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Strategy for International Cooperation Haukeland University Hospital 2010

Introduction Over long period health workers and clinical departments at Haukeland University Hospital (HUH) have participated in international health work. In 2003 the Western Regional Health Enterprise (Helse Vest) decided to establish the Department of International Collaboration (DIC). This event initiated a new phase in the HUH international work. The major task of the department is to ensure that international work is implemented in a coordinated and structured manner. Since its establishment DIC has managed to secure external international project funding. The department has also provided administrative support to more than 100 HUH employees who have participated in the HUH international health work. DIC has up to now been financed through external funds. The annual DIC turn over the last three years approximates 25 million Norwegian Kroner (NOK).

HUH international work has mostly been financed through NORAD and Fredskorps project funding. The aid policies of these organisation have therefore strongly influenced HUH international work. This situation has constrained HUH from developing long-term SouthNorth partnership cooperation. In January HUH decided upon a new strategy for its international work. The strategy underlines the importance of HUH also benefitting from international work. Provided that HUH benefit, it is expected that HUH will manage to develop North-South long-term and sustainable partnership cooperation. Moreover, the agreement gave the board a mandate to propose an alternative way of organising and financing HUH international work. Furthermore, it emphasized the importance of developing HUH partnership cooperation featured by equality and long-term perspectives. According to the new strategy, partnership cooperation with two hospitals in Africa and two more “advanced� teaching hospitals in India and South Africa, constitute the basis for HUH international work. Such partnerships will ensure that HUH future international work is carried out within well-structured framework.


Overall Objective

An important lesson learned from the HUH international work is that both health workers from the South as well as HUH can have a huge educational benefit from participating in international health work. The international work shall therefore contribute to improved health services provided by partnership hospitals in the South as well as better health services provided by HUH to its patients. In this new phase HUH will build on this lesson learned and focus on the following overall objectives. Improved global health for all trough:  In South emphasis on improved health services for the population covered by HUH partner institutions  In Norway improved health services for the population covered by HUH

Major Objective The major objective of the HUH international strategy is that international work shall contribute to: Trough competence, capacity and infrastructure development improve the treatment of patients

Employees at the HUH partnership hospitals in the South are severely affected by the global health work force crises. HUH concentrates its international health work to a limited number of countries. These countries bear a high percentage of the worlds’ disease burden, but are among the countries that have the lowest density of health workers in the world. Competence and capacity development are therefore key focus areas in HUHs efforts to support these countries. HUH ambition is to mobilise its professional and financial resources in order to provide vital support to the partnership institutions’ efforts concerning enhancing health workers’ skills and competence. The health situation in Norway does not allow for HUH’s professional staff obtaining sufficient training within specific medical fields. Moreover, the health situations in the HUH cooperating countries diverge significantly from the health situation in Norway. Consequently, through cooperation with these countries, HUH employees will have the opportunity to strengthen their competence within a number of different medical fields. 2

Targets The HUH international work focuses on seven targets. The following paragraphs explain these targets and associated activities. 1. Enthusiasm and Commitment among HUH Employees and South Partners The cooperation with hospitals in the South is to a large extent based on the individual HUH employee’s commitment. In order to boost the commitment further HUH has to facilitate the development of strong and permanent relations between the different HUH departments and hospital departments in the South. HUH’s international work is founded on network and partnership at individual and departmental level. Consequently, during the first phase of strategy plan implementation the consolidation of existing networks as well as the establishment of new professional network, will become crucial elements in terms of clinical cooperation and development work. The strategy underlines the importance of developing well-functioning and sustainable professional networks anchored at the hospitals’ departmental management level. If the HUH is to succeed, all managers at different departmental levels must be given the chance to visit our partner hospitals. Moreover, the cooperation with Christian Medical College, (CMC), India has been a success. In 2005 HUH managed to construct a ” Bergen House” with 8 residential units. Establishing ”Bergen Houses” is also an excellent way of communicating to our South partners that we emphasise our long-term strategy. The”Bergen Houses” will also make it easier for our health workers to live and serve as interns in the South. To facilitate further networking HUH intends to build “Bergen Houses” at the locations of our five partner hospitals. Based upon our good experience from India other “Bergen Houses” will also be financed through external projects and through renting out to international guests. Staff employed at HUH partner hospitals also see project cooperation as very positive. International cooperation creates commitment and motivation among health workers in the South. Participation in international health cooperation therefore makes health workers want

to remain at their current work stations and refrain from looking for work abroad.



