D+C Development and Cooperation (No. 3, May/June 1999, p. 16-18)
International Peer Learning in the Health Sector
DSE Promotes Public Health Systems in Developing Countries
Walter Seidel
The objective of the Public Health Promotion Centre of the DSE is to assist developing countries in the implementation of Primary Health Care services. It does so in a number of innovative approaches which are a far cry from traditional health care projects.
The Public Health Promotion Centre (ZG) is one of the most recent addition to the service units of the German Foundation for International Development (DSE). In 1991, the ZG was founded in Berlin in the wake of the take-over of the management of scholarship programmes awarded to developing-country nationals by the former GDR.
As for other departments of the DSE, its task is to organise training and dialogue programmes for professional and executive staff from developing countries. These programmes are practice oriented and therefore usually closer in nature to vocational and in-service training than to classical academic training which often is known to be out of touch with participants' and many societies' most pressing needs.
With ZG programmes aimed at building the problem-solving capacities of its participants, the Centre is well aware that solutions have to be tailored to the specific context and that this is an essential part of the learning process. Ready-made transferable solutions or technologies do not exist, but much can be learned from sharing experiences in the context of "International Peer Learning" - something the ZG aims to achieve in its programmes.
In its work, the ZG draws on a comprehensive set of instruments including seminars, short term training courses and long term scholarships. Expert meetings, national and international conferences and other dialogue events promote a mutual exchange of experience, at the same time providing a forum for debating the basic problems of health and development. In addition, the ZG carries out training needs assessments, curriculum development workshops and evaluations of training programmes. It also compiles health care training materials and makes increasing use of the internet in the preparation and follow up work of events (see the Virtual Health Library).
From a health policy point of view, activities of DSE-ZG are designed to support national and regional governments' efforts to implement "Primary Health Care" (PHC). This approach was developed by the World Health Organisation in 1978 and subsequently adopted by most member countries and has lost nothing in relevance or actuality since. PHC places health in a wider context of nutrition, education, water, sanitation and housing, emphasises prevention and health promotion and gives priority to essential care for all over highly specialised care for a few. As such the concept of PHC is closely linked with poverty alleviation as the overall goal of development cooperation.
"International Peer Learning" is the conceptual idea underlying most ZG programmes. The participants are put into an active position, bring their own problems and materials and use them to go through a structured learning process. If this process works as intended, participants at the end of a programme have an improved understanding of the specific problem in question, have developed possible approaches and solutions and have fixed a number of simple and realistic "next steps". To explain what this means in practice, a few examples typical of ZG-programmes are presented in this article.
District health management courses
in Africa and Latin America
Professionals in the health sector are usually trained to assess and treat individual patients. In decentralised health services (often termed district health systems), however, they are given new roles. Increasingly they are put in a position to take decisions on how to make better use of the existing scarce resources. To decide which drugs to buy and in which quantity, how to organise the maintenance of an autoclave, which topic to choose for continuing medical education and how to detect early warning signs of an imminent malaria epidemic and what specific action to take are just a few examples: the wrong managerial decision might incur high costs both in loss of lives and in resources wasted, whereas the right decision might save resources that could be used for other important purposes and contribute to improved productivity and well-being. Looking at whole populations and at the health service as a whole, and managing resources become important tasks of the health management teams, in which they might become involved. Therefore they would need to improve their capacity in planning, organisation, management and applied epidemiology, communication and leadership skills and know-how to give continuing medical education. Health services and development agencies have reacted to this need to some degree, but need and demand for such type of training is still much higher than the offer. Local health services and agencies are mostly in a better position to tailor these courses to the needs of the participants and the service, and the ZG therefore strives to work in close partnership with these agencies and services when organising training courses. The ZG encourages and supports the participation of international partners from other developing countries as well as the exchange of tutors in such programmes so that experiences from other places can be used to help solve local problems. In the end the basic problems and the dominating diseases do not differ so much that health workers could not profit from each other's experiences. Field visits and in-service analysis of solutions to health problems have often stimulated participants to attempt new approaches in their own setting. A thorough study and understanding of the specificities of each setting is however an important precondition for making optimal use of these experiences. The ZG support aims at structuring district health management courses in such a way that this can happen.
Teaching and learning methods
for African health professionals
In many poor countries, allied health professions are the back bone of peripheral health services. They perform most tasks of primary care, and only complicated or rare cases requiring more complex types of care are referred to higher levels of the health system. Training of this cadre is often provided by part-time teachers and practitioners from the health service, who have little training in modern adult learning concepts. These trainers usually are senior staff with considerable practical experience, but when asked to train they tend to replicate their own initial learning experience. Training and learning methodology has considerably changed, however, over the last decades, and the low effectiveness of old concepts of teacher-centred training are well known nowadays. To help resolve this problem, a 6-weeks training course was designed, that provided instruction and practical exercise in learner-centred problem-solving approaches. After many years of cooperation and support to a national training institution in Tanzania (CEDHA/Arusha) to run these programmes, some 900 teachers had been trained. The ZG has then started to support international exchange on this type of training. Human resources development experts from several countries of East and Southern Africa have studied the Tanzanian experience, exchanged experiences on their own activities in this field and a similar training programme is about to be started in Namibia. Regular exchange of tutorial staff from different countries and international seminars for curriculum development and further improvement of learning and teaching methodology is part of the ZG support in this country. Although it is difficult to quantify the benefits of this type of international exchange, the ZG and its partners believe that this kind of international learning from professionals in similar positions is an effective and efficient way to help local institutions to improve their performance.
