Mentoring in Zambia: George and Dorothy

MENTORING IN ZAMBIA

Strengthening and Integrating Palliative Care

 Ndola Central Hospital is a large, efficiently run 800 bedded district general hospital set in the Copper Belt of Zambia whilst Mazabuka hospital is a smaller, less well-resourced 170 bed hospital in the Southern province of Zambia. At the start of the project there were small Palliative care teams in both hospitals, and these were enhanced by the THET Integrate project training in 2013 delivered by the Palliative Care Association of Zambia and the Mulago Palliative Care Unit.

George and Dorothy, UK mentors on the THET Integrate project, arrived in November 2013 to see a good standard of service being delivered by dedicated staff teams working long hours in challenging circumstances providing secondary care for palliative care patients but struggling to address what happens to patients back in the community following the closure of hospices.

The Mentors

Dorothy Logie is a retired NHS GP, and Public Health Masters (LSTM).  She has twenty years of strong connections with Zambia covering HIV/AIDS, Palliative Care, and general medicine.  She was an external evaluator of Diana Princess of Wales Memorial Fund palliative care work in Zambia 2009-2011 and is the recipient of 3 previous THET funding allocations for work in Zambia.

George Smerdon is a retired NHS GP with a special interest in Palliative care.  His Palliative Care mentoring experience began with the Tearfund PC Pilot project in Tanzania. And since 2010 he has worked with the local Palliative Care team co-ordinator in Geita, Tanzania. As a GP in Cambridgeshire, England he worked closely with dedicated district nurses and other professional colleagues caring for those with life limiting illnesses.

Why mentor?

The THET Integrate mentoring programme is helping to raise the profile of PC in Zambia, both with the MOH, Provincial, District, and hospital staff. Mentoring has a role to play in highlighting the urgent need for Palliative Care to be promoted as an essential part of the health care package and not as an optional “add-on”.

The timing of the World Health Assembly’s 2014 edict to “Strengthen palliative care as a component of integrated treatment within the continuum of care” has given added impetus to the Integrate mentoring objective to strengthen Palliative Care services throughout Africa.

The need is huge.  The challenges are huge.  There are so many people who are suffering and their suffering could be eased by giving the people who want to help the ability and resources to ease that suffering.  The Palliative Care teams are made up of committed individuals who need affirming and mentoring as they work hard to give end of life care to patients.   George and Dorothy’s approach is collaborative, “It is important to support what the carers are trying to do, to help them do it in a more effective way with the resources they have and to say, ‘let me help you with your thinking, where are you going with this?’  That’s what people kept on saying to me in Zambia, ‘I knew this is what I wanted to do for my patients and now I understand it’s about Palliative Care, you’ve given me the extra confidence to keep doing it’.  The pace of change can be slow but these are resilient and willing people eager to learn and poised to grow in confidence with some gentle guidance of a mentor.

Mentoring Activities

  • Advocacy

It was hard to discern what people really knew about Palliative care. Did they really understand about the principles of symptom control and psycho social support?” George and Dorothy were delighted to have the opportunity for important meetings with the senior hospital doctors. They were heartened to meet with the Provincial Medical Officer in Ndola, a man passionate about getting Palliative Care included in the 2015 Zambian healthcare plan, who, after meeting with the mentors went on to support the re-opening of Cicketelo hospice.

A significant aspect of George and Dorothy’s mentoring and advocacy was for protected time for palliative care hospital leads.  Their message was simple, “PC is there for everybody, it’s not an extra: it is a part of the core of your responsibilities as a Doctor, Nurse, Pharmacist, Social worker or whatever”.

  • Service Delivery

A key part to ensuring quality service delivery is having a strong Palliative Care champion to lead by example and empower and support the rest of the team.  This is something the mentors found at both Ndola and Mazabuka.

Added to this, the training delivered by the THET Integrate project in 2013 provided a solid foundation for the mentors to build on.  George reflects: “You couldn’t have this kind of mentoring without the initial training because Palliative Care is such a new concept. Crucial to good service delivery is helping people translate theory into practice.  It comes down to pain and symptom control and to staff who understand drugs, have access to those drugs and who can use them on a sufficiently regular basis to become competent in their use.”

