This document describes a partnership between EMMS International, a Scottish healthcare charity, and Ekwendeni College of Health Sciences in Malawi to establish nursing and clinical officer training programs. With funding from 2013-2016, the project renovated facilities, purchased equipment and books, and developed curricula for registered nurse and clinical officer courses. The first graduates are expected in 2016. Challenges included a change in college leadership and delays in accrediting the nursing program, but the partnership overcame obstacles through open communication and mutual support. Lessons learned include the importance of financial oversight, contingency planning for staff changes, and recognizing student willingness to self-fund their education.

1. Developing a Sustainable Programme of
Cervical Cancer Screening
A Scotland-Nkhoma Partnership
With 3 years funding from Scottish Government International
Fund for Development in Malawi, 2013-2016

2. • In Malawi, cervical cancer is commonest cancer in women (45.4%)
• Malawi Minister of Health estimates that if nothing is done, the number of
cervical cancer cases will rise by 60% by 2025.

3. Partnership
Scottish team:
- Co-leads: Prof Heather Cubie; Dr Christine Campbell
- Gynae team: Sr Hilary Brown; Dr Graeme Walker;
Dr Miriam Deeny [Oct-Dec 2013]
- Academic and Support: Dr Liz Grant; Dr Isabel Bruce
Nkhoma Team:
- Medical Director & Surgeon: Dr Reynier Ter Haar
- Deputy Medical Director & Physician: Dr David Morton
- Project co-ordinator: Mr Savel Kafwafwa
- VIA: Belito Madetsa, Harriet Chirwa, Savel Kafwafwa
- Laboratory- Edson Kawonga, Rose Nkhoma, Mike
First planning meeting, May 2013
‘VIA Clinic’, May 2013

4. Aims of Project
To reduce the burden and mortality from cervical cancer by:
• Upskilling VIA in Nkhoma Hospital and its associated Health Centres
• Sensitisation of healthcare professionals and local population to value of
cervical screening
• Providing treatment by cold coagulation through Scottish professionals
spending time in Nkhoma
• Ensuring good follow-up of all non-negative VIA patients
• Increasing awareness of data collection and analysis to establish a robust
evidence base for appropriate cervical screening
• Providing HPV testing for potential triage to VIA
• Interacting with Colleges of Nursing through VSO nurse tutors to develop a
curriculum module based on knowledge of cervical cancer screening and
prevention

5. Successes -1
Numbers!
Awareness/ sensitisation delivered to
• Hospital Clinics [VIA, ART and Family Planning] daily for 4 months reaching 5,600 males
and females
• 2 Traditional Chiefs, 24 Group Village Heads, over 150 Village Heads within the 10
villages, reaching ~20,000 people
Infrastructure
• 3 clinic rooms equipped and 7 Nkhoma staff trained to deliver VIA, with clinics running
daily
Screening
• In Feb 2013, 24 women presented for cervical examination while in Feb 2014, 341 were
screened.
• Overall, 2336 women seen in VIA clinics between October 2013 and March 2014
Roll-out
• 7 Health Centre staff now trained
• Clinics commenced in 2 Health centres, one Government and one CHAM , in May 2014

6. Successes – 2
Numbers cont
• 75% of women with treatable lesions received it on same day
• Monthly increase- influenced by rains and harvest
• Word of mouth spread of regular service has led to women
travelling from much further afield
VIA CC
Total
First
visits Neg (2) Pos (1)
Suspect
cancer (3)
Advanced
cancer (4) Other
Done on
day
Postponed
Tx (P1) Other
October (from 16/10/13) 275 267 235 26 5 1 3 20 0 1
November 282 212 223 19 6 3 16 12 0 0
December 192 159 146 29 5 0 8 19 10 0
Total Q4 749 638 604 74 16 4 27 51 10 1
2014
January 157 130 108 21 9 1 15 19 5 1
February 341 318 290 27 7 2 11 20 7 0
March 1089 1047 988 53 14 5 18 42 6 0
Total Q1 1587 1495 1386 101 30 8 44 81 18 1
Half year total 2320 2109 1993 175 46 12 71 132 24 2

7. Successes – 3
Additional skills
• Treatment by cold coagulation rather
than cyrotherapy has been well
received by staff and women, is
cheaper, more transportable
• Biopsies – can now be taken in clinic
rather than in surgery, giving cost
saving and greater accuracy
• Expanded surgical skill set to radical
hysterectomy due to expertise in
Scottish team, providing better chance
of survival for more women

8. Challenges
• For Partnership: Recognising
The magnitude of the problem e.g with population served by Nathenje (first
Government Health Centre involved) it would take 8 years of daily clinics to
reach all eligible women
Success should not be measured mainly by numbers of women screened
but by good clinical outcomes for women with abnormalities
• For Scottish team: Understanding that
there are capacity pressures when staff have many different duties of which
VIA is one small part
Data keeping is not a strong point and considerable input is required on on-
going basis to ensure records are up to date
• For Nkhoma team: Recognising the
importance of follow-up - addressed by introduction of monthly biopsy
review and weekly palliative care clinics
service and skills must be maintained by consistent working practices and
quality control, team work including sharing knowledge across different
professional groups and by regular assessment of competence

