The Liverpool Mulago Partnership

Development of the partnership

Mulago Hospital and Liverpool Women’s NHS Foundation Trust are, respectively, two of the biggest maternity units in Africa and Europe. Despite this similarity, there are marked differences in the populations they serve and the resources they have available. Mulago has a wealth of fascinating and complex pathologies among its patient population, but it is very understaffed and under-resourced. Liverpool, by contrast, is well resourced with high-cost technology and staff. The opportunities for training are excellent in both units but also restricted: in Mulago because of the limited resources, and in Liverpool because of the limited numbers of serious maternal complications. It is therefore appropriate that these two units should share resources and knowledge within a formal twinning scheme.

Andrew Weeks, a consultant obstetrician at Liverpool Women’s Hospital, held a visiting lectureship in Mulago Hospital in 2001-3 and set up Liverpool Mulago Partnership in 2008. In 2010, Liverpool Mulago Partnership became a registered charity with these objectives:

• To support the achievement of the Millennium Development Goals (maternal and infant mortality) through the development of a sustainable, reciprocal, and effective healthcare partnership

• To enhance human resource capacity through a carefully managed and supported educational and staff exchange scheme.

At the core of the partnership sits the exchange scheme. Exchanges of clinical staff are supported by active project teams in both countries to help to embed new skills and experiences in patient management and thus reduce mortality rates and increase patient wellbeing. The exchanges are focused on capacity building through training and service delivery. Liverpool Mulago Partnership visits are conducted in pairs twice a year for two to three weeks. So far, 12 people have taken part. The Ugandan and British pairs mentor each other during the visits so that a working relationship develops. Participants are also supported by the Eleanor Bradley fellowship, now in its third year, which provides for a specialist trainee from Liverpool or Cardiff to spend a year in Mulago.

Exchange visits have allowed staff from Mulago to observe maternity care in a developed world environment and to develop ideas about transferring these approaches to Mulago. The partnership has driven change in areas such as postoperative recovery, rejuvenation of maternal death audit, midwifery educational updates, protocol development, and triage of obstetric patients.

Selection decisions are made by the local Liverpool Mulago Partnership committee. Advertisements are displayed throughout the hospitals and applications are invited. Applicants are judged against the following criteria:

• Commitment to the Liverpool Mulago Partnership programme

• Expected benefits of the visit to the hospital visited

• Expected benefits of the visit to the hospital of origin

• Potential for personal development.

Evaluation

The partnership benefits from ongoing evaluation by two researchers from the Liverpool Law School (HLA and CJP). The evaluation includes the development of data collection and audit systems in Mulago, the analysis of post visit reports, interviews with exchanges and other staff, and regular visits to Mulago.

The box shows the benefits obtained by the exchange visits to the hospitals in Liverpool and Kampala, as reported by the first 12 participants.

Evaluation interviews after the visits have identified several levels at which the scheme has made an impact on Liverpool Women’s Foundation Trust and its personnel:

• The people who visit Mulago have benefited through their focused educational experience, and from experiencing women’s healthcare in an alternative setting

• Their teambuilding skills have improved through working and living together in a challenging environment

• The quality of care in the trust should benefit from the enhanced experience and training of the hospital staff. This will especially apply to women at the highest risk—those with HIV, severe intrapartum complications (ruptured uterus or eclampsia), and immigrants with rare health conditions (for example, untreated congenital heart disease)

• The scheme appears to be having a beneficial effect on staff attitudes and motivation

• The reputation of the trust has been enhanced in the public eye after publicity about the scheme in the media.

Funding

Running the Liverpool Mulago Partnership is expensive. Each visit costs around £1500 (€1800; $2300), so with eight people travelling each year the total cost for visits amounts to about £12 000 a year. Start-up costs for the scheme were obtained from the North-West NHS Leadership Academy, with a bursary of £10 000, and from matched funding from the Liverpool Women’s Hospital.

Since then funding has included the Pennies from Heaven scheme (www.penniesfromheaven.co.uk), in which staff from an organisation agree to round down their monthly pay to the nearest pound and give the remainder to an agreed charity. On average each employee contributes 50 pence a month, raising around £4500 a year. It was agreed with the hospital staff unions to offer this as an “opt out” scheme; that is, all staff were included unless they returned a form opting out of the scheme. After a publicity drive, 800 members of the hospital staff were included in the scheme. This is augmented by local fundraising by staff at Liverpool Women’s Hospital (for example, coffee mornings, raffles).

Future developments

The partnership has recently received grant funding from the International Health Links Funding Scheme to set up a high dependency unit in Mulago Hospital. The funding scheme aims to strengthen the capacity of health services in developing countries by providing funding to support the work of health links. The idea for the application came from one of the Ugandan consultants who was on the second exchange to the United Kingdom. His report identified the need for a high dependency unit at Mulago Hospital and the potential plans for its development. Liverpool Women’s Hospital has extensive experience of running a high dependency care unit in obstetrics and has developed the midwifery early warning system (MEWS), which has been used nationally. The Mulago high dependency unit project includes comprehensive training in high dependency obstetric care and reallocation of staff to this area, improving experience in the diagnosis and management of high risk obstetric patients. It is starting to play a pivotal part in improving triage and patient care for those at greatest risk of mortality.

In addition to this, two members of the Liverpool Mulago Partnership team (HLA and CJP) spent five weeks in Mulago helping to develop the record keeping facility to support improved patient management and audit. To continue to develop capacity in this area, the partnership has been awarded two Commonwealth professional fellowships to enable the deputy manager of the records office and his assistant to spend a month in Liverpool in 2011.

Conclusion

The Liverpool Mulago Partnership has developed a unique approach that combines bilateral (and reciprocal) short term stays, underpinned by the longer term Eleanor Bradley fellowship, and a strong focus on benchmarking and evaluation.

The partnership emerged from strong pre-existing relationships developed during the founder’s original time in Mulago. According to a 2008 report from the Department for International Development, this is a critical factor in the success of any north-south healthcare partnership.4 Furthermore, despite its broad objectives, the partnership has sought to be narrowly targeted, highly contextualised, and closely responsive to the identification of need and policy initiatives raised by practitioners and managers in Uganda. These factors have been found to be associated with successful north-south healthcare links, and we hope they will lead to a lasting and mutually beneficial programme.