The jhpiego logo, a j with a semicolon. Tagline reads: "Saving lives. Improving health. Transforming futures."

Jhpiego: The Benefits and Challenges of Involving Political Leaders in Medical Training Efforts

Cover image courtesy of jhpiego.

–by Logan Cates and Evan Rabb–

Jhpiego is a non-profit health organization affiliated with The Johns Hopkins University in the United States; it focuses on providing low-cost, effective health care to women and their families in the developing world, including numerous African countries. Dr. Theodore M. King founded it in 1974 with the intention of sharing knowledge about advancements in women’s and maternal health with health care professionals in developing countries. Today, with funding from both the public and private sectors, Jhpiego’s employees focus their work mainly on women’s health issues and reproductive health policy, while also working to address issues like infectious diseases and HIV/AIDS. To carry out its goals, Jhpiego uses trained professionals to travel to developing countries to train other healthcare professionals, spreading knowledge and skills in a seemingly sustainable way. This report will investigate various issues with this critical health care intervention in Africa, including hurried, cursory training methods used with employees and lack of consensus between healthcare field workers and high-level stakeholders. Furthermore, this report will examine the extent to which Jhpiego’s “urge to help” translates into helpful, truly sustainable healthcare methods in the communities in which they intervene.

Introduction

Founded in 1974 at Johns Hopkins University with funding from United States Agency for International Development (USAID), Jhpiego is a global non-profit organization focused on health issues in over 155 countries with a mission to improve the health of women and families in countries with a need for strengthened healthcare systems.[1] Jhpiego, originally an acronym for the Johns Hopkins Program for International Education in Gynecology and Obstetrics and now just written as “Jhpiego,” states on the “Our History” document on their website that the organization was initially founded to address a need to raise awareness of reproductive health breakthroughs with medical professionals in developing countries.[2] The organization started off by holding training sessions in the United States on family planning and reproductive health before expanding to other countries in 1979, starting with Tunisia, Brazil, Kenya, Nigeria, Thailand, and the Philippines. In 1993, Jhpiego established its first field office; it now has field offices in more than 30 countries globally.

As the organization expanded geographically, Jhpiego’s programs also expanded beyond family planning and reproductive health to encompass infection prevention and control, maternal and child health, infectious diseases, HIV/AIDS, and even reproductive health policy. Jhpiego now collaborates with both health professionals and governmental and community leadership in various countries where they have field offices. Jhpiego works to develop strategic planning initiatives to help countries get to a stage where they can most effectively care for themselves. In addition to developing health care systems, training workers, and improving the quality of services, Jhpiego works to find new health care solutions to reduce costs and increase effectiveness of care. According to the organization’s website, “these practical, evidence-based interventions are breaking down barriers to high-quality health care for the world’s most vulnerable populations.”[3] The goal of these efforts is to ensure that the many people who are not readily and easily able to access necessary services have those services made available to them more locally.

One of the primary ways Jhpiego works to expand local health care for women and families is through training and education of local health workers from doctors and nurses to midwives and community health workers. Training procedures even offer solutions for community health workers to implement on-site in a patient’s home so that women and their families are able to be treated together. Specifically, in regards to maternal and child health care services, Jhpiego works to train nurses and midwives to be the primary service providers for mothers and their newborns. This has manifested in several programs from USAID starting in 1998 with the MNH Program and progressing to the current Maternal and Child Health Integrated Program (MCHIP), which has an added focus on child healthcare in addition to maternal and newborn health care. Through its efforts, Jhpiego maintains a goal of being able to leave the countries in which they intervene after helping establish developed health care systems and networks of service providers that can continue to grow and prosper after Jhpiego leaves. However, while training and stakeholder involvement are two of Jhpiego’s greatest areas of emphasis, neither is entirely effective in fulfilling their purposes. Jhpiego’s training methods do not always result in very effective practices upon graduation, which reduces the productiveness of their work in saving lives. Additionally, stakeholder involvement ultimately results in slower implementation of initiatives and potential barriers for health care professionals to go through to provide care. Jhpiego’s training methods and business model could be improved in order to create more effective change in the local communities’ healthcare systems.

