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

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

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

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

Afya Bora: Timeline and Activities  2-day Orientation and Responsible Conduct of Research Training  Core Curriculum 3 one-week modules Attachment I (~3 months)  Independent Projects at Attachment Sites  1-day workshop for Mentoring Teams within first 2 weeks  Weekly meetings with primary mentor  Semi-monthly meetings with Country Lead and Fellows in-country  Monthly meetings with Mentoring Team  Project report due last day of rotation January 7-28 January 31-April 28

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

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

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

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

Afya Bora: Timeline and Activities  2-day Orientation and Responsible Conduct of Research Training  Core Curriculum 3 one-week modules Attachment I (~3 months)  Independent Projects at Attachment Sites  1-day workshop for Mentoring Teams within first 2 weeks  Weekly meetings with primary mentor  Semi-monthly meetings with Country Lead and Fellows in-country  Monthly meetings with Mentoring Team  Project report due last day of rotation January 7-28 January 31-April 28

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

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

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

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

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

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

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

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

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

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

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

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

Preliminary Data Analysis

Major Bottlenecks 3848 HIV % % % % % % Eligible for Program CD4 Testing Retention >90 days #Extra If Eliminated

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