Universities in Transition for Better Health Outcomes
We acknowledge the significant contributions of the following institutions: Ministry of Education and Vocational Training Ministry of Health and Social Welfare Aga Khan University, East Africa Bagamoyo District Council Bagamoyo District Hospital Catholic Universiy of Health and Allied Sciences Hubert Kairuki Memorial University Ifakara Health Institute ITECH Tanzania Kilimanjaro Christian Medical College Muhimbili National Hospital National Institute for Medical Research Prime Ministers Office, Regional Administration and Local Government Tanzania Commision for Science and Technology Tanzania Commission on Universities Tufts University We gratefully acknowledge financial support from the Bill & Melinda Gates Foundation
What an exciting journey we have had at MUHAS and UCSF over the last three years! Faculty, staff and students from across our campuses, and many other participants, worked intensively to complete the activities that we describe here. In late 2008, Muhimbili University of Health and Allied Sciences (MUHAS) and the University of California San Francisco (UCSF) received a grant from the Bill and Melinda Gates Foundation for the Academic Learning Project (ALP), one of a group of “learning” projects to explore how university partnerships can contribute to better health outcomes. We structured the MUHAS-UCSF ALP around building university capacity to increase the number of health professionals who are competent to provide quality care for their people. This summary of some of our activities demonstrates how we collaborated – by developing pre-service curricula, supporting faculty to advance their teaching, and ensuring that university research is directed towards priority health issues, and informing education. We also developed a tool to facilitate planning the availability of practicing health professionals. The unique feature of this project is that faculty across all our schools worked inter-professionally to complete these activities. People from many other institutions participated in this work and we gratefully acknowledge their significant contributions. We learned that three years is a very short time and that there is a lot more to do. We hope that readers of this document will also share their knowlege and experience, and collaborate to further health professions education for better health outcomes in Tanzania and around the world.
Ephata Kaaya MUHAS Principal Investigator, ALP
Sarah Macfarlane UCSF Principal Investigator, ALP
Universities for health THE CHALLENGE
In Tanzania, there are approximately three doctors, 40 nurses, two pharmacists and one dentist per 100,000 inhabitants, in contrast to 240 doctors, 810 nurses, 80 pharmacists and 60 dentists per 100,000 inhabitants in the United States. This extreme shortage of health professionals in Tanzania undermines the ability of the health system to provide for the significant health needs of the population.
Universities are transitioning to address the health workforce crisis and improve health outcomes. The Government of Tanzania is calling on universities to rapidly scale up their output of health professionals â€“ doctors, nurses, dentists, pharmacists and public health workers. Some universities, such as MUHAS, are working to increase their student intakes, other universities are opening professional schools, and the government and private institutions are establishing new universities with health professional schools. But, as elsewhere in Africa, Tanzaniaâ€™s universities are challenged by severe shortages of teaching faculty, inadequate teaching facilities, and the need to update curricula to meet changing epidemiological profiles and new professional practice. Such challenges can be ameliorated by financial resources but their long-term solution requires more teachers and rapid accumulation of educational capacity, technologies and resources across the country.
THE MUHAS-UCSF PARTNERSHIP
Growth of universities is commonly accelerated through partnership, for example by collaborating in research, students undertaking sandwich training, external examining, and visiting fellowships and faculty. MUHAS and UCSF decided to take university partnership to another level by partnering at the institutional level. 6
In 2005, when our partnership began, MUHAS was planning to become a university of health sciences â€“ with a vision to educate Tanzaniaâ€™s health professionals to serve the health needs of their people. UCSF was setting up Global Health Sciences to support its vision of educating health professionals and scientists to advance health in the United States and worldwide. We agreed that, through partnership, we could transition both our institutions to contribute to global health, and address the acute shortage of health professionals in Africa.
MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES
With around 314 faculty across its schools of Dentistry, Medicine, Nursing, Pharmacy, Public Health, and Institutes of Traditional Medicine and Allied Health Sciences, MUHAS provides education and training, at any one time, to about 2,283 diploma and first degree students, and 404 postgraduate students. Faculty conduct basic, clinical and social science research in, for example: HIV and AIDS, tuberculosis, malaria, cancer, diabetes, cardiovascular disease, mental health, maternal and child health and health systems. The Directorate of Continuing Education and Professional Development (DCEPD), in which the ALP is based, works with all MUHAS Schools, Directorates and Institutes to promote health professions education.
