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Bridging nations, partners and rural health inequality

Posted in: Uncategorised, by bridg71481, on 30th September 2019 | 0 comments

A blog post written about our recent visit to Malawi by one of our Site Clinical Leads, Trustees and Clinical Advisory Group member – Andrew Paterson. Andrew is also a Senior Lecturer / Honorary Consultant at the University of Dundee Dental School, 

I am very fortunate to be a volunteer, trustee and site clinical lead for the UK charity Bridge2Aid which for the last 15 years has trained clinical officers in rural settings in Tanzania to provide safe, sustainable and simple emergency dentistry to their communities whilst delivering relevant oral health messages and appropriate referrals of more complicated cases to dental therapists and dentists in district health facilities.

During that time 570 health workers have been trained and around 20 District Dental Officers trained to be potential local trainers. The ongoing programme in Tanzania has treated 56,500 patients and provided 5.7 million rural Tanzanians access to simple emergency dentistry. Put in the words of Dr Mohammed Khalfan, Clinical Director of Bridge2Aid’s Tanzanian partner Education & Health for All (EH4all), “that’s access to the equivalent of more than double the population of Botswana due to the efforts, drive and collaboration of many”.

Bridge2Aid has more recently felt that the Tanzanian training model was applicable to other nations and Malawi was one of the countries in which it may provide benefit to the health system. Ongoing discussions in 2018 culminated in Professor Jeremy Bagg visiting Tanzania to see the model first hand during a programme I was privileged to lead (https://www.wordpress.com/post/themaldentproject.com/171). Many discussions were had and Jeremy’s sterling efforts brought partners together to investigate collaboration possibilities including the Dental Association of Malawi, Smileawi, Bridge2Aid and the Universities of Glasgow and Dundee towards a common goal of improving oral health in the rural periphery in Malawi. The concept has been  approached with a positive mindset by everyone

Bridge2Aid and the Dental Association of Malawi were successful in gaining a new projects start up grant from the Tropical Health Education Trust and in June 2019 Paul Tasman, Bridge2Aid’s Operations Manager, visited Malawi to assess the feasibility of the project with, amongst others, the Dental Association of Malawi, The Medical Council of Malawi, The Ministry of Health and the Chief Dental Officer (https://www.wordpress.com/post/themaldentproject.com/834). Responses of the Malawian Government and dental community to Bridge2Aid’s proposals were very encouraging as they appeared to dovetail well with the Government’s existing policies and their ongoing attempts to facilitate access to care in rural and hard to reach areas.

Underpinned by this goodwill, Bridge2Aid CEO Shaenna Loughnane and I travelled to Malawi on 10th September 2019 to have further discussions with Malawian stakeholders and to try to put arrangements in place for a first Bridge2Aid programme to be delivered in 2020. September had been chosen as Smileawi were running a programme that provided emergency dental care near Mzuzu at that time, which gave us the opportunity to see first-hand the challenges of providing dentistry in rural Malawi. Smileawi had been instrumental in bringing together the Smile North Dental Therapists Group and they organised a conference in Mzuzu which gave a forum for discussion and CPD for therapists from all parts of the Northern Region. Smileawi and Smile North had kindly invited Bridge2Aid to present and discuss the training model to them at the conference. We would be joined on the visit by Dr Mohammed Khalfan who in addition to his role with EH4all is a Dental Therapist. Mo had had to travel independently from Mwanza via Dar-es-Salaam. The dental therapists would be at the heart of Bridge2Aid’s proposed training model in Malawi where the Medical Assistant cadre, rather than Clinical Officers, would be trained and later they would be mentored and supervised by dental therapists.

Shaenna and I arrived in Lilongwe on the 11th September 2019 to be greeted by Dr Wiston Mukiwa, a proud alumnus of the University of Dundee (where I have my “day job”) and Secretary of the Dental Association of Malawi. Whilst I had lived in Malawi, many years before, more recently I had travelled frequently to Tanzania so it at first felt strange to not be landing in Dar or Mwanza.

Meeting Wiston

Wiston’s welcome was warm and we were driven through the busy Lilongwe traffic to our hotel, the Korea Garden Lodge. After a quick freshen up, Shaenna and I joined Wiston for dinner during which many issues were discussed and solutions brainstormed.