Jhpiego in Ghana

Jhpiego’s involvement in several Sub-Saharan African countries’ health facilities focuses on newborn and maternal care. Making the health of women in the community a priority and focusing on the specific care of women and children can help prevent many of the serious public health issues that greatly affect these areas. For example, the countries of Ghana and Tanzania struggle with high newborn and maternal mortality rates resulting from preventable complications with preterm birth and infections.[4] This high level of maternal mortality highlights an unmet need in the community for expanded access and improved quality of antenatal, labor & delivery, and postnatal care services.[5] By focusing on improving women’s healthcare, several issues such as population growth, low contraceptive use and high mortality rates can be remedied.

In the past few decades, Jhpiego has worked alongside local governments in these countries to expand and develop training programs in their health care facilities. Since the 1980s, Jhpiego has collaborated with Ghana’s Ministry of Health to help strengthen and develop its national inservice training program, and since 1995 it has been funded by private donors to continue its government partnership.[6] Ghana’s government has been committed to curbing population growth and mortality rates, and increasing levels of consistent contraceptive use, and Jhpiego’s goal is to work alongside the government to achieve these goals through nurse and midwife training services. This is achieved through stakeholder meetings, in which various prominent donors, health care workers and community members discuss the needs of the community and the gaps in education and training that need to be addressed most urgently.[7] This stakeholder involvement helps to ensure that the program is culturally appropriate, since stakeholders are typically members of the local community, and also helps to ensure the continued function of the training programs after Jhpiego is no longer involved.

In order to help reduce infant and maternal mortality rates, Jhpiego partners with the Ghanaian Ministry of Health to strengthen the preservice education of midwives and nurses in women’s healthcare facilities. Reducing the maternal and infant mortality rates requires skilled midwives and nurses capable of applying up-to-date training and information to their work, and increasing quality of family planning services requires well-developed counseling skills. In order to address the gaps in education and training contributing to troubling public health statistics, Jhpiego and the Ghanaian government have worked to implement a standardized training curriculum and provided resources and materials to reduce barriers resulting from underfunded facilities.[8] This standardized curriculum is developed with cooperation from the stakeholders, and is implemented in health facilities throughout the country. This promotes cooperation among local healthcare facilities, as they are able to share information and resources more easily since they all receive the same training.[9] This curriculum development and improved clinical practical experience since the beginning of its intervention has improved the education of over 8,400 nurses and midwives in Ghana alone.[10]

Jhpiego utilized a control group study meant to prove the value of its interaction providing updated training to Ghana’s healthcare workers. As with many control group studies, this effort to prove Jhpiego’s worth in the community meant that vital training and skills were deliberately withheld from various sectors of the community that could have benefitted from them. This control group study was done in order to measure and examine the effects of Jhpiego’s interaction in Ghana’s healthcare service training methods, to determine whether or not the training was worth expanding into more healthcare centers. In this study, updates in training and resources were implemented into schools and training centers in “phases”; Phase 1 included development in two midwifery training schools, as well as the Korle Bu Hospital in Accra.[11] Phase 2 would include an expansion to an additional three schools, and Phase 3 includes expansion into 5 more schools throughout Ghana. It was already widely accepted that the training provided valuable knowledge and skills that could only help the local population, but the test was done to prove just how effective the training really was. The development of the program in each phase included training clinical teachers and tutors with the most up-to-date knowledge and skills and an introduction of competency-based training materials.[12] In followup visits, surveys and examinations were given in order to assess the effects of intervention and performance of the teachers and tutors and also to make recommendations for further levels of expansion. These studies demonstrated that overall, across various categories, the nurses and midwives in the intervention group performed better than in the control groups (the schools that did not receive the standardized trainings). By withholding the training in various phases of the study, Jhpiego was able to show that their training methods were more effective than past trainings; they also put many patients at risk during the study–the control group communities whose nurses could have been training and developing life-saving skills during that time.

Jhpiego’s work with the Ministry of Health in Ghana has expanded knowledge and skills amongst health care service providers, which in turn strengthens the response to public health crises and concerns in the field of women’s health, but the extent will be explored in the analysis section. In addition to developing training curriculum to combat overall maternal and newborn health care concerns, Jhpiego also works with community health leaders to assess and develop responses to specific concerns that may be contributing to public health issues. These developments strive to address all possible barriers to access of quality care and remedy problems that lead to public health concerns.