THE UNIVERSITY OF CALIFORNIA SAN FRANCISCO
With some 2,400 faculty across its schools of Dentistry, Medicine, Nursing and Pharmacy and its Graduate Division, UCSF provides education and training, at any one time, to about 2,940 degree students, 1,620 residents and 1,030 postdoctoral scholars. Faculty conduct basic science investigations and research to prevent and treat conditions such as HIV and AIDS, tuberculosis, malaria, cardiovascular disease, neurological disorders, cancer, diabetes, and reproductive and developmental disorders. UCSF Global Health Sciences (GHS), in which the ALP is based, integrates UCSF expertise in all the health, social, and biological sciences, and focuses that expertise on pressing health issues of global importance.
Building curricula THE CHALLENGE To educate health professionals to be competent and confident to serve the health needs of their people
Both MUHAS and UCSF are committed to providing excellent education to our students. We adapt our curricula to ensure that we educate our students to become health professionals able to meet the needs of their people. In 2008, MUHAS decided to revise its curricula, and to make them competency-based in accordance with the new requirements of the Tanzanian Commission for Universities (TCU). Since few faculty were familiar with competency-based education, MUHAS worked with UCSF to advise them to revise their curricula.
We consulted stakeholders about the quality of MUHASâ€™s current curricula through focus group discussions, in-depth interviews, and a nationwide tracer survey. Through the tracer survey, we wanted to learn how recent graduates felt their training had prepared them for employment, and if employers thought they were adequately prepared for employment. Students asked for more clinical and practical training, active learning, and training in information technology. They felt that their course loads were overwhelming, particularly in the pre-clinical years; Faculty wanted to increase active learning, use more educational technology, develop and communicate expected student outcomes, teach and assess professionalism, and to work inter-professionally; Recent graduates requested more clinical and practical training and wished for stronger mentorship from faculty; and Employers and supervisors felt that graduates needed more clinical skills and greater ability to apply their strong theoretical knowledge to real world problems. Some expressed concern that graduates lack professionalism in the conduct of their duties.
We developed competencies that address all aspects of the working life of the professionals MUHAS trains. A student’s progress in each of MUHAS’s programmes will now be determined by achievement of competencies in all eight of the following domains.
MUHAS COMPETENCY DOMAINS
On October 10th 2011, MUHAS started teaching its new competency-based curricula to all first year students across its schools and institutes. Faculty welcome students into their professions in a ceremony where students and faculty don white coats and pledge their commitment to their respective professions. New features of the curricula include: • • • • • • • •
Students learn professional ethics from their first year; Students interview patients during basic science classes to understand how their conditions correlate with the science they are learning; Medical students begin junior clinical clerkships in their third year; All students participate in enhanced and extended clinical and practical experiences, including practice in district settings; First year students learn information and communications technology; Students participate regularly in active learning and problem solving; Students learn to work in inter-professional teams in classroom, clinical and community settings; and All students learn teachings skills and postgraduates undertake an entire course in education.
THE FUTURE All Tanzanian health professional schools work together to teach and assess their graduates using an agreed set of competencies
Strengthening teaching capacity THE CHALLENGE To equip faculty with the teaching skills they need to educate increasing numbers of competent health professionals
As at most universities, MUHAS recruits faculty for their scientific and academic merit rather than for their educational expertise. The development of the new competency-based curriculum and its new teaching requirements demonstrated the need for MUHAS to support faculty to develop their educational skills. UCSF similarly trains and mentors its faculty in education and recognizes excellence in teaching. Through the ALP, we nurtured the creation of a group of young teaching faculty to lead faculty development at MUHAS.
THE HEALTH PROFESSIONS EDUCATORS GROUP (HPEG)
MUHAS leadership recruited nine mid-level clinical faculty with interest and aptitude in education, from all schools, to undergo training in curriculum development and evaluation, student instruction and assessment, and academic leadership. The training of the Health Professions Educators Group (HPEG), as these faculty became known, included an intensive two-week course at MUHAS, led by educational experts from UCSF, MUHAS and the University of Dar es Salaam followed, two months later, by a two-week visit to UCSF to learn from the educational process there. Subsequently, five basic science faculty joined the HPEG after a two-week study visit to UCSF. The HPEG are now mentoring other faculty to join the group.
