Yale-Uganda collaboration improving health education, patient care

Twelve years ago, faculty and students from Yale and Uganda’s Makerere College of Health Sciences (MakCHS) began working and learning together with one goal: to improve patient care in Mulago National Referral Hospital (MNRH) in Kampala. During the course of this partnership, the goal — and the results — have become much broader.

The seeds of the idea that would become the Makerere University-Yale University (MUYU) Collaboration were sown in 2002 when Dr. Majid Sadigh, an associate professor of medicine at Yale, began traveling to Kampala to teach under the umbrella of the Academic Alliance for HIV Prevention and Care. During his visits he noted a contrast between the advanced clinical and epidemiologic research activities at Makerere University and the challenges of patient care on the wards of Mulago Hospital.

In the fall of 2005, Sadigh and Dr. Asghar Rastegar, professor of medicine and current director of the Office of Global Health in the Department of Internal Medicine, travelled to Kampala, Uganda on behalf of the Yale University School of Medicine (YSM) to explore a collaboration with Makerere College and Mulago Hospital.

Over the course of the week, Sadigh and Rastegar held meetings to work out the basics of the partnership with the leadership of both institutions — including the then-chair of internal medicine, Harriet Mayanja-Kizza (now co-director of MUYU in Uganda), and dean of the medical school, Nelson Sewankambo. Under the MUYU memorandum of understanding, Yale physicians, residents, and medical students would travel to Kampala for clinical rotations, and Ugandan physicians and students would train in New Haven. The goal for both groups was to improve patient care through education, training, and research; to build up the educational and clinical infrastructure; and to support research that could be easily translated into practice. 

To date, the collaboration has been resoundingly successful, according to YSM’s Dr. Tracy Rabin, co-director of MUYU in the United States and assistant professor of medicine. The agreement was renewed in 2011 and is up for review a third time.

Rabin attributes the collaboration’s success to the bilateral commitment toward a unified vision, a focus on maintaining an equitable and ethical partnership, mutual respect and trust, and a shared passion for educational capacity-building.

“This collaboration has made a clear impact on the numbers of highly trained internal medicine subspecialty physicians that teach and provide patient care on the wards of MNRH,” said Rabin, who is also assistant director in the Office of Global Health and associate program director for global and community health in the Yale Primary Care Residency Program.

“Some are academic faculty who have also used their training at Yale to inspire or launch scholarly projects, and others are Ministry of Health physicians, who have brought back different perspectives on health system improvement and care delivery,” she said. “Additionally, the U.S. trainees who have done clinical and scholarly rotations in Uganda return with a host of new perspectives on their clinical practice, on health care delivery in resource-limited settings, and on their own career and personal goals.”

Today, the collaboration has expanded to support capacity-building efforts led by colleagues in other clinical areas, including pediatric surgery, endocrine surgery, emergency medicine, pathology, obstetrics & gynecology, and nursing/midwifery, she said.

“Taking into account the additional projects that have grown out of the MUYU collaboration, our focus on improving patient care at MNRH has evolved into a focus on improving healthcare in Uganda,” she adds.

Here are some of the program’s accomplishments to date:

Training MakCHS and MNRH faculty/physicians at Yale

Select junior faculty at MakCHS and physicians at MNRH have received further clinical training at Yale, with a focus on areas of greater needs, specifically with respect to non-communicable diseases. Participants were selected with the input from leadership at both institutions, and the training has been funded by the Yale-Mulago Medical Fellowship Corporation.

The length of training at Yale has ranged between 6 weeks and 12 months, based on the need of the individual. Since 2006, 21 faculty/physicians have been trained in the following specialties and subspecialties: cardiology, endocrinology, gastroenterology, nephrology, rheumatology, oncology, pulmonology, intensive care, pediatric surgery, endocrine surgery, emergency medicine, pathology, and neurology. Since receiving their training, participants have returned to Uganda, and the majority serve as faculty or specialists/consultants at MakCHS and/or MNRH. 

Rabin notes, “The faculty training component of MUYU owes its success to the hard work of the talented Ugandan colleagues who we have been able to bring to Yale, and the dedication of the YSM faculty who have served as their mentors. The enthusiasm that the YSM faculty have had for this project, and the fact that the visitors have been embraced by their respective subspecialty sections, is a testament to the high quality and generous spirit of our educators.”

Student exchange program

Since 2006, the MUYU collaboration has hosted 114 Yale-sponsored trainees (medical, nursing, physician assistant, and public health students) to either work clinically or on locally-mentored research projects in Uganda. During that same period of time, 31 senior MakCHS medical students have engaged in four-week-long internal medicine clerkship rotations at Yale New Haven Hospital. These rotations are funded by the YSM Office of International Medical Student Education in reciprocity for the resources devoted by MakCHS faculty to educating Yale students in Kampala. During these rotations, the Ugandan students are exposed to the U.S. health care system, different styles of teaching and providing patient care, and American culture outside of the hospital.

“In spite of all of the systems and cultural differences,” noted Rabin, “these students quickly adapt and function at the level of their Yale counterparts, and consistently impress the Yale faculty and residents with their breadth and depth of knowledge. Although there are many diagnostics and therapies that the students see here at Yale that they do not yet have the opportunity to use in Uganda, it is also very impactful for the Ugandan students to appreciate how strong their medical training at home is, and realize how much they have to contribute.”

Clinical experience for U.S. postgraduate students and faculty

MakCHS/Mulago National Referral Hospital has been one of the six partnership sites for the Yale/Stanford Johnson & Johnson Global Health Scholar Program. Each year this program selects, from a national pool of applicants in the U.S., up to 55 residents in their final year of training, as well as career physicians/faculty, for a six-week rotation at one of the six sites. During the past 12 years, 152 residents and 51 career physicians and faculty have rotated through MakCHS/MNRH through this program.