Accredited Internship for HUH Employees at Partner Hospitals

In order to stimulate enthusiasm and commitment, HUH will have to focus on idealism as well as HUH employees’ personal interests. International work gives the employees new professional challenges and chances to obtain additional medical training. It is therefore crucial that HUH manage to develop arrangements that make it possible for HUH employees representing different medical professions, to be involved in challenging training activities, preferable supervised training.

From 2010 HUH intends to develop models that facilitate the development of an understanding of how internship at partnership hospitals can be accredited as training for different educational paths. The positions will be advertised internally at HUH, preferable as 3 to 4 months rotational positions. The individual employee will be refunded his/her basic salary through DIC. In addition chief physicians that will go out on leave will be encouraged to work at partnership hospitals during their leave, preferable as supervisor for assistant physicians. Moreover, “seed funds” will be made available in order to promote collaborative research and development cooperation between partner hospitals in the South and at HUH.


Strengthening the Bio-medical and Medical Expertise and Development Cooperation.

There is a significant international demand for Norwegian health expertise. In line with this it is expected that HUH partnership hospitals will benefit significantly from getting better access to Norwegian expertise. HUH intends to become a long terms partner in competence building within most professional medical fields and at all levels of the partnership hospitals. HUH has a long experience in terms of medical competence building. HUH expertise constitutes a crucial basis for further training of health personnel from the South within several medical fields. In addition HUH is an advanced teaching hospital with a strong wish to contribute to the development of specialist educational programmes. Such efforts will be made in close cooperation with our two more “advanced” partner hospitals in the South, CMC and Medunsa/Univ. of Limpopo in South-Africa (check the illustration). The competence and capacity building will to a large extent be financed through external funding.

Bio-medical competence development is a key element in HUH international health work. In terms of such work it will in particular be important to focus on HUH’s opportunities to 4

donate medical equipment and consumables to our partnership hospitals. In relation to such efforts HUH will also provide staff assistance. A part-time assistant will become responsible for controlling shipment of equipment, organising storage of technical equipment and contribute to education and installation of medical equipment in the South.

4. Remedy the Health Work Force Crises at Partner Hospitals

There is a serious shortage of health personnel at our partnership hospital in the South. In a long-term perspective this crises can be remedied through further education of local health personnel, but in a short-term perspective this strategy is unsatisfactory.

Many international aid organisations currently working with health have realised the seriousness of the health work force crises and are therefore supporting efforts aiming at remedying the crises. Several organisations have also realised that the best and probably only current solution to this crises is to recruit health workers from abroad. In accordance with this understanding HUH will support remedying the crises by recruiting Norwegian health workers. HUH will also have to continue to depend on external funds in order to recruit and finance health personnel working at the hospitals in the South.

The new strategy for international cooperation provides a new opportunity for DIC to secure base funding. Even so, it is expected that DIC still will be financed through external funds. Thus, the development and operation of external funded international health programmes will continue to be a significant part of the DIC work.

HUH emphasises the importance of local ownership and the development of relevant programmes. In accordance with this principle it is expected that partnership hospitals will take the initiative in terms of developing new programmes. Furthermore, in order to secure external support HUH will have to develop new health programmes within the frame of Norwegian and international organisations’ strategies for health assistance. DIC staff and heads of departments therefore need to be sufficiently informed about priorities and opportunities in international health assistance. DIC will in cooperation with the different professional circles at HUH continue to identify and apply for external funds.

5. Reputation Management and Branding - Local, Public and Private 5

International work is as an important part of HUH reputation management and branding. Generally aid work, and perhaps especially health work, receives substantial support among the Norwegian population. This constitutes a significant basis for creating an interest for HUH international work. HUH has managed to demonstrate that when local communities and local organisations are given the opportunity to assist hospitals in the South, significant local interest in international health work is created.

At the national level HUH is a major actor within the field of international health assistance. Nationally HUH is now recognised as a hospital employing staff enthusiastically engaged in promoting better global health. The communication department in close cooperation with DIC will hold the major responsibility for information activities related to the international work at HUH.

Currently the two departments do not have the capacity to organise comprehensive informational campaigns. By employing a journalist in an earmarked position, DIC will for example be able to organise coverage from partnership hospitals. Cover stories will be published through a number of different media including intranet, internet, journals, local and the local national press. In this way an understanding of how HUH contributes to the improvement of global health will be created. The journalist will in close cooperation with DIC become responsible for ensuring that the individual departments regularly organises information days. Through such information days the departments can for example inform about the opportunity to apply for internship in the South.