FIRST FORMAL FACULTY DEVELOPMENT PROGRAMME
With UCSF educators, the HPEG developed a programme to provide faculty with the skills they need to teach the new curricula and to assess students in their achievement of competencies. The workshops, offered by the HPEG in 2010/2011, include competency-based education, large group teaching, clinical teaching, effective mentoring, designing multiple choice exams, teaching procedural skills, and writing objectives. In the first year, nearly half the faculty body, across all schools and institutes, attended at least one workshop. Evaluations of the sessions have been positive, with requests to repeat certain workshops and to expand the range of topics covered.
TRAINING POSTGRADUATE STUDENTS AS EDUCATORS
If trained and mentored, postgraduate students can serve as teaching assistants and near-peer educators, and could be tempted to become future faculty. MUHAS asked the HPEG, working with UCSF educators, to develop a course for post-graduate students in instruction, assessment and curriculum development. In the 2010/11 second semester, the HPEG piloted this course and postgraduates from across the professions attended enthusiastically, on a voluntary basis. The HPEG will deliver this course to all MUHAS postgraduates in the 2011/2012 academic year and evaluate its effectiveness.
LEARNING SURGERY OUTSIDE THE OPERATING THEATRE
It can be daunting for young doctors posted to rural hospitals to undertake their first surgeries. Three MUHAS surgical faculty and a UCSF clinician developed an innovative way to teach medical students to develop basic surgical skills. In a classroom, using PVC and foam, they simulated the skin and tissue on which students could learn to make incisions, suture and tie knots, using actual surgical instruments; and using a bicycle inner tube, they learned to perform bowel excisions. All medical students at MUHAS now pass through this â€œsurgical skills laboratoryâ€? at the start of their surgery rotation, so that they can practice new techniques ethically and safely before entering the operating theatre. Feedback from students has been positive and preliminary results shows that practicing in such a laboratory helps students learn and retain surgical skills.
Before this I was just learning by observing others... this made me feel like I could be a surgeon. -MUHAS Surgery Student
THE FUTURE The HPEG calls on faculty at other institutions to form The Tanzania Academy of Health Professions Educators. The Academy will support excellence and leadership in education 11
Harnessing research expertise THE CHALLENGE To harness institutional research to inform policy makers and educators about national health issues
MUHAS has considerable bench, clinical, epidemiological, economic, social science and other specialist expertise among faculty in its schools of dentistry, medicine, nursing, pharmacy and public health and its institutes of traditional medicine and allied health sciences. As part of the ALP, MUHAS developed its first research agenda. The agenda will harness faculty expertise to address gaps in knowledge about conditions that are prevalent in Tanzania and whose alleviation is key to achievement of national development goals.
THE MUHAS RESEARCH AGENDA
Working in inter-disciplinary teams with other national and international experts and stakeholders, faculty will: develop drugs, diagnostics and vaccines; conduct clinical trials, large-scale community interventions, and health promotion research; describe epidemiological profiles and identify risk factors and social determinants; evaluate health system functioning and support policy making and planning; to address: • • • • • • • 12
The highly prevalent infectious diseases, HIV and AIDS, tuberculosis, and malaria; Important neglected tropical diseases such as lymphatic filariasis, The growing burden of non-communicable diseases including cancers, heart disease, and diabetes; Safe motherhood and child health to reduce high rates of maternal, neonatal and child mortality and morbidity; Prevention and treatment of injuries as a major cause of death and disability, particularly those resulting from traffic accidents; Health system strengthening by developing human resources, health information systems, and health care financing, and evaluating public private partnerships; and The quality of health professions education by evaluating methods of teaching and assessment to improve students’ achievement of competencies.
SUPPORT TO FACULTY TO IMPLEMENT THE AGENDA
Working with UCSF research administrators, the Directorate of Research and Publications has reviewed its capacities and established three professional units to support faculty to undertake their research. The existing unit responsible for institutional proposal review will streamline its process to provide speedy response and advice to researchers; the research development unit will assist investigators in securing funding and writing and submitting proposals; and the grants management unit will set up systems to track proposals and sponsored research, and manage awards. The Directorate will encourage donors and national and international partnerships to support research activities that fall within the agenda. The Directorate will work with partners to build faculty capacity to undertake research, and pair senior mentors with young researchers.
