Rwanda has a doctor problem—there aren’t enough of them. For every 100,000 people in the small east African country, there are approximately seven doctors. Compare that with the U.S, which has 273 doctors for every 100,000 residents.
Yet Rwanda has achieved remarkable gains in public health; it’s the only country in the region on track to meet all the health-related Millennium Development Goals by 2015. How’s this possible given the dearth of docs? While it’s a complex answer worthy of a dissertation, it doesn’t take a Ph.D. to realize that nurses have played an instrumental role in the country’s turnaround.
But ensuring that thousands of nurses with varying levels of education and professional experience deliver consistent care is a logistical and pedagogical challenge. Fortunately a program pioneered by Partners In Health in close collaboration with the Rwandan Ministry of Health (MOH) provides an innovative and cost-effective solution that’s fundamentally changing the quality of care nurses provide.
Known as MESH—short for Mentoring and Enhanced Supervision at Health Centers—the program links experienced nurse mentors to staff nurses at rural health centers. It’s similar to the clinical mentoring that’s common in wealthier countries, just far more flexible.
“This is a simple solution that yields remarkable improvements in quality of care,” says Anatole Manzi, MESH-QI program director. “It’s simple in the sense that we use existing resources to address huge quality and systems gaps while boosting nurses’ confidence.”
Mentoring the Mentors
In many developing nations, formal continuing education for nurses isn’t standardized. To keep them abreast of best practices and new policies, countries often host massive weekend-long seminars in large cities. For those in rural clinics, travel to these events is costly and time consuming. And determining whether the participants actually apply what they learn in real-life clinical scenarios is impossible. This one-shot approach leads to inconsistent skill levels among nurses, which directly affects the health of the poor.
MESH alleviates these shortcomings through layered mentorships and continued follow-up meetings. Inshuti Mu Buzima (IMB), PIH’s Rwandan sister organization, works with nurse supervisors who are hired by the government and specialize in four clinical fields: child health, women’s health, HIV care, and adult acute care.
Before these nurse supervisors are deployed, IMB helps polish their mentoring skills so they can be effective educators once in the field.
“Educating nurses to be good mentors is important and rarely happens in any country,” Sheila Davis, PIH’s chief nursing officer, says. “Being a good clinical nurse doesn’t necessarily mean that someone can be an effective mentor.
A vital part of MESH is assuring that our mentors are experts clinically and that they have the skills to provide specialized support for nurses in the health centers.”
Over several days, the mentors are introduced to theories of adult learning and hone communication techniques for delivering feedback to the less-experienced nurses they’ll encounter. This initial training is reinforced through monthly follow-up meetings led by IMB.
After the training, mentors visit their assigned posts every four to six weeks to work alongside the nurses. These trips usually last between two and three days, during which the mentors guide the nurses’ decisions and review what worked and what didn’t.
Bridging the Gap
MESH first launched in November 2010, when PIH and the MOH implemented it at 21 health centers spread across two rural districts that serve approximately half a million people.
After a few months, mentors discovered that nurses across sites struggled to screen and treat children under 5 who had symptoms such as diarrhea, fever, and acute breathing and feeding difficulties.
The mentors reported this gap in care to the MOH, which responded by having its Child Health Unit organize trainings focused specifically on childhood illnesses. After the trainings, the nurses’ abilities to manage child illnesses improved significantly, according to a recent article in the peer-reviewed journal Nursing Outlook.
“Identifying a need and being able to implement a strategy that can improve patient care effectively and efficiently is exactly how health system strengthening should happen,” Davis says.
Other data showing the benefits of MESH have recently started to surface. A year into the program, participating nurses increased the accuracy of their clinical performance by nearly 20 percent for child and maternal health, and by 13 percent for adult health.
“We are thrilled to get these results within such a short time,” Manzi said. “MESH is not a magic secret; rather it’s a shift in thinking and strategic planning. I am excited to see fewer kids dying due to bad quality of care, fewer women dying while giving births, and more successes at IMB-supported sites and throughout Rwanda in general.”
Based on the initial success, the Rwandan government has decided to expand the HIV portion of MESH throughout the entire country. There’s little doubt that this will help the country sustain and build on its impressive health gains.