Creating an Overview of Alternative Hospitals in the South for Treatment of Patients

HUH spends annually about 10 million NOK for sending patients for treatment abroad including Germany, England and USA. The patients obtain treatment abroad because HUH faces problems due to shortage of capacity and lack of necessary competence. HUH now wishes to create an overview of alternative treatment at our partnership hospitals including potential treatment at CMC in India. CMC maintains a professional high standard and run their services at a cost that is significantly lower than the cost at HUH.


Operative Health Teams for Action during Crises abroad


The Health and Social Care Department has ordered the Western Regional Health Enterprise to prepare emergency plans relating to catastrophes and crises abroad. The plans will facilitate the organisation of support to Norwegian citizens. The Western Regional Health Enterprise will have two emergency teams on alert. One of these teams will be a HUH team. The Surgery Service Clinic will take the lead in organising the emergency work. The organisation of emergency work will be carried out in close collaboration with DIC.

Follow Up and Evaluation HUH has developed the strategy plan in a way that facilitate assessment of HUH achievements. The plan therefore describes long-term objectives as well as short-term targets. Moreover, the plan describes a hierarchy of objectives and targets. This description will make it easier to assess how HUH by achieving its short-term targets also will manage to achieve its major objectives.

As a part of strategy plan implementation HUH will develop a separate system for follow up and evaluation. HUH especially emphasises the importance of formulating good quantitative and qualitative indicators. Through this work HUH will identify information required in order for HUH to measure progress and assess achievements.

HUH will define indicators for each target. The targets can for example describe how many department managers HUH hopes will take part in cooperation with departments in the South. In addition the indicators will describe the results of such collaborative efforts. In a similar way HUH wish to formulate targets for how many assistant physicians who will participate in internship arrangements at the partnership hospitals. HUH will also make estimations concerning the number of health workers from the South trained through the arrangement of courses or on the job-training. In this context HUH will define targets for how the training has improved the health workers’ competence. Moreover, HUH expects that the recruitment of health workers from the North will improve the capacity at the partnership hospitals. Consequently, HUH will develop targets for achievements in terms of remedying the health personnel crises at partnership hospitals. With regard to reputation management and branding, HUH will further explain how comprehensive information campaigns lead to an increase in the number of positive press coverage, in the local and the national press, about HUH international work. 7

DIC will become responsible for data collection necessary to measure progress against targets. Moreover, an external company or organisation will be given the task to evaluate major impacts of HUH international efforts. It is expected that data collected by HUH will constitute the basis for such evaluations. The objectives describe the more far-reaching impacts of the international work and it is therefore envisaged that evaluations will have a major focus on how HUH have managed to achieve its objectives. The HUH Research and Development Department is probably the institution with the best expertise required to conduct this type of study.

The Partnership Model HUH has developed excellent cooperation with several public hospitals and medical educational institutions in the South. These partnerships are based on the conclusion of cooperation agreements (Memorandum of Understanding – MoU). Such cooperation has been developed within the framework of the individual countries’ health policies and in close cooperation with the national health authorities. In the coming years HUH hopes to facilitate and effective way of developing and running new international health programmes. South partners’ initiatives will constitute the basis for program development. The cooperation will take place in close cooperation with the local health authorities and within the framework of the authorities’ priorities. HUH will strive toward the development of a comprehensive cooperation with the different professional departments at the South institutions. The following paragraphs details the HUH cooperation model.

There at two categories of partnership hospitals

1) Universities in the South with a relative high level of expertise. These universities hold the necessary competence to organise education of medical students from other hospitals in the South and they are also prepared to organise such education. 2) Partnership hospitals in poor African countries that are in shortage of resources and professional expertises.

Category 1


Medical University of Southern Africa (MEDUNSA)/University of Limpopo, situated 65 km north of Pretoria, and being the largest educational institution for health personnel in South Africa. The university and associated hospitals (ca 2 100 beds) mainly organise teaching of black health workers and educate physicians, dentists and various other categories of health personnel. HUH for example cooperates with MEDUNSA/University of Limpopo concerning specialist education of physicians within such medical fields as orthopaedic (South Sudan) and anaesthesia (Botswana).

