netsanet Fetene was inspired to pursue a career in medicine to help the ill people, especially children, he observed in Ethiopia. “Many of deaths in Ethiopia were caused by treatable, even curable diseases,” explains Dr. Fetene, “this was something I just could not overlook.” Motivated by his strong will to make a difference in his community, Dr. Fetene went on to study medicine at Addis Ababa University.

Dr. Fetene’s commitment to improve the lives of those around him has been evident since the beginning of his career. As a practicing medical doctor in Ethiopia hospitals, he quickly realized his work could have an even greater impact if he focused on the field of public health. This led him to become involved in with some of the world’s preeminent public health organizations such as the World Health Organization. Dr. Fetene believes that research, management and leadership programs are the key to strengthening a nation’s health system – and in turn, strengthening a nation’s overall health.

Prior to working at GHLI, Dr. Fetene worked on capacity building projects for the reproductive and primary health care teams in South Sudan, Pakistan and Sudan. There he established protocols and systems for drug management, developed reporting tools, and implemented case management based on Ministry of Health and World Health Organization protocols.

As part of GHLI, Dr. Fetene enjoys translating research into actionable results that help solve health problems in his community. While Dr. Fetene and the GHLI team have achieved great success in Ethiopia, he believes that there is still much more work to be done. A slow response to change in disease patterns related to population growth and urbanization is just one of the many challenges he and the team in Ethiopia face. Additionally, making health care facilities ready to provide quality health care services and allow the community access to standardized and equitable health care remains one of the biggest global health problems today. Still, Dr. Fetene remains optimistic that the work GHLI does is an integral part of overcoming these challenges and looks forward to continuing to serve his community in the field of public health.

Amanda Brewster, Ph.D., GHLI research and education associate

Health care professionals constantly invest time, effort and expense trying new methods to improve care only to see promising innovations evaporate rather than become part of everyday work habits. When this happens, hospitals miss potential performance improvements, waste money and time, and feed quality improvement fatigue among staff.

New evidence published in Implementation Sciencefrom the Yale Global Leadership Health Institute shows that there are predictable patterns in what it takes to make change “stick.” Reviewing data from hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, GHLI researchers examined different strategies hospitals tried to reduce readmissions.

The research showed that getting new practices integrated depended on how the integration process was executed. When hospitals appointed staff to oversee that a new practice was performed regularly for several months up to a year, more permanent integrating mechanisms had time to start working. Staff had a chance to feel direct benefits from the new practice – like greater job satisfaction or less stress – which motivated them to keep doing it even without close oversight. Or failing that, job expectations had a chance to catch up with the new practice, making it a non-negotiable part of work.

What should hospital leaders make of these results? Truly integrating a new practice takes patience and extended effort over time. And, staff members’ own desires to improve patient outcomes can give a powerful boost to quality improvement. Ensuring that staff responsible for implementing a new practice have the opportunity to see the positive impacts – through data feedback as well as personal interactions – can enlist them as partners in integrating the innovation into the permanent fabric of the organization. Finally, the work does not ever go on auto-pilot, but incorporating the effort into ongoing management oversight efforts allow champions to move onto the next burning platform.

Kim Miyauchi, Chief Nursing Officer
Kingman Regional Medical Center, AZ

Saving the lives of heart attack patients is one of the biggest challenges for hospitals. When every minute counts, we all need to be looking at the same clock…that is one of the key messages our hospital learned when we examined mortality rates of patients with acute myocardial infarction (AMI).

Kingman Regional Medical Center (KRMC) discovered that sometimes the simplest solutions can be the keys to saving lives. As part of the Leadership Saves Lives program, KRMC partnered with the Yale Global Health Leadership Institute and we were challenged to examine our hospital culture and treatment methods for patients with AMIs. We were part of 10 U.S. hospitals involved in the two-year program to determine causes of high AMI mortality rates.

To reduce the AMI mortality rate at KRMC, we examined several possible determinants and honed in on three: 1) timeliness of EKGS; 2) protocols, pathways and guidelines; and 3) discharge process. We first addressed the causes by encouraging more teamwork. We created committees to examine each of the three causes contributing to our high AMI mortality rate. As teams engaged with each other and with other hospital staff they were better able to understand how and why goals weren’t being met and how to improve the results.

For example, a large number KRMC patients arrive at the hospital by private vehicle – delaying the electrocardiogram (EKG) process that normally would take place in an emergency vehicle. Kingman Regional Medical Center strives to complete EKGs within 10 minutes of an AMI patient’s arrival. However, when we reviewed patient charts, we discovered our EKG completion times were inconsistent and recorded times depended on which clock a staff member was using. We had eight clocks in the ER and they were not synchronized. This had to be addressed to improve patient care.