Jhpiego in Tanzania

One such program works to foster Respectful Maternity Care (RMC) in medical facilities in Tanzania, in conjunction with Jhpiego’s Maternal and Child Survival Program (MCSP). The MCSP focuses on both the major direct causes of maternal mortality, including postpartum hemorrhage, preeclampsia and prolonged labor, and the indirect causes, which can be many and varied.[13] It has been proven that birth in a medical facility, barring other conditions such as transportation issues, is safer and has fewer health consequences than a home birth. Promoting childbirth in health facilities is a main focus of various Tanzanian health programs to remedy indirect causes of maternal mortality.[14] However, it has been determined that mistreatment, such as abuse or harassment, by doctors or nurses during the childbirth experience causes a deterrent to birthing in a medical facility, prompting expectant mothers to choose to give birth at home instead.[15] In fact, many women deliberately bypass their nearest primary care facility in favor of a more distant one because of concerns about the quality of care at government dispensaries and health centers.[16]

Jhpiego recognized this as a barrier to quality maternal and newborn healthcare and strove to address it in order to promote delivery in medical facilities by implementing RMC training into its curriculum. However, Jhpiego faced challenges at both the societal and health system levels, such as structuring a functional training program, convincing community leaders of the gravity of the issue and courting stakeholders.

The main issue is that stakeholders had to be convinced that this is a serious issue in the maternal health care field, and that it was worthy of devoting resources to. The Maternal and Child Survival Program in Tanzania is a $32 million program that affects over 5 million people, so serious consideration must be given to what and where resources are given.[17] Jhpiego in Tanzania worked as policy advocates in order to bring this issue to the attention of key partners such as the Ministry of Health and Social Welfare in order to implement necessary RMC training into the MCSP. The process to implement this training involved a consensus on an evidence-based approach and gaining the approval of the Ministry to implement the intervention.

Jhpiego has been unable to successfully implement this RMC into their MCSP training curriculum after facing great challenges in gaining an overall Ministry consensus that is necessary for implementation. A reliance on private donors and stakeholders means that framing of new problems and healthcare concerns must be in such a way that they see it as beneficial to incorporate into the program, usually as a political move. This can stand in the way of beneficial public health development and is a barrier to improvement when political gain conflicts with health improvement. Jhpiego found during conversations about the mere existence of abuse and neglect that there was no collective agreement among partners, officials of the Ministry of Health, and among community members about its relevance.[18] There is also no straightforward method of developing an RMC intervention program that aligns with existing training models. They also found an element of discomfort during discussions of this issue from community members and professional leaders, resulting from societal differences. Jhpiego suggests that field workers may have experienced disrespect in their personal lives, and in professional areas people may have been socialized to behave disrespectfully, even if unknowingly.[19] This causes some uncomfortable personal reflection amongst stakeholders that can make consensus and implementation extremely difficult, and is a unique issue not usually confronted with other public health problems. While these interactions with government and district-level authorities were difficult, partnerships with other agencies such as the Tanzania Midwives Association (TAMA) were easier and necessary for successful implementation, as they provided valuable practical knowledge and skills.[20] Overall, Jhpiego’s reliance on private donors and stakeholders has proven to be a barrier in the implementation and development of valuable public health training curriculum.

Training Methods with Healthcare Providers

One of the biggest goals of Jhpiego is to ensure health care providers are equipped with the necessary skills to best serve their local communities. Jhpiego works to prepare providers adequately through various training sessions, offering tools for implementation of training skills and methods, and performing follow up to trainings to assess results. To participate in training sessions, individuals must complete a Participant Registration Form. Jhpiego’s Sample Participant Registration Form indicates specific qualifications that Jhpiego looks for in participants, including the participant being a current health professional in family planning services, such as nurses, midwives, paramedics, and physicians. Additionally, this registration form includes an evaluation form for trainers to assess the abilities of participants pre, mid, and post-training, though the only criteria the form gives is whether or not the participant is competent enough to provide relevant clinical services.[21] Participants also have the opportunity to assess their trainers using an Evaluation of Clinical Trainer form, which uses a Likert scale to assess performance. The form puts a strong emphasis on the interpersonal skills of the trainer.[22]   Along with these trainings, Jhpiego offers tools to participants for implementation of skills. For example, as a part of the Maternal and Child Health Integrated Program, USAID created the MCHIP Pregnancy Wheel, seen below, for healthcare providers in Africa caring for expecting mothers. The tool is used to help determine gestational age of clients and steps that should be taken during each client visit. [23]

