Summary of iH Teaches
by Henk Eggens.
This presentation is about capacity development as part of improving quality of care for Hansen’s disease patients.
It is my experience and that of many colleagues that the capacity to diagnose and manage Hansen’s disease is disappearing fast. In endemic countries, Ministries of Health often combine several disease control programmes in one department, for instance the Department of Neglected Diseases. Its central staff need to be trained and qualified in the management of all diseases. In the field the same need is present. Also, Hansen’s disease is not a popular specialty for most young professionals. It needs special motivation to choose a career in HD.
The presentation starts with a concrete clinical example of Maria, a Hansen’s disease patient. She is not treated well and suffers the consequences.
Maria was diagnosed with Hansen’s disease in the health centre close by her house. She received Multi Drug Therapy and went to collect her medicines every month at the centre. After three months she started to feel pain in her right elbow. The medical worker in the health centre gave her paracetamol and an ointment. It did not help her. After some time the pain disappeared. Then she noticed that she dropped things from her hand, a book, a cooking pan. The physician in the health centre told Maria he could not help her and advised her to go to the specialist hospital. Maria did not go there: it meant an 6 hour trip by bus, for which she did not have the money. Maria developed a claw hand, the result of damage in her right ulnar nerve, inadequate reversal reaction treatment and no measures for the prevention of disabilities provided.
The Why analysis
When we start the analysis for the reasons why this end result happened, we look for contributing causes. Causes have a relationship with each other. One cause may be triggered by one or more other causes. In the presentation a simple method is used to analyse what happened to Maria and why.
The Whys analysis is a simple method to find out root causes of a problem. You ask several time why something is a problem. The Whys analysis is a precursor for the first part of the Logical Framework Approach, popular in international organisations and commercial companies about 10-20 years ago. In this approach the first steps were to define the problems and its relationships was to build a problem tree. Problems would be organized in a cause and effect flow, creating a problem tree. Using that tree, solutions would be identified.
Why did Maria develop a claw hand?
It seems clear that Maria’s condition was primarily caused by failure to diagnose her reversal reaction episode. Thus she was withheld adequate treatment.
Poor diagnosis. Why?
The delayed or even absent diagnosis can be attributed to mainly two causes:
The patient does not seek help at health services, or delays going to the service. Reasons are various, from lack of awareness of a disease, no motivation, self-stigma that prevents procuring help, lack of access, because of poverty or approval of a husband. Or if you are working and paid by the day, missing out one day to go to the clinic may cost you your job, and you decide to wait.
In this presentation, we concentrate on health service delay.
Health service delay. Why?
Maybe there are no Hansen’s disease services available in the wide surroundings. Perhaps Hansen’s disease patients are not allowed in the health centres (access). Maybe patients have to pay for services more than they can afford. Perhaps the service is there, the patient is in the consultation room, but the health worker is not qualified to diagnose a reversal reaction in Maria’s case (poor quality of services).
No qualified staff available. Why?
Was the staff ever trained in Hansen’s disease? Was the training so long ago that most of it was already forgotten? Was the staff motivated to do their work? Perhaps they were not paid in months; perhaps they did not see any career opportunities and became poorly motivated to do their jobs.
Training was a long time ago. Why?
Possibly Hansen’s disease had no priority by the health authorities. There may have been no budget available for training. No supportive supervision existed to train the staff on the job.
No priority by authorities. Why?
We are reaching the core problem. Hansen’s disease is a neglected disease, there is fierce competition with politically more important health problems.
And in the Ministries, policies are not always based on public health priorities. Maintaining your position in the hierarchy, or aiming to climb to the top may mean you decide for priorities that give you quick and visible success. A chronic disease programme as for Hansen’s disease or tuberculosis is not something that will give you public praise and a step upward.
Political commitment is the key to solve the core problem. This commitment involves government agencies responsible for implementing the Hansen’s disease control strategy. It also includes non-governmental partners (WHO, ILEP members, Nippon foundation, patient organisations) for lobbying, financing and implementation.
Concentrating on human resources as part of a solution to improve quality of services I mention three dimensions:
Better training capacity.
It is good to analyse where training is needed. A training needs analysis would give the responsible authorities a better idea what to train, to whom and where. Not all problems are solved by training staff.
Better supportive supervision
Supportive supervision is an indispensable pillar in the development and maintenance of service delivery. It means supporting peripheral staff by on-the-job training, NOT just checking someone’s performance. Supervision helps and motivates health staff. Also informs superiors about professional problems of peripheral health staff.
Better remuneration of staff (financial and career options)
There is a need for governments and NGOs to implement a policy to preserve expertise and staff for Hansen’s disease control. Specific material and non-material incentives to make the job an attractive career option. For instance: risk allowances, housing allowances, educational possibilities (professional diploma, MPH, PhD) and more.
Capacity development is only a partial solution to improve Hansen’s disease services. But it is essential, for instance to prevent the development of Maria’s claw hand by providing timely and adequate clinical care for her.