Namibia ranks fifth in the world for HIV prevalence, with nearly 230,000 people — nearly 10% of its 2.5 million-strong population — living with HIV. In this sparsely populated and largely rural country, chronic doctor and nurse shortages impede the likelihood of people receiving care.
In 2015, the Namibia Ministry of Health and Social Services took the bold step of piloting the first example of a program called Project ECHO (Extension for Community Healthcare Outcomes) in Sub-Saharan Africa, supported by funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR), which sought to change that by expanding expertise to health administrators in rural areas.
Here’s how the program seeks to transcend location constraints to transform how medical training is delivered in various contexts around the world.
Launching Project Echo
Project ECHO’s story began in 2003 in Albuquerque, New Mexico, where thousands of people with hepatitis C were not receiving treatment because the desert city had a lack of specialists with knowledge of how to treat the disease.
In New Mexico, specialists were all located in urban centres so people living outside large cities had to travel a significant distance to get the 10 to 12 treatments Hepatitis C required — that was after six to eight months wait times for treatment.
Sanjeev Arora, a liver doctor in New Mexico who treats hepatitis C patients, channelled his frustration with the provider shortage into developing Project ECHO in 2003 to create a larger community of local providers who could be mentored to provide high quality best practice care for hepatitis C within their communities.
He made a case to providers in rural and underserved communities whose patients were dying from a disease that had viable treatment options: spend two hours a week working closely with him and a team of experts at the University of New Mexico Health Sciences Centre until they were able to treat people on their own.
In 2004, the University of New Mexico’s (UNM) Center for Digestive Diseases Clinic, the main source for Hepatitis C treatment, treated approximately 100 patients per year. Project ECHO and its partners treated 1,100 patients a year in 2016, while the UNM Center for Digestive Diseases Clinic increased to 250.
Expanding a network of specialists
Rather than requiring health providers to attend structured courses that often have stringent schedules, Project ECHO permits health care providers to work virtually and on their own timeframes.
It works across public and private health centres as well as providing interprofessional learning so physicians, community care workers, pharmacists, nurses and laboratorians can all benefit.
Project ECHO learners follow a curriculum using short lectures for “low dose, high frequency” learning that is interactive and participatory. ECHO participants are encouraged to engage for months and years for continuous learning. The courses also use case-based learning to help providers solve practical problems they have encountered in their daily work.
National and local specialists within the country where the program is being run are responsible for providing their subject matter expertise, but can also draw on regional and international experts as needed.
Project ECHO programs are being implemented by more than 300 partner organisations in 35 countries for more than 70 different health program areas, including addiction treatment in areas with high opioid addiction rates in the United States, and to train mental health service delivery workers in Mumbai.
Bringing specialists to Namibia
Namibia, a Southwest African state bordering the Atlantic, is sparsely populated and although there have been some urban developments, it is largely rural. But doctors are largely stationed in predominantly urban areas, which means people have to travel a long way to seek treatment.
A significant shortage of health workers is also a problem. Prior to 2010, medical students had to travel outside of the country to receive medical education because there wasn’t a medical school. According to the WHO Global Health Observatory, Namibia has 0.4 doctors per 1,000 people. In the UK there’s 2.8.
The Namibia Ministry of Health and Social Services [MOHSS], in collaboration with the US Centers for Disease Control, Project ECHO and a number of other implementing partners, and with funding from PEPFAR, developed the first Project ECHO pilot in Namibia in order to test the feasibility of bringing HIV treatment to marginalised, rural communities that were experiencing a shortage of HIV specialists.
The pilot consisted of 24 weekly video-teleconference sessions between November 2015 to September 2016. Leading experts in the HIV field in Namibia used Project ECHO to connect with regional clinical mentors, doctors, nurses, pharmacists, laboratorians and health assistants from 10 clinical sites across the country that supported the care and treatment of over 60,000 people living with HIV
The sessions included a combination of brief lectures, case presentations and interactive discussion.
According to a study of the pilot, participants earned more credits for new specialisms than they had previously. Knowledge levels related to HIV care and treatment increased over the course of the pilot, particularly for nurses, and health care workers felt confident that they had acquired the skills and knowledge from HIV experts to treat patients. They also reported that greater opportunities for peer to peer interaction was more motivating.
“Overall, participants reported improved self-efficacy in managing HIV patients, increased professional satisfaction and reduced professional isolation,” stated the report, published by the MOHSS in December 2017.
The Namibian project has since expanded to 40 hospitals and health centres that care for over 140,000 HIV patients.
Bruce Baird Struminger, a Senior Associate Director of the ECHO Institute, said that building a community that spans geography is central to the model.
Struminger, who is also Associate Professor of Medicine in the Division of Infectious Diseases at UNM, added that having local and national leaders leading the program empowers the agency of local experts to train community practitioners so that they can treat complex health conditions within their own clinics.
“Education is the most sustainable development intervention that the US government or any development organisation is able to do,” he said. “If we educate someone and leave, that remains.” – Amelia Axelsen
(Picture credit: Pixabay)