A critical piece of the new research agenda is its link with education There is little published scholarship about education for health professionals in Africa. It is novel that MUHASâ€™s research agenda prioritizes educational research as one of its major themes. MUHAS will reward faculty with small grants, and through promotion, for published research that focuses on improving the quality of health professionalsâ€™ education. Furthermore, MUHAS will encourage faculty to engage students in their research and to directly feed their findings into the curricula, keeping their students up-to-date with cutting-edge research relevant to the populations they will serve.
THE FUTURE Health professional schools in Tanzania conduct educational research to evaluate and disseminate new approaches to teaching and learning
Increasing practicing health professionals THE CHALLENGE To engage all stakeholders in the planning of training adequate numbers of competent health professionals, and retaining them to provide quality care, particularly in rural areas
To fulfill its Development Vision 2025, the Government of Tanzania is pressing for more health professionals practicing throughout the country. But training institutions are short of teaching faculty and their facilities are inadequate to train more graduates. Employers are unable to provide adequate facilities and supervision for the increasing numbers of graduates, through their internships and early employment. Without supportive supervision, continuing education and better employment conditions, graduates are unwilling to go to remote areas and are tempted to work in administrative jobs or to seek employment overseas. In the absence of other interventions, increasing the number of graduates will not translate into as many competent health professionals practicing where they are most needed.
Responsibility for planning interventions to increase the numbers of practicing health professionals cuts across ministries and organizations, including the Ministries of Health and Social Welfare, Education and Vocational Training, Planning, Finance, training institutions, public and private employers, and funding partners. A group of ALP researchers from MUHAS and UCSF decided to develop a tool to facilitate policy makers and others to make joint and realistic plans to increase the quantity and quality of health professionals in Tanzania â€“ beginning with medical doctors. We consulted graduates and their employers and reviewed available literature about the health worker shortages in Tanzania in order to determine the most helpful ways to support the planning process, and developed the ICAD tool.
ICAD is a quantitative tool that enables users to predict the impacts and costs of policies to increase the number of clinically active doctors in Tanzania 14
In creating ICAD, we identified four key stages in the development, employment and retention of clinically active doctors, stages in which well-designed policy interventions could have the greatest effect on increasing the percentage of medical school graduates remaining in clinical practice, in Tanzania, throughout their working lives.
In the preparation & selection stage, interventions focus on ensuring that medical school applicants have sufficient science knowledge and are screened for their interest and suitability to become practicing professionals in Tanzania; In the training stage, interventions focus on the capacity of professional schools to educate students to become competent and confident to practice their clinical skills; In the placement stage, interventions focus on allocation of health professionals to work where they are needed throughout the country; In the retention stage, interventions focus on finding appropriate incentives and benefits and making continuing education available to ensure that more professionals remain clinically active in Tanzania. We built ICAD as an Excel workbook using data gathered from various sources â€“ the number of students entering medical schools, the 2006 Service Availability Mapping undertaken by the Ministry of Health and Social Welfare, a small survey of doctor movement conducted by MUHAS, human resources for health surveys from other countries in sub-Saharan Africa â€“ as well as expert opinion. While the numbers are plausible, users may alter some data if they have different assumptions or information. Use of ICAD highlights the paucity of data to evaluate the impact of policy interventions on the distribution of human resources in Tanzania and could drive further information gathering.
"This has expanded our understanding... in the end it helps decision makers to know the cost effectiveness of their interventions -Tanzanian Health Policymaker
THE FUTURE The ICAD development team invites stakeholders to test the planning tool and to contribute to its further development 15
Universities for Health THE FUTURE
There is still much work ahead. The activities we describe lay some foundations for strengthening of health professions education in Tanzania. The use of competency-based education will be assessed as the new curricula are implemented and as other universities start the journey MUHAS has begun. Faculty want to continue to learn and explore new methods of teaching and assessment, and to evaluate the effectiveness of different approaches. Researchers plan to familiarize themselves with educational scholarship in order to properly assess innovations in health professions education. THE PROFESSOR HAILE DEBAS
CENTRE FOR HEALTH PROFESSIONS EDUCATION
Our plans for the future are based around activities in the Professor Haile Debas Centre for Health Professions Education (CHPE) now being built on the MUHAS campus. The Centre, built through the ALP, will open in 2012.
