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The challenges of delivering culturally appropriate medical education in African countries and how pharma can help.

By Danielle Barron on Jan 28, 2016

Improving healthcare standards in developing countries does not simply mean enhanced access to medicines. Often medical education systems are not fit for purpose, and inherent problems with infrastructure, communication, and facilities in remote areas, in particular, mean that modernization of medicine is next to impossible.

The African Institute for Medical Education (AIM) is a CPA-audited 501 c.3. organization registered in the US in 2014, and its goal is exceptionally admirable – to educate nurses, midwives and other medical professionals by visiting the most remote villages in Uganda by delivering “the most advanced medical education in the world”. Their educational programs are adjusted in order to accommodate cultural differences and reach 100 medical professionals in remote villages, serving more than 200,000 villagers across the country.

Ultimately, AIM can have a significant influence on many of the 40 million people there in the short and medium-term, and 140 million people over the longer term.  They are already in conversations with Tanzania, Nigeria and Rwanda officials.

AIM is now looking for support – financial or otherwise – so that they can continue to grow their operations in Eastern Central Africa.

AIM’s founder Robert Britting was recently nominated for Humanitarian of the Year by Healthcare Marketer's Exchange. He comes with a strong pedigree of working within the pharmaceutical industry, being a former Marketing Director, Marketing Research Manager, Executive Director and Chief Strategist, as well as VP with several major communications companies with more than 25 years of experience. Having worked in a variety of roles, he currently works on a consultancy basis, helping companies with communications and vendor architecture and restructuring and behavioral strategy.

“What that means is that I work to restructure their communications program and vendors focusing on healthcare professionals and consumers and help them to understand the behavioral techniques necessary to increase revenue opportunities. Basically, I am the go-between the pharmaceutical company and their vendors,” he tells eyeforpharma.

Yet five years ago his life’s work took on a distinctly altruistic slant when he read a magazine article about children in Uganda receiving radios thanks to a South African philanthropist.

“I started doing some research on it and found that there were some very interesting issues that the country was facing. The average salary was $1780 per year. But the big thing was that they did not have a continuing medical education program. When the doctor graduates from school over there, they have no formal mechanism by which to continue their medical education like we do here in the United States and other medically advanced countries.”

Digging deeper, he came in contact with a missionary worker who eventually introduced him to his business partner, Michael Kiyaga, whose grandfather was the first prime minister of Uganda. The two hit it off and began to work together, and a meeting with the Ugandan Ambassador in Washington led to the creation of AIM.

“When we told him about our hope to create a program of continuing medical education in a country that doesn’t have any, he jumped all over it and became one of our biggest supporters along with the Health Minister.”

The process of establishing their endeavor as a tax-exempt not-for-profit took about 18 months but Britting and Kiyaga used that time to foster relationships with the various relevant stakeholders.

“Through the ambassador, who incidentally, became an advisor for us, we were introduced to the health Minister for Buganda, Dr Bernard Kiwanuka. He loved what we were doing and flew here to meet us.” He is now a key advisor representing 10 million people, as is Robert Mugimba, Third Secretary of the Permanent Mission of Uganda to the United States. Other advisors include pharmaceutical executives and other industry luminaries.  AIM is also endorsed by the King of Buganda.

First steps

Last year, Britting and Kiyaga personally financed the development of an Ebola program, to function as a pilot project for the organization.

What the pharmaceutical industry does is we go over there and often we bring doctors to the city, but the only people that really benefit from it are the people in the city, that is, the people who can afford it and have access to it. The people in villages are handled by nurses, who weren’t getting the benefit of what was happening in the cities.

“(Working with the Health Minister) we trained a doctor and some nurses, and then they went out to three different villages to teach 31 different medical professionals such as nurses and midwives there, and educate them on Ebola,” he explains, adding that nurses were first targeted as they see more than 90 per cent of cases in Uganda. This differed markedly from previous educational efforts by industry.