Wiston would pick us up the following morning and fortunately the airport was on the road North so we picked up Mo and headed on the six hour drive to Mzuzu. Discussions continued in the car regarding the programme and many other subjects. I was beginning to understand that Wiston was both knowledgeable and engaging on many important issues ranging from hybrid mangoes to the problems of deforestation in Africa. It made the time pass quickly through the beautiful scenery, past familiar rural scenes but in a ‘more Scotland-like’ mountainous terrain (without the inevitable rain) than Tanzania

We arrived in Mzuzu at the glorious Umunthu camp and were joined by the founders of Smileawi, Nigel and Vicky Milne, during the evening. Our plan was to visit Smileawi’s training sites the following day as any first Bridge2Aid programme would require collaboration and cooperation with both local partners and Smileawi. Accordingly it was important to see the Smileawi model first hand, the potential logistic issues that may occur and to understand who to engage with within the local community. Nigel and Vicky were amazingly open and helpful offering great advice and local knowledge.

Andrew, Nigel, Vicky, Mo, Wiston and Shaenna at Umunthu Camp, Mzuzu

We followed Vicky and part of the Smileawi team early next morning to the Kambombo Health post, following her car flying the St Andrew’s cross up the rutted dirt road, a remarkably similar journey when accessing a Tanzanian dispensary.

The health post was in a beautiful setting with banana plantations and mountains in the distance. This multi-purpose building was used by villagers throughout the year mostly for childcare and had been funded by our late Scottish dental colleague and Smileawi volunteer Alan Walker and is a lasting legacy for the local rural community.

View from the Kambombo health post

On entering the health post it became a bit of a reunion for me. Former colleagues from the Maxillofacial Unit at Crosshouse Hospital in Kilmarnock, Helen Patterson and Liz Leggate, were volunteering with Smileawi – a fairly surreal experience to bump into them here.

Dr Patterson and Dr Leggate I presume! In Kambombo Clinic

Shaenna, Mo, Wiston and I each had different roles in trying to make the most of our visit. Mine was largely to look at the logistics of Smileawi’s operation, so I spent time looking at their sterilisation facilities and how the clinic operates and flows. There were far more similarities than differences and indeed the sterilisation facilities were identical to those Bridge2Aid uses in Tanzania. Whilst Bridge2Aid concentrates on training and Smileawi concentrates on treatment much of the ethos of the organisations is remarkably well-aligned. Smileawi have really engaged with a local youth organisation “Taarifa” led by the engaging and impressive Shupo Kumwenda who we met at our next Smileawi site. Taarifa provide local volunteers who facilitate waiting patients and act as interpreters and it was great to see the symbiotic relationship between Smileawi and the local community.

After meeting the local chief and holding further discussions with community headmen we travelled to another Smileawi site at Ekwendeni hospital near Mzuzu. Here Nigel was leading a team with large patient numbers waiting for treatment. Smileawi were running a slick operation and were working hand in hand with the local dental therapist. This was excellent collaboration but Mo, Wiston and I had to resist our urge to put on some gloves and assist in clearing the backlog of patients. We observed the desperate state of oral health in these rural areas with widespread dental decay in many, meaning there was a massive need for both safe emergency dentistry and oral health education exactly like Tanzania.

We left the Smileawi sites convinced that the Bridge2Aid model was both feasible and much needed in Malawi and that it would be possible to cascade-train health workers here which Wiston felt was such an important priority for Malawi.

It is imperative that NGO’s planning on putting programmes into new areas discuss and negotiate plans with senior local stakeholders so that the programmes appropriately meet the needs of the community. Wiston therefore arranged for us to meet Dr Don Chiwaya, one of the two dentists at Mzuzu Central Hospital. Wiston and Shaenna discussed Bridge2Aid’s plans and were met with a very positive response. I was able to send greetings to Don from his former colleague, Remus Chunda, a dental therapist and now a PhD student at the University of Dundee.

Don, Shaenna, Mo, Andrew & Wiston at the Dental Department, Mzuzu Central Hospital

On leaving the hospital we bumped into Alan Stewart and his team from Smileawi Spanners, mechanics who repair local ambulances and train local people in vehicle maintenance. They had already managed to put two ambulances back into service – great work.