One specific Jhpiego training program for women and newborn-focused health care providers targets threatened preterm birth care to better the outcomes of preterm births in accordance with recommendations from the World Health Organization. This is a two-day long course (totaling twelve and a half hours of teaching) in English and designed for healthcare workers that provide care for women at high risk of delivering prematurely in an effort to improve survival rates.[24] The materials of the program are meant to be implemented specifically in hospitals that meet four conditions: providers must be able to accurately estimate gestational age and/or determine when accurate estimation cannot be made, providers have the ability to accurately diagnose the four key conditions that lead to preterm birth, adequate postnatal care for preterm infants must be available, and maternal infection must be able to be identified and treated quickly and effectively. The primary focus of the training program is the identification of women who are likely to deliver their preterm baby within the ensuing seven days and the steps to be taken to improve the likelihood of survival before the baby is born.[25]

In 2003, Jhpiego issued a technical report documenting the evaluation of midwives’ skills and knowledge in Ghana two years after they had graduated from training programs meant to improve their basic knowledge and skills.[26] The report followed preservice education in family planning/reproductive health (FP/RH) and essential maternal and neonatal care (EMNC) programs that were implements in three phases across twelve midwifery schools. The implementation of programs was divided into Phase 1 with two schools, Phase 2 with three schools, and Phase 3 with seven schools.[27] In the study, as the programs where implemented in Phase 1 schools in 2000, Phase 2 and 3 schools were left as controls. Following graduation, Phase 1 graduates were assessed in comparison to the control group graduates. The programs were subsequently implemented in Phase 2 schools and evaluated and finally Phase 3 schools, which were then evaluated. Jhpiego concluded that midwives trained under the new programs showed greater clinical skills and knowledge in comparison to midwives trained under different methods. [28]

Overall effectiveness of the programs comes into question when assessing the unmet need for family planning services and contraception education after childbirth. Jhpiego devotes much work and resources to collaborate with local communities to increase the quality and scope of maternal and newborn care. However, once these services are provided, there is a great unmet need for family planning skills and contraception in the postpartum period.[29] This lack of information regarding family planning affects the very problems of population growth and unplanned pregnancies that the local governments and Jhpiego are working to correct, and yet they do not consider this part of their work for maternal and newborn care. A more comprehensive approach to maternal and newborn care that ensures needs are met before, during, and after pregnancies in families would lead to overall better public health policy and development and would ensure that Jhpiego is truly benefitting the communities they are working in.

Consequences of Stakeholders and Government Involvement

A key aspect of Jhpiego’s intervention in healthcare practices is stakeholder involvement. These stakeholders come from various backgrounds, but can include partners in implementation, officials of the Ministry of Health, various authorities at district, facility and community levels, and donors.[30] Stakeholders are involved throughout planning, decision-making and implementation processes, as discussed earlier in the section on Tanzania.

This involvement with stakeholders and the government sector can be beneficial. The involvement of stakeholders ensures that programs are culturally appropriate and relevant.[31] Utilizing the opinions and knowledge of local community health leaders and national policy organizers can help verify that proposed practices and trainings will actually benefit the communities that they’re meant for. Working closely with the opinions of local community leaders will ensure that programs are meaningful and helpful within those communities. Additionally, this helps ensure that the implemented trainings and systems will last once Jhpiego ends its involvement. Jhpiego is an organization that relies on donors and government grants, thus resources are finite and focus is directed onto different programs and regions as need arises. Eventually, Jhpiego’s involvement in certain areas will diminish, and it will be up to the communities and the stakeholders to continue the work that was done. This is one of the ways in which Jhpiego creates sustainable impact in communities; the work will continue being beneficial once their involvement has ended.