9. Learning
Value of preliminary preparation- 6 months before the first woman was
screened
Need for continuing preparation for roll-out – training, competence and
capacity, practical issues (Sufficient instrumentation for every clinic, adequate
sterilising facilities and instruments ready for every clinic; stock taking eg
vinegar)
Communication – monthly, minuted skype calls with actions in addition to
frequent email traffic with all members of both teams and more frequent
visits
Flexibility- change from funding request for 9m each year of senior registrar
level to shorter time from consultants
Recognition of time commitment – project funds part of salary of 5
permanent staff in Nkhoma; Scottish team have also invested much more
time than anticipated
which have resulted in

10. Learning -2
Enthusiasm, ownership and pride of local team –
now see themselves as centre of excellence for cervical screening
(commitment to quality service)
likely to become additional training centre for MoH
now part of MoH Safe Motherhood Sub-Committee
word has spread not only to other parts of Malawi but beyond

11.  International healthcare charity
 Founded in 1842
 Works in Malawi, India, Nepal, Scotland
 Turnover £1 million
 Helping 68,000 poor and vulnerable people/year
 14 staff, all in Edinburgh
 3 programmes:
 Maternal and Child Health
 Palliative Care
 Disease and Disability
EMMS International

12. PARTNER: EKWENDENI COLLEGE OF
HEATLH SCIENCES

13. RNM AND CLINICAL OFFICER TRAINING,
EKWENDENI COLLEGE OF HEALTH SCIENCES
 Funded by: Scottish Government (£75,162) and EMMS
International (£45,000)
 July 2013 to March 2013
 £120,162, of which:
 £58,819 to partner to start courses
 £45,000 to partner for students’ fees and maintenance
 £13,343 for Edinburgh project management and 2 visits
 £3,000 for final evaluation

14. By 2016, Ekwendeni College of Health
Sciences is running accredited 3-year
RNM Diplomas and then Degrees, and 3-
year Clinical Officer training, sufficient to
graduate
> 20 COs/year and >200 RNM/year,
with the first graduates in September
2016 (20 RNMs and 20 COs) bonded for
5 years to hospitals serving rural areas.
OVERALL OBJECTIVE

15. RENOVATIONS

16. EQUIPMENT

17. BOOKS FOR LIBRARY

18. CURRICULUM DEVELOPMENT

19.  Working in partnership with 2 other donor-partners, Kwacha
Foundation (Netherlands) and Medical Benevolence
Foundation (USA)
 Fortnightly Skype calls
 Kwacha Foundation has mentored us
 MBF has provided additional monitoring
 Renovations of hostels and classrooms are complete.
 Equipment and textbooks are nearly all purchased.
 Curricula are developed and approved by relevant authorities.
 RNM course starts this month (June 2014).
 Clinical Officer course starts when Kwacha Foundation
approves its quality.
SUCCESSES WITH OUR PARTNERSHIP

20.  Principal resigned right at project start! (Got a better job.)
 Replacement still not recruited.
 No deputy, but competent Acting Principal started immediately.
 Financial management turned out to be less good than expected.
 We put 1-year finance training programme in place.
 Assistant accountant is responding well to training.
 RNM courses in Malawi turned into 4 years instead of 3
 Took months for College to gain accreditation for 4th year from Mzuzu
University.
 Partner happy to start CO course with approvals from Malawian
authorities, while we 3 donor-partners want better quality.
 Potential for tempers to fray, but good relations with College chair help
smooth things over.
 Good relations among 3 donor-partners helps us stand firm.
CHALLENGES WITH OUR PARTNERSHIP

21.  How to develop a curriculum in Malawi
 1 year to develop each curriculum
 Medical Council of Malawi, Nurse and Midwife Council of Malawi
 Equipment, books, renovations
 Costs of developing a course and fees and maintenance
 Many students are prepared to self-fund
 Partner wants to add in self-funding students in addition to those funded
by Kwacha Foundation.
 All partners need some sort of financial capacity-building
 We contracted a Scottish accountant in Malawi to train.
 Check which staff will take over if key staff leave.
 Know at least one board member well.
 Know deputies of key staff.
LEARNING FROM OUR PARTNERSHIP

22. Externally audited accounts
If only the government would implement the
requirement for all organisations to submit their
annual externally audited accounts – College and
Synod.
This would make a massive difference to Malawi.
Remember that many students are
prepared to self-fund.
Education is valued.
People need it to improve their lives.
People at this level of education (completed high
school) are prepared to find funding for it.
HOW SCOTLAND MALAWI PARTNERSHIP CAN LEARN
FROM OUR EXPERIENCES AND STRENGTHEN
BILATERAL RELATIONSHIP