“What the pharmaceutical industry does is we go over there and often we bring doctors to the city, but the only people that really benefit from it are the people in the city, that is, the people who can afford it and have access to it. The people in villages are handled by nurses, who weren’t getting the benefit of what was happening in the cities.”

Culturally appropriate

The AIM team travelled personally by car to these remote villages – many of which still have witch doctors practicing.The ultimate goal of the project was to glean an understanding of what AIM would need in order to create a medical education program culturally appropriate for Uganda.

“This is a program where we are mindful of the culture.We educate the nurses, midwives and other village medical professionals that the clinical is much more important than certain cultural, misdirected influences. Our goal is not to change the culture of a country as we can’t do that – our goal is to try and fit within a culture and make it work by providing factual information using world class resources,” Britting explains.

“There is no way we can train, using the same levels of medical education we have herein the United States; they are smart people, but their knowledge level is substantially lower. We have to adjust everything we know and then incorporate their cultural nuances, as well as running it past the directors at medical universities in Africa so that they can apply their cultural insights and ensure what we are doing is appropriate. These people are just happy to have someone help them and believe me their level of knowledge is nowhere near what we think it should be or could. For example, 50% of the village medical professionals did not know to whom they should go if they suspected an outbreak of Ebola.  And, 31% did not know not to touch bats or non-human primates or their blood or fluids or eat raw meat from these animals.”

Infant mortality

Following the success of the Ebola education program, (the medical professionals who were trained ranked the program 97% as “very helpful”) the focus turned to pregnant women; the high infant mortality rate in these areas made this an obvious next step; “20 per cent of these infants will die before they reach the age of five, and this has a lot to do with the malnutrition and the poor care that the women get from the nurses in the villages,” says Britting.

AIM’s Pregnant Mother & Baby Lifesaving and Survival and Malnutrition Program covers a wide variety of health issues and topics, from HIV/AIDS, malaria to sudden infant death syndrome, for example – even explaining what certain diagnostic tools are, including for example, an ultrasound, and when it’s necessary to triage a patient.

This includes what Britting considers “one of the most unique diet programs there is in the entire continent”. Knowing that it would be impossible to provide nourishment to all of the pregnant women in Uganda, AIM hired a dietary professional, Thomas Malkinski, to draw up the program, which was then reviewed by a pediatrician in the US, as well as the Health Minister in Buganda.  Britting explains: “The program personalizes the dietary needs – based on the availability of food in a village and the standards of the leading institutions in the world.  This is a completely unique approach to ensure pregnant mothers and their unborn babies obtain the appropriate foods necessary for a healthy experience and babies will have a better chance of living longer.”

“If you live near Lake Victoria, for example, you can get fish, but if you’re living in another part of the country, the North for example, you cannot get fish, but have access to meat. There are no pharmacies where you can buy vitamins. We can’t provide food for nine months for these women, that’s impossible, but we created a dietary program that allows a nurse to identify all of the types of food that are available to people in their village, which then allows them to calculate all of the vitamins, minerals, trace elements, in those foods and that creates a personalized diet program which will allow these pregnant women to get much closer, if not achieve the amount of vitamins and trace elements that are necessary.”

He calls it SPAN (Selective Planning for Alternate Nutrition).  SPAN basically spans intercontinental medical knowledge exchange between more advanced countries and African medical professionals in places where information is needed the most to decrease mortality and morbidity rates.  Essentially, AIM teaches them to fish, as the saying goes.

The future for AIM

Additional funding will finance travel to Africa and pay for village outreaches including sending medical professionals from universities to Africa to train and implement programs.  As AIM goes forward, larger funding initiatives will allow AIM to provide webcasting of educational seminars, meaning they can reach even more people and reducing costs substantially. With that in mind, they are also looking to provide inexpensive computers to certain villages, as well printers, paper and ink; this means that when patients are seen, the health professional can print out a set of guidelines for them in order to adhere to the dietary program, as well as provide patient education materials they can bring back to their homes and share with family and friends.