A drawback of stakeholder involvement is that it can greatly slow down the implementation process of new programs or trainings. In order to develop a new program and devote more resources to a certain issue, the stakeholders must be on board, such as in the case of RMC development in Tanzania. However, many of the stakeholders are concerned with political traction, and are less likely to approve the implementation of programs that do not offer the promise of political gain.[32] Likewise, donors who devote their personal resources must personally see the benefits of proposed new programs, which are sometimes hard to prove convincingly, such as was the case with RMC. Donations are often given to gain either political or other sorts of traction with the general public, and donors want to know that their resources are affecting valuable change in order to promote their beneficence. Because of this, it is often necessary to put forth convincing and thorough presentations for donors and stakeholders to get on board with a new project, so they can see the necessity of it. Even so, donors would usually prefer to solve an existing issue rather than create a new one, as Jhpiego did with RMC. Donors failed to see this as a pressing healthcare issue and preferred to devote their resources to issues that would look more impressive in a brochure. Donors and private stakeholders are sometimes unable or unwilling to see the benefit of allocating resources into new trainings or programs, but that does not mean that the new programs would not be beneficial to the communities and can slow down or halt the development of quality medical care. A balance is necessary between appeasing the stakeholders and keeping them personally and financially involved while also making sure they are not interfering in the development process.

The governments and stakeholders that Jhpiego works with are also responsible for setting the licensing requirements after graduation and maintaining that licensure over time. Licensure can be an important standard in ensuring quality care throughout the various professions in the healthcare field.[33] However, it can also pose a barrier to further training and development of health care service providers depending on the requirements for this licensure.[34] The purpose of licensure requirements are ideally to ensure service provider competence, but this certification does not always reflect sufficient capabilities and instead may simply act as an additional hurdle for capable care providers to surmount.

Conclusion

Jhpiego’s purpose is to improve the health of women and families in developing countries. They emphasize this by focusing on the development of health systems and networks and health professionals in local communities to reduce maternal and newborn mortality rates, specifically in Ghana and Tanzania. The organization advocates for health policy changes on national levels. They work with stakeholders to identify public health issues and implement solutions through trainings and solutions. These stakeholders benefit Jhpiego’s work by providing necessary local knowledge and experience, but can often slow or halt the process of implementation. The training that Jhpiego provides is not as effective as it could be due to the fact that, in many cases, resources that are used in trainings are not readily available in participant’s local healthcare facilities. This issue not only makes the trainings impossible to implement in the current state, but reduces the likelihood that participants will remember the procedures they used should they obtain the necessary resources at a later time. Overall, Jhpiego’s work could be more effective by providing more resources and focusing on broader aspects of healthcare.

This post may have been edited by admin for clarity and length.

Sources

[1] “About Us.” JHPIEGO, 2018. Web. Accessed 10 October 2018. https://www.jhpiego.org/who-we-are/about-us/.

[2] “Our History.” JHPIEGO, 2018. Web. Accessed 10 October 2018.https://www.jhpiego.org/who-we-are/our-history/.

[3] Ibid.

[4] De Graft-Johnson, Joseph et. al. “Cross-Sectional Observational Assessment of Quality of Newborn Care Immediately After Birth in Health Facilities Across Six Sub-Saharan African Countries.”  BMJ Open. 10 Oct 2016. Web. Accessed 26 Sep 2018. https://bmjopen.bmj.com/pages/authors/.

[5] Fogarty, Linda A, et al. “A Matched Case-Control Evaluation of the Knowledge and Skills of

Midwives in Ghana Two-Years after Graduation.” Jhpiego, Aug. 2003. Web. Accessed 8

October 2018.http://resources.jhpiego.org/resources/matched-case-control-evaluation-knowledge-and-skills-midwives-ghana-two-years-after.

[6] Griffey Brechin, Susan J, et al. “Strengthening Preservice Midwifery in Ghana: Achievements

and Phase 2 Expansion Plans.” Aug. 2000. Web. Accessed 8 October 2018. http://resources.jhpiego.org/resources/strengthening-preservice-midwifery-ghana-achievements-and-phase-2-expansion-plans.