Crash course in consulting skills
for African health experts
It is a general request from most development agencies and policy makers, that local experts should play a more important role in the strategic design, in planing, follow-up and evaluation of projects and programmes. Obstacles to do so have been identified:
Little knowledge about the structure and the modes of functioning of the bilateral and international development agencies,
lack of information about the formats and structures of documents used in planning and in evaluation of programmes and
problems in actual reporting and writing, prob
ably due to to the fact that written reporting in many African bureaucracies plays a minor role as compared to oral communication.
Based on this problem analysis a two-weeks course was developed that gives opportunities to practice proposal writing and evaluation report writing in a simulated exercise using real life data. Four batches of participants have been trained so far with some 35 participants from French speaking and about the same number from English speaking African countries. Again the principle of international peer learning was applied: the African participants together with their counterparts from industrialised countries developed a set of criteria for quality of proposal writing, and then applied these criteria to their own products through mutual peer review and appraisal.
Questionnaires sent to the participants 9 to 12 months after the course revealed that a high number had been requested as consultants. Participants said that the course had helped to do their job by improving their courage in report writing and by having helped to acquire some additional essential skills. In addition the participants reported a positive side effect: as most of them are senior health officials, their duty is frequently to go through and comment on planning and evaluation reports handed in by the various development agencies. These participants said, that they were in a better position to identify strengths and weaknesses of those reports and to make better use of their contents. As the market for consulting in the health sector of the African region is limited, it was decided to stop training more participants after 1999, and to rather follow up those that had been trained and organize an exchange of experiences made; sector wide approach and decentralisation as well as considering opportunities of intersectoral collaboration in the fight against the HIV/AIDS epidemic are likely to be on the agenda.
Changing roles for learners and advisors
in solving health financing problems in the Philippines
The ZG has been organising international short courses on health financing and health insurance development for those involved in health financing reforms since 1993. Since 1995 a two-step approach is used: First a common language and a set of tools for analysis are developed using the German health insurance system and its history as a case study. After introductory talks on a number of key issues, the participants themselves formulate questions and critical items, that are later discussed with key actors of the health system during site visits, e.g. with private practitioners, hospital doctors, health insurance fund employees and directors etc.. The German health professionals interviewed at various occasions expressed their surprise about the pertinence of questions asked by developing country participants and about the high level of comprehension of the complex German health system. In a second step the participants present their national systems of health care financing and discuss them with their peers using the criteria developed in the first stage.
Participants from the gtz-supported project SHINE in the Philippines (cf. the article by Christoph Fuhr in this edition) who took part in one of these seminars requested that a seminar with a similar approach should be held in the Philippines using their own system as a case study. When planning this seminar together with the ZG, their major idea was to present the achievements of this project and make their experiences available to an audience from other countries of the South East Asian region. When the seminar was held, it appeared that the profit was equally shared between both sides: The regional participants from neighbouring countries learned new approaches from the Philippine example, but the Philippine side at the same time had advantages for their programme through the critical analysis made by the foreign participants. The seminar was even able to discuss some issues of the ongoing Philippine health insurance reform with national decision makers passing from a learning to an advisory role. International peer learning thus also means continuing role changes between learners and advisors or teachers. The ZG intends to continue holding this type of structured and result-oriented exchange of experiences both in Germany and with partners in developing countries.
Sexual information for young people
is vital to stop the HIV/AIDS epidemic
Access to and provision of high quality information for young and unmarried persons about reproductive health was one of the major recommendations of the International Conference on Population and Development (ICPD) in Cairo 1994. Various organisations governmental and non-governmental have tried to disseminate effectively information about sexually transmitted diseases, particularly HIV/AIDS and their prevention, as well as about family planning to young and unmarried persons. Examples of what has been done, successes and failures in an environment sometimes hostile to the provision of such information, were discussed in an international workshop organised by the ZG in Berlin in 1998 for participants from English speaking countries of the African region. As in the previous example, the ways in which German institutions had tried (successfully or unsuccessfully) to approach particular high risk groups served as case study material. Participants presented their approaches and learned from each other how to overcome obstacles to the dissemination of sexual information to young and unmarried people, a problem apparently encountered in Africa as well as in Europe. A documentation about the various approaches and lessons learnt is in preparation and will be available from the ZG in the near future. It is also in this field, that the value of international peer learning becomes apparent: There are no simple recipes and no ready-made solutions, the literature and the body of evidence is still scarce and mainly opinion-based. In such a situation lessons have to be learnt predominantly through evaluation and exchange of experiences between actors and practitioners. The documentation will provide some more information about the difficulties of targeting appropriate messages to particular risk groups. The seminar also drew attention to the fact, that most programmes are for fairly limited target groups of a few thousand people at best, and that nation-wide coverage with appropriate information for young people is still very low in many African countries, leaving an enormous gap for further action.
The ZG and its partners in Europe
and in the developing countries
The ZG is a learning and training agency working for health in developing countries, and sees itself in a mediating and linking role, bringing the appropriate professionals and executive staff together and thus triggering off joint international learning experiences among peers and the acquisition of new skills and new ideas. It can only do so because it has competent partners in Germany, the most important ones being the Department of Tropical Hygiene and Public Health (ATHÖG) at the University of Heidelberg and the health unit of the German Agency for Technical Cooperation (GTZ), complemented by many other institutions and individuals. The ZG favours programmes of cooperation with national and regional partner institutions, where mutual trust and common understanding develop over longer cooperation periods and where each side fixes its contribution in a joint agreement. The ZG is financed through funds of the German Federal Ministry of Economic Cooperation and Development (BMZ).
Dr. Walter Seidel is the Director of the DSE Public Health Promotion Centre (ZG) and looks back at many years of experience as a doctor and public health advisor in developing countries.
D+C Development and Cooperation,
published by: Deutsche Stiftung für internationale Entwicklung (DSE)
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