Q&A: Training Haiti's Next Generation of Health Care Providers

By training physicians, nurses, health workers, and administrators in settings of poverty, Partners In Health is developing a new generation of health care providers to deliver comprehensive, community-based care in the poorest and most remote places.

We recently sat down with two people on the front lines of PIH’s training efforts in Haiti: Emily Dally, a curriculum and training specialist from Central Valley, NY, (pop. 1,857), and Vernet Etienne, general training coordinator from Cap-Haitian, Haiti, (pop. 190,000).

What kind of work do you do together?

Etienne & Dally: We’ve been collaborating since June 2012 and working together directly since Emily transitioned from the Boston training team to the Zanmi Lasante (ZL) training team in September 2012. We work together to develop curricula, improve training methodologies, and to organize trainings for Zanmi Lasante and ZL’s partners. We also develop tools to help trainers as well as training materials and tools for participants. Finally, we collaborate on the production of a quarterly bulletin to share the work of ZL among our colleagues and partners.

The training team is based at the National Training Center in Hinche, Central Plateau, Haiti. However, our team oversees training initiatives across ZL sites, so we travel frequently between sites.

How do you describe what you do on a daily basis?

Etienne: I plan, organize, implement, and report on the trainings we host at the National Training Center and other ZL sites. On average, we have about 10 trainings each month—the participants include doctors and nurses, but also community health workers, accompagnateurs, and others. I also gather and edit articles for a quarterly bulletin that we produce, and manage weekly and monthly meetings to structure our work at the NTC and increase collaboration.

Dally: I work mostly on revising and writing training curricula and brainstorming with Vernet and other team members about how we can improve our trainings and the training process at ZL. Some of our large trainings, such as the accompagnateur training, is written in English and translated into Creole, Kinyarwanda, etc., for various PIH sites. I work with the ZL team to develop or adapt curricula to the Haiti context, and to integrate ZL and Ministry of Health protocols.

Why is training important? How is it improving ZL's work in Haiti? How does your work fit with all the services ZL provides? 

Etienne: Training is important because it is an opportunity for professional development. Second, through training ZL can inform staff of new protocols or information that is important to their work. Trainings help to create unity among ZL staff and consistency with service delivery–the standard of care provided at one site is the same as that provided at another. Through training, we build capacity to break down the gap between theory (what one learns in school) versus what the individual is expected to do on the ground.

Dally: Vernet, you raise a great point about turning theory into practice. The trainings we deliver are not just an opportunity for the trainer to deliver information from his or her own point of view; they are opportunities for the participants to discuss what they are learning, draw from their own varied experiences, and question each other about best practices. We always try to incorporate role-plays or simulations into the trainings. For example, we just worked on a curriculum for accompagnateurs (community health workers who are responsible for accompanying our TB and HIV patients) on active tuberculosis case finding, so we incorporated a training session on sputum collection using the materials the accompagnateurs will use in the community. The main purpose of training is to provide knowledge and skills that will help participants perform their jobs, and this gives them an opportunity to practice these skills before they hit the ground running.

How did you find your way to ZL and your job today?

Etienne: In October of 2010, I was working as a cholera-training translator for Doctors Without Borders-Spain during the cholera outbreak in Port-au-Prince. I translated trainings for nurses and doctors on cholera care and treatment. I realized how important training was in continuing professional development and to quickly respond to problems that were not well understood. After my contract ended, a friend told me about a vacancy with the ZL training team. I really love to work for ZL and I share ZL’s philosophy “ for helping those most in need.”

Dally: As a graduate student at the Yale School of Public Health, I spent a summer working in the Artibonite region of Haiti (at Hôpital Albert Schweitzer) to develop an exclusive breastfeeding curriculum for community health workers. When I returned, I knew I wanted to work on training initiatives in Haiti and found the perfect opportunity with PIH. The PIH approach to training—providing quality and comprehensive training opportunities for a range of stakeholders in community health—was what drew me to the position. I started working with PIH a few weeks after graduating with my master's degree in public health and transitioned to working full-time with ZL in Haiti a few months later.

It was planned that Emily would only be in this position for one year. What was the thinking behind that? 

Dally: In my role I accompany the ZL team to support a variety of initiatives, specifically curriculum development and monitoring and evaluation. I act as a liaison between the PIH Boston and ZL training teams and support both teams’ work. The thought behind the defined timeframe for this position is that as I transition from Haiti to Boston, a liaison between the ZL team and PIH team will no longer be necessary. I will have worked with both teams to set up a system in which the teams collaborate on projects without a designated point person. 

What about your work together embodies the ZL approach or "model"?

Etienne: ZL strives to deliver high-quality care to those most in need—and this is the approach we use for delivering trainings as well: We deliver quality trainings and training materials to those most in need. Our trainings are not only for doctors. They are also for nurses and nurse auxiliaries, psychologists, social workers, and above all, community health workers and accompagnateurs, who are the pillars of the ZL system.  We also train those functioning outside the traditional medical system, such as matrons—traditional birth attendants who take care of a majority of pregnant women at the community level—and oungan (“witch doctors”), who see many patients before they present at the clinic or hospital.

Dally: In training, it’s important to recognize that a significant portion of medical care and preventative care happens at the level of the community health worker and accompagnateur. Community health workers administer childhood vaccinations, check in on women during pregnancy, educate families on methods of family planning, and search for cases of malnutrition and refer to the clinics. Accompagnateurs ensure that HIV patients take their medications properly and find active TB cases in their communities. Their roles are crucial to the success of the ZL model, and training gives them the knowledge and tools necessary to perform their jobs. 

Social justice and solidarity with the poor are core values for ZL. How do you incorporate those values into your work?

Etienne: First and foremost, the ultimate goal of any training is to improve the care we provide to patients and in communities through enhancing the knowledge and skills of our participants. But trainings also serve to influence the attitudes of the participants. Our trainings always respond to real social and economic problems faced in rural Haiti. It is important that we set an example and deliver our trainings within the context of a human rights approach as we show respect for our training participants by providing them with all materials and meals and a comfortable and secure training location.

Dally: These values are the threads that bind our trainings together. In training, it is important to incorporate discussions of the social and economic context in which we are working. How can we ensure access to health care? Why is it important that women have access to appropriate family planning? When we train on cholera prevention and hygiene and sanitation, for example, we can consider these issues in the context of human rights: The people in our communities have the right to access clean, safe drinking water. Now how can we improve their access?

What gives your trainings the "Zanmi Lasante" spirit? 

Dally: I think we do a great job of integrating adult learning principles into our trainings. We avoid using traditional training methodologies in which the trainer stands in front of the room and lectures at the participants. We use things like case studies, role-plays, and group discussions. 

Etienne: We make sure to keep our trainings small (no more than 25 participants) so that each participant is involved in the activities. A majority of our trainers participate in a “Training of Trainers” to prepare them to be effective facilitators. The entire ZL team, not just the training team, is responsible for ensuring quality training for the most in need.