Stella is a nurse anesthetist in Liberia, a country where women have limited social status and operating rooms have little in the way of infection control. Both have been elevated with the help of the Yale-Clinton Foundation Fellowship in International Healthcare Management, a program in which Western health care managers work side-by-side with hospital employees in developing nations to improve the quality of health care.

The premise of the fellowship, a joint effort between the Yale School of Public Health and the Clinton Foundation, is that, without strong health care systems, reducing the rates of mortality and AIDS transmission in struggling nations will be largely impossible. By tapping the knowledge and expertise of health care providers from the United States and other developed countries, the partnership seeks to improve—or, in some cases, introduce—standards of care in the hospitals of Africa and other struggling nations. “These countries have resources, what they don’t have are systems,” says Elizabeth Bradley, Ph.D., associate professor and director of Global Health Initiatives at the Yale School of Public Health, who co-directs the program with Mae Podesta, country director for the Clinton HIV/AIDS Initiative in Liberia. To strengthen those systems, the fellowship program has sent senior health care managers and postgraduate students with experience in hospital administration and public health to share their education and know-how with health care workers in both Liberia and Ethiopia. Their job is to import the best practices in hospital management from the Western World to their African counterparts, while providing leadership training to ensure improvements can be measured and sustained. “The idea is not to do for them, but to give them the expertise they need to function on their own and to teach them how to build capacity within their groups,” says Bradley.

The program, which received 180 applications for its first 25 fellowship positions, has been successful at recruiting highly qualified health care workers from around the world. Each has a master’s level degree in hospital administration or public health and, as a group, they average 10 years of work experience in both the private and public sectors. In 2006, the first group of 25 fellows was sent to Ethiopia to work in 12 public hospitals and health bureaus, and nearly half of them stayed on for another year. A second wave of five fellows was stationed in the much smaller country of Liberia beginning in early 2007.

Once abroad, the fellowship teams implement a strategically designed educational experience that offers both classroom instruction on topics such as human resource and financial management, procurement and infection control, along with on-the-job training. “With just didactic learning, employees may learn how to do a spreadsheet, but they don’t get the practical experience,” says Bradley. “We put a realtime mentor right in their workspace with them.” A ‘Blueprint for Hospital Management,’ developed by the Yale-Clinton Fellowship teams, guides the fellows in establishing management structures.

Every quarter, fellows measure their progress on each of the Blueprint’s goals, including eight critical functions and 125 standards—from an  organizational chart to a payroll system to privacy curtains and bed nets to organized pharmacy supplies

Making Progress with New Standards and Systems
By the end of the program’s first year in Ethiopia, it was evident that the intensive education and mentoring in the field had paid off. The fellows reported significant improvement on 40 of the program’s 70 standards. “Tremendous headway has been made,” says Bradley. “Clinical outcomes are being established, structural changes have been made and a patient satisfaction tool is in place. Patient registration is smoother, wait time is down and cleanliness has improved.”

What’s more, a whole new class of African executive health care managers has emerged: at half the country’s 100 hospitals, newly appointed chief executive officers have assumed responsibility for the institutions, including monitoring the quality of health care offered on a going-forward basis. “The addition of chief executive officers was a major step forward,” says Bradley. “We convinced Ethiopia’s Ministry of Health that CEOs were needed for each hospital, instead of being run by a physician who didn’t want to manage a hospital.” Of those 50 executive managers, 26 have completed the Yale educational program and are being paid at a high level of civil service pay. “These CEOs have become quite good at lobbying,” says Bradley. “We watched them go from shy and mumbling to putting together PowerPoint presentations and being able to stand up and lead.”

A Life-Altering Experience for All Involved The new hospital CEOs aren’t the only ones who have evolved in profound ways. For the fellows  who left homes in the United States, Spain and the Philippines to spend a year or more abroad in a developing nation, the program is much like a stint in the Peace Corps.

“It’s just exceptional what happens to both our health care workers and the employees they mentor,” says Bradley. Arriving in Liberia, which is just emerging from years of civil war, fellows found the country’s hospitals lacked basic systems that Westerners take for granted—from running water on patient floors to an on-site incinerator for hazardous waste to a complete list of employees’ names. “It can be quite shell-shocking,” says Bradley. “The fellows can look agog at the conditions, which can be quite frustrating.”

As their work continues, the fellows experience lots of ups and downs, and admittedly, a few points where they think nothing will ever change, says Bradley, who has spent considerable time abroad as well. “It’s difficult, but in the end it’s an unbelievable experience, very fulfilling,” she says. That’s no doubt due to the fact that, over time, the fellows are able to affect the future of care provided to millions of Africans, many of whom face dire
health circumstances. On a personal level, there is no discounting the impact of living and working among the Liberians and Ethiopians, who often express profound gratitude for the fellows’ guidance.

“The people are so warm and so thankful,” says Bradley. “Our fellows become a part of their families.” For the African health care workers, the fellowship program can be nothing short of dramatic. “The workers say the experience gives them hope and makes them feel good about themselves,” says Bradley. “They believe they’ll all be in a better place as a result.” In Stella’s case, organizational changes in the operating room have given her and other surgical nurses an opportunity to shine. New operating room protocols to help reduce post-surgical infection rates – that need to be enforced by nurses – have changed the dynamics between male surgeons and female nurses. “Here is a group of women who are in the position of telling male surgeons what to do now,” says Bradley. “It has been empowering for them.” Being a catalyst for change—and equipping health care workers with the skills they need to go forward on their own – is all part of the plan for the Yale-Clinton Foundation Fellowship program.

“Our exit strategy for this program was to put ourselves out of business and move on to another country,” says Bradley.  

AUTM Better World Report, 2009

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