Our hospital replaced all of the ER clocks and synchronized them with our computer system. This simple, inexpensive solution, along with its other efforts ended up significantly improving timeliness of care. Although all of KRMC’s process changes were not as simple as replacing clocks, we have already seen the efforts paying off with a decrease in AMI mortality rates.

Itumeleng Ntatamala, M.D., Community Service Medical Officer

Working in a lower income country’s public health sector is usually fraught with challenges, but this work can be equally fulfilling when a smile is shared…or a life is saved. It was in my first year as a medical intern at Mokopane Regional Hospital in rural South Africa that I found myself faced with either giving into an inefficient system or helping to transform it. Being selected to partake in the Advanced Health Management Programme (AHMP) and Yale University’s GHLI, was life changing as it jump-started an exciting journey of profound self-discovery and professional development.

The AHMP approach to health management is the concept of action research, which requires identifying challenges and then conducting research and continuous self-inquiry to solve those challenges. It was this approach that forced me to reflect on why I was concerned about health systems and how my own values tied into this work -- a far cry from my previous notion of leadership that oft times neglected the self and only focused on “getting the job done.” I undertook a collaborative hospital renovation project that saw our hospital’s pediatric ward -- which was originally designed for adult patients -- morph into a conducive healing environment for children with the support of colleagues, local business and interested community members. Colorful murals and paintings adorned previously dull walls, a kitchen was built to teach parents about healthy ways to prepare children’s food and a secure playground was erected to the children’s delight. The Limpopo Province recognized the transformation of the ward with the Limpopo Province Premiers’ Service Excellence Silver Award for “Innovation in the Public Service.”

As I reflect on this past year, I started out as a frustrated young health professional in a small town and am now a confident professional with the skills and capacity to lead an award winning team to help improve hospital efficiency and patient care. I am grateful for this work and the group of people with which I get to work. Each day I have the opportunity to redefine my concept of health leadership.

Leslie Curry, Ph.D., Senior Research Scientist, Yale Global Health Leadership Institute

Well-intentioned and smart scientists devote their careers to generating new knowledge they hope will benefit the health and well-being of the population, and ultimately, save lives. The discouraging reality is that only a small fraction (14%) of original research findings are published in scientific journals, and those findings take an average of 17 years to integrate into health care practice and policy.

Scientists are growing impatient with the gap that currently exists between moving research into practice, and have begun to question whether traditional journals are the best way to accomplish this goal, especially in an era of rapid information dissemination through online and social media outlets. Long publication processes can render findings obsolete before they are even known, the narrow readership of journals consists mostly of like-minded scientists and the static, one-way medium publication format prevents constructive critique and debate that is essential for good science.

What can be done to best reach appropriate and wider audiences with research findings in a timely manner? The good news is that, in addition to journals reinventing themselves, there are emerging alternatives. First, the digital communication revolution provides extraordinary opportunities to reach large diverse audiences through dynamic formats such as social media, websites, blogs and online platforms like Tumblr and YouTube.

In addition, the emerging new scientific disciplines of knowledge translation and implementation science focus on how to move science out of the lab and into the world. Finally, where advocacy has historically been forbidden among scientists, many are mobilizing to bring pressure for research to be more transparent and widely accessible. As a research community, it is our responsibility to leverage these three trends – digital communication, the field of implementation science, and advocacy -- to shrink the gap between research and practice and make our research matter. #Reachingwideraudiences.

Growing up in Southern Arizona near the Mexican border, Marguerite Callaway was exposed to many cultures, which ultimately influenced her decision to pursue graduate education in international nutrition, cognitive and developmental psychology, and business. Her career includes position in executive leadership and and partnerships in several international management consultancies, which led to Callaway founding her own leadership institute.

Callaway currently partners with the GHLI on the Advanced Health Management Program in South Africa. In this role, Callaway says she had to find the balance with her sphere of concern (global) with her sphere of influence (local).

Callaway shares three insights she has learned in her years as a health care professional: 1) Unfamiliar circumstances often cause discomfort. The more aware we are of how core beliefs affect our personal and professional behavior, the greater our capacity to excel in the global community; 2) When working across cultures, our preferred method may seem efficient, but these assumptions can create barriers to ingenuity; 3) Good intentions and the right motivation are important, but practical skills are a necessity in the health care field.

Callaway emphasizes that the success of any health care initiative depends on how well we listen and adapt to meet the needs of our beneficiaries. She notes that GHLI staff hear what our partner’s goals are and don’t apply ‘cookie cutter’ solutions to its various programs around the globe. She says that workers/educators “from the outside” can offer insight, tools, and, especially, encouragement to help local partners carry the work forward. She cites GHLI’s South African partner, the Foundation for Professional Development, of which several of the training course graduates have gone to leadership positions with the provincial departments of health.

