How international health links help improve family planning services

In 2008 NHS South Central launched an initiative entitled Improving Global Health through Leadership Development, aiming to provide both leadership and quality improvement skills development for NHS staff, and improve health in developing countries.

The first partnership of the scheme was formed with the Maddox Jolie-Pitt (MJP) Foundation in Cambodia.

MJP was originally founded in 2003 to protect and preserve Cambodia’s forests, wildlife and waters in the northwest. In 2005, under the leadership of Stephan Bognar, the organisation adopted a holistic approach to development focusing not only on the environment, but education, agriculture, health care and women’s empowerment.  

MJP is currently working in isolated rural communities in northwestern Cambodia serving approximately 7,000 people. It works closely with the Cambodian government in designing and implementing its projects.

Since September 2008, over 30 health professionals from various disciplines - GPs, nurses, physiotherapists, midwives, occupational therapists, public health specialists, paediatricians, mental health therapist - have been recruited as fellows and have completed placements of between two and eight months working with MJP’s health team.

The fellows’ become members of the MJP health team and apply quality improvement methods and project management to increase the capacity of the local health system and thus improve services at two rural health facilities supported by MJP. A number of work streams have been developed at the rural health centres, focussing on Millennium Development Goal’s 4 & 5 which are concerned with maternal and child health.

The NHS South Central scheme is registered as a “health link” with the Tropical Health & Education Trust (THET), a UK based NGO that has been advocating for and supporting health links for over 20 years. It defines health links as “long-term partnerships between UK health institutions and their counterparts in developing countries”.

Common objectives of health links include health system strengthening, and improving health through training, capacity building or clinical service delivery. Some links are set up as small charities whereas others, such as Improving Global Health, which is a leadership development programme, are funded directly by the NHS.

In recent years the number of health links has expanded and it is estimated that there are currently more than 120 formal partnerships in the UK.

Working together to improve family planning services

After three decades of conflict and four years of living under a brutal Khmer Rouge regime, Cambodia is one of the poorest countries in Asia with a human development index rank of 124 out of 169 countries. There exists a shortage of trained healthcare professionals, particularly in rural areas where the majority of the population live.

The 2005 Cambodia Demographic and Health survey (DHS) reported an unmet need for family planning in Cambodia; 79 per cent of married women either wanted to delay the birth of a new child or to have no more children, and yet only 27 per cent were using modern birth control methods.

In rural areas basic family planning, such as condoms, combined oral contraceptive pill (COCP), and three-monthly depot injectable, are generally available from government health centres or via private sector social marketing schemes at private pharmacies. Long-acting methods, which are popular in Cambodia, are provided in urban areas by NGOs such as Marie-Stopes International.

One of the first activities for the health team was conducting a baseline health needs assessment survey. This identified an unmet need for family planning, complementing findings from the DHS. There were also anecdotal accounts from women who reported unsafe abortion in unlicensed private clinics.

A family planning workstream has been implemented by the MJP Foundation since November 2008 working in close collaboration with the Cambodian Ministry of Health (MOH) and other NGOs working in reproductive health.

The initial focus of work involved establishing a family planning service at a government health post supported by MJP. The district MOH and NHS staff provided training to the four health post staff and a basic family planning service was started in February 2009 providing condoms and three-monthly depot injectable, with the addition of the COCP.

Subsequently, a service was established at a second health facility, and a community-based approach was added, aimed at promoting family planning (particularly condom use) to men. Links were forged with other NGOs working in reproductive health, enabling women to access long-acting methods of contraception, for example the intrauterine device. This area of work has resulted in many women being able to access a wide range of contraceptive methods, similar to those routinely available in the UK.

Successes and challenges

The family planning workstream has been one of the most successful areas of work for the partnership, with several NHS Fellows being actively involved. The family planning workstream was recently evaluated (by the author); finding evidence that a high standard of clinical care was being provided at the health facilities and that contraceptive prevalence had increased in the area.

However, challenges remain, and there is a continued need to improve awareness and access to the service. Furthermore, fear of side effects has led to high contraceptive discontinuation rates, highlighting the importance of providing good quality information and effective follow up.

The NHS SC scheme partnership has provided abundant opportunities for mutual learning, and working in Cambodia has provided NHS staff with an unparalleled learning experience. MJP runs an integrated development programme that spans a range of sectors. NHS Fellows have had the opportunity to work in close collaboration with both the agriculture and education programmes, giving them a unique insight into the interrelations between these sectors; something that rarely occurs in the NHS.

Despite the obvious differences between health service provision in the UK and Cambodia, there remain some similarities with regards to family planning, making family planning service provision an attractive area of work in Cambodia.

First, similar methods of contraception exist between the two countries, albeit a far smaller range available in Cambodia, which has just one combined oral contraceptive pill available. This has meant that NHS Fellows with prior knowledge of family planning, many of whom have completed the Diploma of Family Planning, are able to engage in training and capacity building activities at an early stage of their placement, rather than wait several months to learn an unfamiliar subject area.

Second, there is a high reported incidence of side-effects, leading to discontinuation, from family planning methods in Cambodia. NHS Fellows have played an important role in working with their Cambodian colleagues in providing good quality method counselling and follow up to clients in this regard.

Third, NHS Fellows coming from a different health system, have been able to look at the wider health system with a fresh set of eyes, and consider how UK systems and ideas might be applied to the Cambodian setting.

At the same time, NHS Fellows have been able to witness solutions to health care delivery in low resource settings that could potentially be implemented in the UK. As an example, Cambodia has a well-established network of village health volunteers who provide basic family planning methods to their local community. Although lacking formal medical qualifications, they are provided with basic training, and are trusted by the local community, and provide an important service. Such ideas could be considered in the UK setting.

The potential for mutual benefit from health links could be greater realised if the partnerships facilitated more reciprocal visits; visits to the UK from developing countries. This would allow developing country partners to see how the UK health systems works, and furthermore, could lead to some potential solutions to problems in the UK.

However, in most cases the majority of visits involve trips to developing countries from the UK. Identified constraints to reciprocal visits have included funding limitations, fear that staff might abscond, and difficulty obtaining visas. These institutional barriers to reciprocal visits need to be addressed if health links are to be truly equal partnerships between developed and developing countries.

The government recently launched a new four-year Health Partnership Scheme, funded by DFID and managed by THET, to provide grants to health partnerships between UK and developing countries. Despite their challenges, health links, such as the Improving Global Health through Leadership Development scheme, do have great potential to result in mutual benefit to all the partners involved; and as this scheme has demonstrated, can make an effective contribution to addressing global unmet need for family planning.