Christian Medical College and Hospital, (CMC) Vellore, Tamil Nadu, is a major referential hospital and one the most prestigious and most advanced medical centres in India. Moreover, it is a prestigious educational institution for all categories of health personnel. The hospital is one of the largest hospitals in India and it has 2 600 beds. It is an independent foundation based on “Robin Hood” principles; and 25% prosperous individual patients from all over India cover the hospital’s operational costs and the treatment of the remaining 75% of the local patients. HUH has purchased a house, “Bergen House”, located within the area of the hospital. The building has 8 apartments. It was opened in 2005 (check photo).

Category 2 These are public hospitals and educational institutions owned by national authorities. During their internship at these institutions HUH personnel are expected to contribute to local competence building. Furthermore, they will remedy the critical immediate personnel crises at the hospitals.

It is proposed that such cooperation will include the following hospitals:

Yekatit 12, Addis Ababa, is a referral hospital owned by the Addis Ababa Health Council. The hospital is a teaching hospital associated with the Black Lion University Hospital. The hospital is made up of nine departments and six units and it has 265 beds. Yekatit 12 has excellent laboratory facilities that perform most categories of routine diagnostic. Since 2001 the hospital has been a HUH cooperative partner and the two institutions have jointly implemented a reconstructive surgery project (treatment of burn injuries and cleft lip). The project also included the building up of a specialist educational programme concerning reconstructive surgery. This NORAD funded programme has operated for 9

more than ten years. In addition to Yekatit 12, ALERT (All Africa Leprosy Rehabilitation and TB Training Centre) is an important cooperative partner. This hospital is owned by the Ministry of Health in Ethiopia. Ocean Road Cancer Institute (ORCI), Dar es Salaam, this is the only medical centre for cancer treatment in Tanzania and the only specialist cancer hospital in Eastern Africa. ORCI has chemotherapy and radiotherapy treatment facilities. The hospital has 150 employees 150 and 130 beds. ORCI is a referral and a teaching hospital associated with Muhimbili University of Health and Allied Sciences (MUHAS), the largest hospital in Tanzania with 1 500 beds, 25 departments and 106 units. HUH project cooperation with ORCI was established in 2004, while MUHAS cooperation was established in 1980.

Kamuzu Central Hospital (KCH) and Bwaila Hospital, Lilongwe, is a central hospital owned by the Ministry of Health with 750 beds and it is the second largest hospital in Malawi. The hospital is a referral hospital for Malawi’s central region and provides services for a population of about five millions. Up to 2009 Bwaila Hospital 2009 was the KCH’s maternity clinic, but it is now split from KCH as a separate local hospital, owned by the local authorities. Since 2007 HUH has participated in project cooperation with KCH/Bwaila concerning mother health. (Bwaila) and surgery/orthopaedic (KCH). This work has been carried out as a cooperation between three Norwegian University hospitals, namely Ullevål University Hospital (UHH), University Hospital of Northern Norway and Haukeland University Hospital (HUH) and KCH/Bwaila Hospital.

Juba Teaching Hospital (JTH) is the largest referral hospital in South Sudan with 500 beds operating directly under the South Sudanese health authorities. The hospital organises education of nurses, midwifes and “medical assistants” The hospital is closely associated with University of Juba and it is a medical educational institution. As a collaborative effort between HUH, OUS, Medunsa and JTH, a new Fredskorps project within the field of orthopaedic surgery competence, is now being implemented. The construction of a new”Bergen House” at the JTH location, is now being planned. The South Sudan health authorities has also commissioned HUH to take a lead in the planning of a large new teaching hospital in Juba; John Garang Memorial Teaching Hospital.


Mnazi Mmoja Hospital (MMH) is the largest hospital in Zanzibar with 500 beds. The hospital operates directly under the Zanzibar health authorities. Zanzibar is a semiautonomous part of the United Republic of Tanzania and it is within a number of areas independent, including an autonomous health sector. MMH is a referral hospital providing services for the Zanzibar and Pemba population of 1,2 million. The hospital educates a number of different categories of health personnel. Zanzibar is a Muslim society. Zanzibar is less criminal and corrupt than most other regions in Africa. Zanzibar is therefore a safe place to send”inexperienced” health workers from the North. MMH contacted HUH with regards to their wish to establish cooperation within a number of medical fields. At the end of May 2010 the Mnazi Mmoja Hospital (MMH) director visited HUH and met with representatives from relevant departments. The HUH Blood Bank has established Fredskorps Exchange programme cooperation with ZNBT Blood Bank Department concerning blood bank services. Moreover HUH has been offered a suitable plot for the construction of a “Bergen House” to be used by HUH health workers.


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