The following day Smileawi and the Smile North Dental therapists group had their conference at the St John of God Conference Centre, Mzuzu. Smileawi had been instrumental in bringing together the Northern dental therapists from a wide and remote geographical area to interact together and enhance their lifelong learning and continuing professional development. This was a very impressive group who would be pivotal as trainers during a Bridge2Aid programme and mentors and role models for trained Medical Assistants after any programme. Helen Patterson gave an inspiring talk on managing disability in rural Malawi and then Shaenna introduced the Bridge2Aid model to the therapists. I discussed the nuts and bolts of the Bridge2Aid model and the proposals of how it may work or be modified for Malawi and Mo discussed the benefits of the training model for a local dental therapist. We were, though, all merely warm up acts for Wiston who gave the audience one of the most inspiring talks I have ever heard in over 30 years as a dentist. His complete understanding of public health issues in rural Africa was inspirational.

Collaboration at the Smileawi Conference

Wiston concluded that he felt that the Bridge2Aid project would make a difference as it brings together many partners to buy into a sustainable programme that will systematically and consistently train Medical Assistants in rural areas in the provision of emergency dental care services and referral of difficult cases that are beyond their competency. He felt that this would in turn free some of the Dental Therapists time for them to deal with more complicated cases and importantly empower them with the opportunity to be the natural trainers, supervisors and mentors of the trainees.

I managed to surprise Wiston at the Conference by presenting him, on behalf of the University of Dundee, with some alumni memorabilia and as a member of staff there I was able to tell Wiston how proud the University is of his contribution to public health and dental public health in Malawi given his many roles and many years of excellent service.

After lunch Wiston, Shaenna, Mo and I facilitated a wide ranging discussion with groups of dental therapists regarding the Bridge2Aid proposals, exchanging ideas and jointly problem solving our way through potential barriers with the therapists to move the proposals forward.

That evening we joined the full Smileawi team for dinner prior to returning to Lilongwe the following day. As they say, a good time was had by all! Our route to Lilongwe involved stops in Mzimba and Jenda to scope out potential sites and accommodation for possible future programmes.

Mo had to return to Tanzania and for the next two days Wiston, Shaenna and I discussed and refined our thoughts on a potential programme based on what we had observed to ensure its relevance to Malawi. In addition we met a local NGO to discuss logistic support needs for Bridge2Aid programmes which is essential for their smooth running.

As Bridge2Aid has a sustainable model, a key aspect of its sustainability is its ability to work alongside local partners and within existing healthcare structures and priorities. To ensure that this is done effectively during our remaining time in Malawi we met key partners and stakeholders including Dr Nedson Fosiko, Deputy Director of Clinical Services at the Ministry of Health and Dr Jessie Mlotha-Namarika, Chief Dental Officer of Malawi. Both were entirely positive and we were reassured that the Bridge2Aid model was relevant to Malawian health needs and supported wholeheartedly by both Government and the dental community.

Shaenna, Andrew, Wiston and Dr Jessie Mlotha-Namarika, Chief Dental Officer of Malawi, at Kamuzu Central Hospital, Lilongwe

Wiston, Andrew, Shaenna and Dr Fosiko at the Ministry of Health

Finally it was sadly time to leave this beautiful country with its friendly hospitable people, but hopefully Bridge2Aid will return to Malawi very soon.

So what now?

Whilst there remains some administrative groundwork still to be done to ensure that both Bridge2Aid and Malawian stakeholders are in agreement over their respective roles, the first Bridge2Aid programme in Malawi has been planned for mid-2020 with tentative plans to further roll out the Malawian training model during 2021 following reflection on the first programme.

In the spirit of collaboration and continued partnership the trainers on the first programme will include Wiston, Nigel and Vicky from Smileawi and myself and EH4all will attend that programme to help train Malawian logistic partners based on their experiences in Tanzania.

I am honoured to be leading a Bridge2Aid programme in Mara Region, Tanzania in November 2019 and it will be a privilege then to have Wiston and a representative from the Malawian Ministry of Health visiting that programme to observe the Bridge2Aid training model in action so final lessons can be learned prior to the first programme in Malawi.

Just like the MalDent project, the Bridge2Aid Malawian project has so far involved the drive, positivity, collaboration and goodwill of many to attempt to build bridges between nations, partners and above all in a small way to try to bridge some of the rural health inequality gaps. I am confident it will be a success that will offer real sustainable benefits to oral health in Malawi.


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