1. Dr Tei Sheraton Consultant Anaesthetist, Royal Gwent Hospital, Newport. Chair of trustees Mothers of Africa.

2. Background of Mothers of Africa A Medical Educational Charity that trains medical staff in Sub-Sahara Africa to care for mothers during pregnancy and childbirth. Set up in 2004 Now input into 3 countries: Benin/ Togo Liberia Zambia ? Tanzania Mothers of Africa ’ s mission: Saving the lives of mothers and new-born babies in Africa by supporting the education of the people who provide medical care. This means that local people are empowered and that care for pregnant women is sustainable. “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime” Chinese proverb

3. MOA Liberia project Invitation of Liberians Since 2008 Partnership Development of a curriculum Teaching and mentorship Reliable personal contacts on the ground

4. Why do women die? Sepsis Haemorrhage Hypertensive disease Unsafe abortion Obstructed labour – a symptom of difficult access to timely intervention

5. Pelvic fistulae But mortality isn’t the only consequence; it is only the tip of the morbidity iceberg, which is probably 30 times greater than the mortality. Such morbidity includes chronic anaemia, stress incontinence, chronic pelvic pain and vaginal fistula. The latter usually resulting in the exclusion of a woman from the local community

6. Large Paired Institutional Partnership 30 month project in Liberia Brief overview of project A Definition of a partnership Definition of a relationship Examples of relationships Keys to good partnerships

8. February 2012 needs assessment partners Dr Williams (Director Bong County Health and Social Welfare) Dr Bernice Dahn (Ministry of Health, Liberia) Mr Sherman (lead for WHO GIEESS) Professor Southall (Director of Maternal and Childhealth Advocacy International, Advanced Life Support Group representative) Dr Mena Cherion (World Health Organization, Geneva) Dr Tei Sheraton (Mothers of Africa)

9. 357,431 population 8772 sq km 8216 deliveries in 2011 3 hospitals 37 clinics 5 physicians Poor access to comprehensive EmONC

10. Recommendations of needs assessment submitted to THET Strengthen emergency obstetric and newborn care in Bong by: 1. CPD courses and training of trainers 2. Increasing human resource for CEmONC by training mid-level healthcare workers to provide safe surgical, obstetric and peri- operative care 1. Obstetric clinicians 2. Anaesthesia and critical care clinicians

11. Cost effectiveness of access to c section

12. Understanding DALYs Global Burden of Disease Project (WHO and World Bank) DALY = Disability Adjusted Life Year (measure of disease burden) DALY = YLL (Years of Life Lost) + YLD (Years Lived with Disability) www.globalburden.org www.who.int/topics/global_burden_of_disease/en

13. Averted DALY = Number of DALYs averted by a particular intervention World Bank arbitrary cut off = US$100

14. DALYs in Public Health Costs per DALY averted TB:  Short course DOTS – US$5-35  Latent TB in HIV negative – US$4,000-25,000  Drug resistance – using second line drugs – US$70-450  BCG vaccination for children- US$40-170 per DALY averted HIV/AIDS  Voluntary Testing and Counselling – US$14-261  Marketing, promotion and distribution of condoms – US$19-205  Single dose of Nevaripine to prevent mother to baby transmission – US$6- 12  Anti-retroviral therapy for HIV - US$350-500 per DALY averted Laxminarayan et al. Intervention Cost Effectiveness. In Debas H et al. Disease Control Priorities for Developing Countries, World Bank 2007

15. Public Health DALYS Malaria Insecticide treated bed nets – US$5-17 Diarrhoeal disease: Oral rehydration solution - US$132-2570 Breast feeding promotion – US$527 – 2,001 Measles immunisation – US$257-4565 Laxminarayan et al. Intervention Cost Effectiveness. In Debas H et al. Disease Control Priorities for Developing Countries, World Bank 2007

16. Surgical Procedures Cost (US$ or I$) per DALY avertedInterventionPaper 5.06Cataract surgeryMarseille et al 1996 7.38AMCFieno 2008 10.93Rural hospitalMcCord et al 2003 12.88Elective inguinal hernia repairShillcutt et al 2010 10.83-21.8AMCAuvert et al 2008 11.23-181AMCUthman et al 2010 11.68-35.55AMCKhan et al 2006 18 (Cost per LYS)CS for obstructed labourJha et al 1998 28Emergency maternalAdam et al 2005 36 (Cost per LYS)AppendicectomyJha et al 1998 38.4AMCNjeuhmeli et al 2011 44.45AMCBollinger et al 2009 54-176 (not in DALYs averted)Cataract surgerySingh et al 2000 71Trachoma, trichiasis surgeryBaltussen et al 2012 74 (Cost per LYS)Hernia repairJha et al 1998 AMC = Adult male circumcision (for prevention of HIV infection) CS = Caesarean Section SSA = Sub-Saharan Africa SEA = South East Asia

17. Bong County Health and Social Welfare Ministry of Health Liberia WHO Liberia

18. Definition of a Partnership “A collaborative relationship between two or more parties based on trust, equality and mutual understanding for the achievement of a specified goal. Partnerships involve risks as well as benefits making shared accountability critical.” WHO African Partnerships for Patient Safety

19. Why not? 1. Involvement as exploitation 2. Involvement as tokenism eg “some people less able than others” oppressive 3. Partnership is not incorporation or “subsuming” to other partners

20. 1. Preparing the ground 1. Understand the motivation of the partners 2. Identify the mutual terrain 3. Understand the power differences Completing a task together is a relationship and not a partnership.

21. Does size matter? The Partners (annual turnover £) PartnerTurnoverSize difference ABUHB£1031 million793 x ALSG ALSG£1.3 million8.6 x MCAI MCAI£150,0005 x MOA MOA£30,000 Health expenditure per capita is 66 x higher in UK than in Liberia (World Bank)

22. Growing space in a partnership To have a growing space you need: Mutual understanding Celebration of achievements Sharing of information and support Belief in each other Honesty Respect Time Shared values Trust

23. Challenging in a partnership Must be possible Should be robust, constructive, open Respectful Even if agreement can’t be met it is the way in which people treat one another in exploring solutions that is important

24. 2. Sowing the seeds Learning from each other Learning from working together Dependent on trust Hindrances: Time Patches of competitiveness Problems arranging cash expenses

25. 3. Maintaining the partnership

26. Definition of a Partnership “A collaborative relationship between two or more parties based on trust, equality and mutual understanding for the achievement of a specified goal. Partnerships involve risks as well as benefits making shared accountability critical.” WHO African Partnerships for Patient Safety

27. Summary Good partnerships are essential for success Develop relationships first A good idea and a mutual goal are important but on their own are not sufficient Trust and respect are the cornerstones of all good partnerships

28. Questions?