On ward rounds the mentors asked the staff to pause and think about what other issues could be considered about their understanding of life limiting illness, patient expectations and fears.  Despite their chronic busyness, members of staff were encouraged to apply their newly acquired learning as they reviewed the patient in this extended way.  Doctors observed the value of this kind of mentoring experience and came to seek it out.

  • Referrals and record keeping

The mentors were struck by the confusion around referral criteria; and the low numbers of patients being referred for Palliative Care assessment. Palliative Care team members were able to see the value and scope of the patient assessment tool in helping address this problem from every aspect; physical, psychological, social and spiritual.

The Palliative Care teams worked with the mentors to create effective recording systems in order to identify patient needs and the resources required to meet those needs.  They saw the potential for accurate records and data to be a powerful tool for advocating at government level for more Palliative Care funding.  

  • Capacity building

George and Dorothy liaised with The National Palliative Care Association of Zambia to endorse their key role in staff education and ensuring sustainability.

Those who had attended the THET Integrate Training of Trainers sessions were supported in their new skills of supporting and teaching hospital and community staff to spread the message about palliative care. Some members of the Palliative Care teams, as their confidence grew, were encouraged by George and Dorothy to take on the role of local mentor.

 Challenges to Palliative Care Delivery

One of the key challenges to Palliative Care delivery is sustainability. Back in the UK Dorothy reflects; “This is important as so many good projects fail when funding stops.  I saw this very clearly while working with DPOWMF. They were generous with their funding to small rural PC programmes which worked well during the 2-year funding period, then collapsed at the end. Staff couldn’t be paid, drugs ran out, and the confidence of patients and relatives fell. Funding must be centrally allocated within the health service, and long-term.”

Without the resources no amount of advocacy is going to convince people that Palliative Care is an effective intervention.  The lack of resources compounds the difficulties of capacity building, dedicated time and sustainability.

 Outcomes

George

“It’s too early to talk about this; outcomes are about an end point.  There’s a continuing relationship with the teams: it’s about having established a Zambian mentor hub, with strongly forged relationships between the teams who are delivering Palliative Care in Zambia. It’s about the mentors, now having some idea of the challenges the teams face, being committed to supporting them in their journey. The empowerment of the team and the validation of the work that the teams are doing are important outcomes if you like, but for me it is work in progress so I’m not looking for outcomes at the moment.” 

Dorothy

“From my experience with the “twinning” between St Francis Hospital and NHS Borders which has lasted over ten years, I believe the same friendship will occur with the two hospitals we visited.  Long term relationships are being made, I first worked with Dr Gilbert Musangu several years ago when he was studying for a Master’s degree at Nairobi Hospice and it was a joy to build on that relationship during the recent mentor visit to Ndola. The links we have made with staff at both hospitals will be lasting and may result in future visits, funding, clinical advice on skype or email, or helping to obtain essential equipment. There are many opportunities in the UK for fund-raising and promoting Palliative Care in Zambia and elsewhere.  One small example of this is that on returning from Zambia I have raised money for bicycles for the home-based care workers in Mazabuka.”

 Sustaining the mentor relationship

How does the mentor relationship ensure Palliative Care continues to move forward once the mentor is back in the UK?  Few people in the teams have their own computers and the obvious challenges of access to emails and skype lead on to the question of building regular contact where meaningful case discussions can be used to share knowledge and improve service delivery.  Once the THET Integrate project  ends how will the momentum be maintained and Palliative Care teams prevented from feeling they’ve been abandoned?  George comments on the need for personal, long term commitment by the mentor, “It would be terrible if we allowed the momentum to sag and walk away?”

It will be very important that, after the funding stops, the mentors keep in touch with their designated hospital Palliative Care teams and keep supporting the hospitals. Long-term associations and friendships are most fruitful. There are also opportunities for mentors within the UK to raise awareness about the situation of those dying in Africa without symptom relief, through teaching, public speaking and publishing.  Universities, and in particular the students and young doctors, nurses, pharmacists, social workers, chaplains and volunteers will, in the future, be the ones to carry the flag.

 

 MR. Dec 2014