In the longer term, Britting adds that AIM also hopes to work with WorldWater, a New Jersey-based company that provides solar panels and could provide energy to villages which in turn will supply fresh water (it is estimated that 80% of hospital visits are due to water-related infections).

“This would allow us to go into villages and create centers for health in order to educate the medical professionals there, and provide educational materials for the patients, and there would be fresh water and mobile webcasting access.”

AIM are also hoping to turn their attention to the omnipresent problems of malaria and HIV within Africa. Britting says the menace of malaria remains a significant problem in African countries and AIM is hoping to roll out a program in the near future that will educate health professionals and the wider population on how to protect themselves against contracting the disease and also how to treat it. HIV also remains rampant and that will be the focus of another educational program by AIM.

“We will have to do several programs in order to bring the medical professionals up a couple of levels – we could not just give them a drug that we use over here and expect them to know how to use it, we have to educate them gradually.”

How can industry help?

These are the future plans of AIM. But for now, their workers are still driving to remote villages across Uganda, and future plans depend on their funding stream.

Britting explains that there are a number of ways that the pharmaceutical industry can get involved, and AIM has tried to be creative in this respect.

“It’s very difficult as a not-for-profit organization to constantly go out and ask for money. After a while it gets old. The question is how you generate regular funding,” he admits. Therefore, AIM is focusing on creating an alternative stream of revenue by getting the more than 3,000 people within the pharma industry on their database involved in their work.

The first collaboration was with a crowd funding program CaringCrowd that is powered by Johnson & Johnson.

“We have been working with them for some time; they are incredibly helpful and the program they have put together is sensational, something so powerful it could positively impact tens of millions of people in need”, comments Britting, adding that any company or individual can contribute directly to AIM via this platform.

In addition, AIM can take donations directly at www.AIMforPROGRESS.org.

Achieving synergies is just one possibility; one pharmaceutical company recently contacted AIM to explore if the organization could assist them in their quest to deliver free medications to the remote villages of Uganda.

“Through our advisors/contacts with the Ambassador and the Health Minister of Buganda, we can help them in implementing that program by building a medical education program around that distribution; you can’t distribute a medical product unless you are going to show people how to use it,” Britting explains.

Other pharmaceutical companies may be interested in sending doctors to Uganda, and build contacts with medical universities there in order to train doctors at these facilities. Again, Britting explains, this is very much city-focused and thus the education and training is of no benefit to those in more rural towns and villages.

“We hope they might fund us in delivering a medical education program built around what they already have in the cities but roll that out on a national basis, as best we can, again just driving to villages but eventually with webcasting and mobile technology.”

Pharmaceutical companies may also have some very specific disease categories that they would like to pursue, or products they wish to market, in African countries; in this instance, AIM can also build the medical education program around this and then provide accreditation for participants who achieve excellence.

Britting also notes that AIM retains the most comprehensive database of all doctors practicing in Uganda – this can also prove useful for companies wishing to engage with these doctors.

“Many companies have female health products for example. They might be interested in developing a relationship in an African country, or doing it for purely altruistic reasons; they can come to us and underwrite a program such as the Survival for Pregnant Women program now in development. In addition, what companies can do is if they are already doing a program with a marketing budget, then we have an LLC (limited liability Corporation) they can go through if they don’t want to go through the grant process.”

Clearly there are myriad options for pharmaceutical companies wishing to work with AIM and Britting says that even at this early stage of AIM’sefforts, the support and interest has been “phenomenal”. The possibilities are endless, he adds.

In fact, he lists 10 different ways companies can work with AIM on their website.

“In that Central Eastern African area, there are about 40 million people; close links between the countries in this zone means that AIM’s programs can be syndicated; created just once, then rolled out in different districts to a potential population of 140 million people. We are just trying to help this population by giving them whatever we can in order to help them survive but in a big way.”