When asked what she likes most about her work, she offered: “being involved with GHLI long enough to see many of the graduates of our programs move into ever-greater positions of responsibility and impact. I am inspired by each new group of men and women who enroll in our management training programs. I know the GHLI model of engagement works.”

Simon Bragg – Executive Director of Finance and Resources, East Coast Community Healthcare

Now back in the UK, reflecting on my recent participation in the GHLI Health and Social Care Strategic Leadership Programme at Yale – I am thoughtful of the takeaways from my experiences with both the mental – and physical – aspects of my visit.

I could wax lyrical about the softer benefits of the programme; the contacts made, the relationships forged and the cathartic nature of shared experiences. It can be incredibly reassuring to meet like-minded individuals battling similar issues elsewhere in the health system. There is nothing like applying raw theory to a practical situation to embed the learning – and from the presentations provided by the course participants it was evident that our class had taken away a great deal from the course – not only about each other, but more about themselves!

The UK and the US are rather languidly referred to as nations divided by a common language, which works on the level of two health care systems divided in their foundations but united by a common purpose and sharing common issues. The excellent site visits to regional health care facilities demonstrated that although hospitals seem to face some of the same challenges in both countries, the patient experience is at the heart of everything that we do. The systems appear to be as similar as they are disparate.

I was inspired by the demonstrable, and personally evidenced, the important link between physical health and mental wellbeing on my professional performance in a leadership role. Early morning exercise sessions were arranged for course participants and both me and my rapidly tightening muscles were heartened to learn that my invigorated metabolism continues to burn calories for many hours after exercise itself has ceased. Like the continued burning of calories following exercise – the GHLI programme promotes the survival of mental acuity by delivering both an immediate intellectual perspective as well as a slower burn of on-going inquisitiveness; in short a full-on cerebral workout.

Medha Vyavahare pictured on the far right with colleagues

during a field visit in Clarens, South Africa

Truly Understanding Health Systems Strengthening

Medha Vyavahare (YSPH ’17),
GHLI Intern

As a GHLI intern, I recently traveled to South Africa to learn about the Chronic Centralized Dispensing and Distribution (CCMDD) Initiative—a national effort to improve access to medicines for South Africans with chronic diseases.

When I learned about the necessity of system-wide approaches in global health as a public health student at Yale the term ‘health systems strengthening’ seemed vague. It wasn’t until I got to South Africa that I realized the nature of system change.

Patients diagnosed with HIV or other chronic diseases face significant challenges accessing their medications in South Africa. Congested public clinics, long waiting times, and stock outs are common. Many patients take days off work to get their medications in crowded clinics—sometimes to find the medicines aren’t even available.

Project Last Mile—a partnership applying The Coca-Cola Company’s supply-chain expertise to public health systems across Africa — works with the CCMDD to expand the availability of medicine across South Africa. Project Last Mile collaborates with the government and local non-profit organizations to create convenient pick-up-points for medicines in grocery stores, post offices, and other community locations.

Though restructuring wasn’t easy, what I saw in South Africa was impactful. I visited public pharmacies starting to receive shipments of the new, neatly packaged individual parcels of medicine. Through the use of mapping tools and strategic thinking, more accessible pick-up points were identified based on patient demand – a very exciting outcome for the resident pharmacists. There was a pervasive optimism about the program—one pharmacist remarked that the CCMDD was a transformation of the pharmaceutical industry.

The program still faces implementation challenges, but I believe that the emerging health system in South Africa is stronger. The nation’s openness to change makes me hopeful for meaningful improvement on patients’ abilities to lead healthier lives.

Call me Shelemat

Why We Do What We Do: Dawit Tatek

Why We Do What We Do: Nikole Allen

Leadership Towards the Advancement of Human Rights

Reducing Hospital Readmission Rates -- What Really Works?

Why We Do What We Do: Halima Mohammed

Never Again or Never Give Up? The Reality for Global Health Workers

“To be amongst the best…”

Uniting for Childhood Health in Puerto Rico

“Providing Equitable Health Care the U.K. Way”

The Challenge of Treating Diabetes….in Barbados

Treating Alcohol as an NCD

Children and Armed Conflict in Colombia

Diabetes and Hypertension in the USVI

UK and US Health Systems: Can we Learn From Each Other?

Safety’s Impact on Physical Activity in Brazil

Addressing Alcohol Use through Policy Implementation

Why We Do What We Do: Netsanet Fetene

Hospital Change -- How to Make it Stick

When Every Minute Counts, Even Minor Details Matter to Patient Care

Redefining the Concept of Health Leadership

Moving Research Beyond Journals

Why We Do What We Do: Marguerite M. Callaway

The “After Burn” of Lessons Learned in Hospital Administration

Article 0