Our vision for CHPE is that it will provide an open environment that catalyses inter-professional development, and transforms and extends education and research at MUHAS to directly benefit the health of the people of Tanzania. CHPE will not only support excellence in teaching and research for faculty and students across all of its school and institutes but will also support the development of inter-professional continuing education programmes throughout the country.
CHPE will house a state-of-the art conference hall, a department of health professions education and a media centre on the ground floor. Inter-professional skills laboratories, e-learning, distance learning and tele-medicine facilities, located on the first floor, will connect MUHAS and other teaching institutions and regional/district level health workers. The remaining three floors will provide facilities that stimulate cross-school interaction in education, research and outreach, including centres for data management and research.
CHPE will serve as a nerve centre for health professions education research in Tanzania. Through CHPE, MUHAS will reach and facilitate training of pre-service students and in-service health care workers at the campus and at remote sites outside MUHAS and within the East African region. Through the centre’s modern communication and video-conferencing facilities, MUHAS will collaborate with other health institutions in delivery of education to all cadres of health professionals – thus reaching a wider audience and significantly contributing to better health outcomes. As a marker of the strength of the MUHAS-UCSF partnership, MUHAS honoured Professor Haile Debas, Founding Executive Director of UCSF Global Health Sciences, by naming CHPE after him.
The Centre for Health Professions Education symbolizes partnership, and will serve as a hub for health workers and their educators— ensuring quality health care for the people of Tanzania.
Project Leadership: Haile Debas, Founding Executive Director, UCSF GHS; Ephata Kaaya, MUHAS Principal Investigator, ALP; Sarah Macfarlane, UCSF Principal Investigator, ALP; Kisali Pallangyo, Vice Chancellor, MUHAS Core Team: Molly Fyfe, Alex Goodell, Kate Gorman, Dominicus Haule, Joel Israel, Gary Koehler, Chloe LeMarchand, Lindsey Lubbock, Mariam Madiwa, Atour Malko, Mercy Mpatwa Masuki, Peter Mbago, Nana Nachene Mgimwa, Lucy Mngao, Margareth Mrema, Mussa Mrindoko, Cat Myser, Thomas Nagunwa, Zulfa Njalumbe, Selma Omer Education: Marcus Banks, Bobby Baron, Emily Christensen, John Friend, Molly Fyfe, Reena Gupta, Dominicus Haule, Sharad Jain, Steven Kayser, Sebalda Leshabari, Royce Lin, Helen Loeser, Peter Loomer, Judy Martin-Holland, Siriel Massawe, Susan Masters, Mercy Mpatwa Masuki, Naboth Mbembati, Charles Mkony, Cat Myser, Helga Naburi, Thomas Nagunwa, Selma Omer, Patricia Oâ€™Sullivan, Dorothy Perry, Carmen Portillo, Teri Reynolds, Victoria Ruddick, Dean Schillinger, Kevin Souza, Chris Stewart, Stephanie Tache, Guy Vandenberg, Sharon Youmans MUHAS Curriculum Committee: Muhamad Bakari, Mhina Chambuso, Rashidi Heri, Deodatus Kakoko, Apolinary Kamuhabwa, Noel Kasanjala, Edmund Kayombo, Anna Kessy, Irene Kida, Emil Kikwilu, Thekla Kohi, Gideon Kwesigabo, Joseph Magandula, Catherine Malika, Khadija Malima, Karim Manji, Emanuel Mauga, Lilian Mselle, Naboth Mbembati, Zacharia Mbwambo, Omary Minzi, Charles Mkony, Doreen Mloka, Rehema Mtonga, Emeria Mugonzibwa, Elifuraha