[7] Ibid.

[8] Fogarty, Linda A, et al. “A Matched Case-Control Evaluation of the Knowledge and Skills of

Midwives in Ghana Two-Years after Graduation.”

[9] Ibid.

[10] “Ghana” JHPIEGO, 2018. Web. Accessed 10 October 2018. https://www.jhpiego.org/where-we-work/ghana/.

[11] Griffey Brechin, Susan J, et al. “Strengthening Preservice Midwifery in Ghana: Achievements

and Phase 2 Expansion Plans.”

[12] Ibid.

[13] “Maternal Health.” Maternal Child Survival Program, 2018. Web. Accessed 10 October 2018.

www.mcsprogram.org/our-work/maternal-health/.

[14] Ibid.

[15] McMahon SA, Mnzava RJ, Tibaijuk G, Currie S. The “Hot Potato” Topic: Challenges and Facilitators to Promoting Respectful Maternal Care within a Broader Health Intervention in Tanzania. Reprod. Health. 2018;15(1):153. Web. Accessed 9 October 2018.http://resources.jhpiego.org/resources/hot-potato-topic-challenges-and-facilitators-promoting-respectful-maternal-care-within.

[16] Maternity care and maternal mortality. (2009). Reproductive Health Matters, 17(34), 205-211. Retrieved from http://www.jstor.org/stable/40647467.

[17] McMahon SA, Mnzava RJ, Tibaijuk G, Currie S. The “Hot Potato” Topic.”

[18] Ibid.

[19] Ibid.

[20] Ibid.

[21] “Sample Participant Registration Form.” JHPIEGO, 2009. Web. Accessed 10 October 2018.

http://resources.jhpiego.org/resources/sample-participant-registration-form

[22] “Evaluation of a Trainer.” Jhpiego, Jhpiego, 2009. Web. Accessed 10 October 2018.

http://resources.jhpiego.org/system/files/resources/TJA_Evaluation_of_clinical_trainer_Formatted.pdf

[23] “MCHIP Pregnancy Wheel.” Maternal and Child Health Integrated Program (MCHIP),

Jan. 2012. Web. Accessed 8 October 2018.

http://resources.jhpiego.org/resources/mchip-pregnancy-wheel

[24] Grenier, Lindsey, editor. “Threatened Preterm Birth Care Learning Resource Package.” Jhpiego

(Maternal and Child Survival Program, Survive and Thrive), Dec. 2016. Web. Accessed

9 October 2018. http://resources.jhpiego.org/HMS-PTB-LRP

[25] Ibid.

[26] Fogarty, Linda A, et al. “A Matched Case-Control Evaluation of the Knowledge and Skills of

Midwives in Ghana Two-Years after Graduation.”

[27] Ibid.

[28] Ibid.

[29] Rossier, Clémentine et. al. “Reassessing Unmet Need for Family Planning in the Postpartum Period.” Population Council. Studies in Family Planning, Vol. 46, No. 4, pp. 355-367. Dec 2015. Web. Accessed 27 Sep 2018. https://www.jstor.org/stable/24642188.

[30] McMahon SA, Mnzava RJ, Tibaijuk G, Currie S. The “Hot Potato” Topic.”

[31] Fogarty, Linda A, et al. “A Matched Case-Control Evaluation of the Knowledge and Skills of

Midwives in Ghana Two-Years after Graduation.”

[32] McMahon SA, Mnzava RJ, Tibaijuk G, Currie S. The “Hot Potato” Topic.”

[33] Schaefer, Lois, editor. Preservice Implementation Guide. United States Agency for International Development, March, 2002. Web. Accessed 9 October 2018.

http://resources.jhpiego.org/resources/preservice-implementation-guide-process-strengthening-preservice-education

[34] Necochea, Edgar. Building Stronger Human Resources for Health through Licensure,

Certification and Accreditation, The Capacity Project, April 2006. Web. Accessed 9

October 2018.http://resources.jhpiego.org/resources/capacity-project-building-strong-human-resources-health-through-licensure-certification.

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