The most critical issue facing health care systems in resource-limited regions is the shortage of people who make them work.

DR. ASGHAR RASTEGAR

During the rotations scholars work side-by-side with their Ugandan colleagues, caring for patients, learning from each other, and contributing to training of Ugandan residents, interns, and students. This program is highly structured and is overseen by co-directors from both YSM and MakCHS. The program includes pre-departure training, supervision of scholars and administrative support (both at YSM and through the MUYU office at the MakCHS), and post-trip debriefing. Scholars are not only exposed to challenges in providing care to patients with a variety of illnesses in a resource-limited environment, but also have the opportunity to learn about the assets of the Ugandan healthcare system, and the social and cultural context of care in Uganda.

Improving postgraduate medical training and patient care

Here are some of the ways in which the partnership has helped improve the infrastructure at MakCHS/MNRH related to postgraduate medical training and patient care:

• RASHOTS (Rainier Arnhold Senior House Officer Teaching Support) Project – Established in 2010 to support postgraduate trainees in the MakCHS Department of Internal Medicine, this organization is funded by The Mulago Foundation through a grant obtained by Dr. Robert Kalyesubula, MakCHS nephrologist and MUYU alumnus, with MUYU assistance. This organization has brought a new level of structure to education and supportive activities for MakCHS residents, known as senior house officers (SHOs) in Uganda. Over the past seven years, RASHOTS has improved the quality of SHO training and assessment, developed a database to track morbidity and mortality on the internal medicine wards at MNRH, and established a new rotating junior faculty position — Chief Resident — to further support SHO education.

• Direct contributions from Yale: Among the items Yale has sent to Uganda are: a mobile mammography van and two ultrasound machines to the Uganda Cancer Institute; library and renal biopsy needles to the nephrology unit; support to the MakCHS Sir Albert Cook Medical Library (provided by Mr. Mark Gentry, senior clinical librarian at the YSM Cushing/Whitney Medical Library); and a bronchoscope for the pulmonary unit. Additionally, funding for the Yale/Stanford Johnson & Johnson Global Health Scholars program has provided supplies for one of the teaching/clinical labs at MNRH, and Dr. Stephen Winter (YSM clinical professor of medicine and former Chief of the Section of Pulmonary and Critical Care Medicine at Norwalk Hospital) provided BiPAP machines and textbooks to the intensive care unit at MNRH.

Supporting applied research

Here are some of the ways the partnership has supported applied research focused on health care worker training and patient care:

• Training program: The MUYU model for training faculty and consultants for MakCHS and MNRH has been described in both PLoS ONE and the AMA Journal of Ethics. Additional projects include an evaluation of the impact of RASHOTS on SHO training, and evaluation of the experiences of the Yale-Stanford J&J Scholars and students rotating through MNRH.

• Quality Improvement (QI) initiative: In 2013-2014, MUYU sponsored a competitive grant application process for SHOs to obtain funds to conduct a Quality Improvement (QI) project at MakCHS-MNRH. This was awarded to one SHO who was jointly mentored by faculty at MakCHS and YSM, successfully examined ways to improve medication administration on the inpatient wards of MNRH, and subsequently published the work in the International Journal for Quality in Health Care.

• Patient-centered education: In 2014-2015, Dr. Trishul Siddharthan, then-Global Health Chief Resident in the Yale Primary Care Residency program, received funding from the Fulbright Scholar Program to investigate the acceptability and feasibility of a patient-centered health education tool for outpatients with congestive heart failure in both a public and private clinic in Kampala. He was mentored by faculty from both YSM and MakCHS, and published the work in PLoS ONE.

• Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD): Catalyzed by a grant from the Yale Global Health Leadership Institute in 2014, UINCD is a research partnership under the co-directorship of Dr. Jeremy Schwartz, assistant professor of medicine at YSM, and Dr. Isaac Ssinabulya, lecturer in medicine at MakCHS, that aims to build capacity in the realms of prevention, care, training, and research to enable the provision of effective and integrated care along the non-communicable disease (NCD) management spectrum. UINCD began in 2013 as a group of doctors, researchers, and government officials representing the Uganda Ministry of Health, MakCHS, and MNRH, joined by Schwartz, Rabin, and Rastegar of YSM. Since then, UINCD has supported the work of trainee and faculty scholars from Uganda, as well as Yale School of Public Health, YSM, Yale College, and the University of Toronto.

• Center of Excellence for Patient-centered Care and Non-Communicable Disease Management in Uganda: This project is funded by Else-Kröner Fresenius Stiftung, a German foundation, and is a collaborative project between Charité – Universitätsmedizin Berlin in Germany, YSM, Johns Hopkins University, ACCESS-Uganda and UINCD, focusing on improving care for patients with NCDs living in rural areas. This has incorporated the work of trainees from Johns Hopkins and Yale and involves the training of community health care workers, assessing models of patient education, and working with the public health care system to develop an effective model of care.

Addressing the most critical issue

Reflecting on the collaboration’s accomplishments, the global relevance of the project, and plans for the future, Rastegar noted, “Those of us working on this project for the past 12 years have the strong belief that — as has been pointed out by the World Health Organization — the most critical issue facing health care systems in resource-limited regions is the shortage of people who make them work. We believe that institutions in resource-rich regions have a responsibility to help deal with this challenge. As a global institution, Yale has the capacity to be a partner in this exciting venture. The MUYU collaboration is a step in that direction.”