Mumghamba, Kennedy Mwambete, Amos Mwakigonja, Olipa Ngassapa, Anne Outwater, Sira Owibingire, Sose Senya, David Urassa MUHAS Health Professions Education Group: Deodatus Kakoko, Apolinary Kamuhabwa, Rodrick Kisenge, Germana Leyna, Magdalene Lyimo, Charles Mkony, Doreen Mloka, Ted Mselle, Patricia Munseri, Amos Mwakigonja, Helga Naburi, Marina Njelekela, Sira Owibingire, Dennis Russa, Phillip Sassi, Edith Tarimo Metrics: Alya Briceno, Brian Harris, Tara Horvath, Eliangiringa Kaale, Jim G. Kahn, Meleckzedek Leshabari, Alex Luo, Joyce Masalu, Rose Mpembeni, Margareth Mrema, Ellen Stein Research: Muhsin Aboud, Daima Athumani, Nina Agabian, Mainda Chanyika, Susanne Hildebrand-Zanki, Limi Kahabi, Gary Koehler, Bakari Lembariti, Susan X. Lin, Erik Lium, Georgina Lopez, Lindsey Lubbock, Eligius Lyamuya, Joyce Masalu, Mariam Masandika, Nana Nachene Mgimwa, Hellen Mtui, Zoanne Nelson, Chuck Smukler, Titus Tibenda, Tija Ukondwa Research Award Winners: Lorna Carneiro, Gasto Frumence , Alphonce Kalula , Alphonce Ignas Marealle Project Administration: Charmaine Bautista, Ann Bourns, Katia Chikasuye, Natalie Collins, Geoffrey Daily, Francisca Eugene, Markay Hopps, Paula Issangya, Ruth Kitundu, Eric Kyejo, Donna Langston, Daisy Leo, Esther Livoga, Georgina Lopez, Margot Mahannah, Godfrey Pascal Mallya, Joyce McKinney, Noru Mkali, Jeff Mulvihill, Paula Murphy, Rashid Mweragi, Mussa Mzuzuli, Amos Nnko, Linda Sam , Chuck Smukler, Kerstin Svendsen, Ellyn Woo Students, Residents and Post-Docs: Renata AbrahĂŁo, Soraya Azari, Kelli Barbour, Bob Bell, Joy Bhosai, Radka Cahlikova, Tobias Chacha, Shuku Charles, Bonnie Chen, Jenifrida Chilala, Courtney Crane, Monique Dail, Simeon Enoch , Molly Fyfe, Rose Gallus, Cathryn Haeffele, Rabia Ismael, Mkinda John, Scholastica John, Achilles Kiwanuka, Gary Koehler, Sher-Ping Leung, Yue Liang, Albert Luciana, Patience Luoga, Mugara Mahungururo, E.Y. Masunaga, Linda Milahula, Baracka Morris, Goodluck Mrosso, Peter Mwadiga, Martha Nkya, Livuka Nsemwa, Gehres Paschal, Mdegela Petro, Chuom Ramadhani, Teri Reynolds, Mastidia Rutaihwa, Linda Sam, Andrew Saunders, Michael Selemani, Lindsay Stone, Arianne Teherani, Kulwa Valentine, Fahran Yusuph, Lin Zhao Consultants: Phyllis Freeman, Will Hector, Lucy Honig, Edward Kirumira, Kelly Low, Terry Mandel, Neema Mattee, Sidney Ndeki, Ina Warriner National Intersectoral Partnership Taskforce: Selmu Abdallah, Godfrida Clement, Ephata Kaaya, Eligius Lyamuya, Leonard Mboera, Gilbert Mliga, Hassan Mshinda, David Ngassapa, Mayunga Nkunya National Health Professions Education Partnership Advisory Group: Salum Abdallah, Catherine Hongoke, Eliangiringa Kaale, Ephata Kaaya, Grace Kibaya, Eligius Lyamuya, Crispin Magori, Augustine Mallya, Siriel Massawe, Charles Mkony, David Ngassapa, Pascalis Rugarabamu, Eunice Siaty Project Advisors: Claire Brindis, Eric Brewer, Craig Cohen, John Greenspan, Robert Hiatt, Phil Hopewell, Joe Kolars, Michael Reyes, George Rutherford, Paul Volberding, Gene Washington We acknowledge the support of university leadership: Muhsin Aboud, Muhamed Bakari, Haile Debas, Susan Desmond-Hellmann, Kathy Dracup, Richard Feachem, John Featherstone, Dina Gasarasi, Sam Hawgood, Ephata Kaaya, Mary Anne Koda-Kimble, Apolinary Kamuhabwa, Angwara Kiwara, Bakari Lembariti, Edda Tandi Lwoga, Eligius Lyamuya, Mainen Moshi, David Ngassapa, Kisali Pallangyo, Zul Premji, Sose Senya, Jaime Sepulveda Designed by Alex Goodell