As first impressions go, Dr. Paul Edwards of the Ministry of Health in Belize made a strong one. When exchanging emails concerning the requirements of a virtual leadership development program in the Caribbean region, he replied to the facilitator’s caution on the commitment involved: “If we start this, we are going to finish it!”
In 2004, the Implementing AIDS Prevention and Care Project (IMPACT) contracted Management Sciences for Health to deliver its Virtual Leadership Development Program (VLDP) in the Caribbean region to complement IMPACT’s Caribbean Regional Program. IMPACT is a USAID-funded project of Family Health International. The VLDP was delivered from May to July, 2004, to 15 teams from 10 countries, all working in organizations addressing HIV/AIDS. The program trains teamsutilizing group and individual work over a 12-week period. Teams identify a workplace challenge, then work to address the challenge while learning and applying practical leadership skills. A commitment of about five hours per week is required, with no travel necessary, allowing participants to remain on the job and minimizing the program’s impact on their schedules.
In Belize, there are approximately 3,600 confirmed cases of people living with HIV or AIDS. Estimates vary on undocumented cases, but they range upwards to 5,000. While seemingly a small number, the country’s population is only 283,000. The UNAIDS estimate for HIV/AIDS prevalence for Belize is 2.4 percent, the highest prevalence rate in Central America. Even small stresses on the public health system are felt deeply—with limited resources and especially limited human resources to perform essential public health functions. Still, Belize has made many great strides in the fight against HIV/AIDS. More than 90 percent of pregnant women get voluntarily tested for HIV; HIV rapid tests and CD4 tests are offered free of charge through a voluntary counseling and testing (VCT) center; ARVs are provided for free to everyone who needs them; and due to the Prevention of Mother-to-Child Transmission (PMTCT) Program many children born to HIV+ women are entering the world free of the virus.
A Committed Team
When Dr. Paul Edwards heard the call for enrollment in the VLDP from the Organization of National Program HIV/AIDS Coordinators, he jumped at the opportunity. “When we found out about the course I said ‘ah-ha!,’ this is what we need,” Dr. Edwards reflected. “It was so easy to select who we wanted in the team. We’ve had the opportunity to work together before, we also knew that we needed to improve our managerial and leadership skills, and here was an opportunity for us.” He approached Dr. Natalia Largaespada-Beer and Mrs. Erika Goldson-McGregorboth Ministry of Health staff who are active in the National AIDS Programabout participating in the program. They saw the potential benefits and agreed to enroll.
When Dr. Edwards speaks it is like a wave of enthusiasm washing over you, with few pauses between ideas. He is the Director of the Epidemiology Unit at the Ministry of Health’s National Office, and also heads the National AIDS Program. A native of Belize, Dr. Edwards went to medical school and started his specialization as a pediatrician in Guatemala, despite initially knowing no Spanish. Later he returned to Belize to care for his family, and took a job with the Ministry of Health as Director of Institutions. This included responsibility for a clinic that treats tuberculosis patients. It was soon afterwards that Dr. Edwards became interested in working in HIV/AIDS: “one of my first clients was a 48-year old female, low socioeconomic and educational status with three small kids. She was diagnosed with tuberculosis, and part of the protocol states you also do an HIV test. . . the result came back positive. So I asked the nurse ‘to whom should I make the referral [to inform the woman of her status]?’ She told me ‘you’re supposed to do it.’ The woman and I cried when I told her… I didn’t have any experience in counseling and knew nothing of that. I then started looking at what was being done in Belize for HIV/AIDS.” In August of 1999, he set off for Mexico to earn his Masters of Public Health and returned to Belize, becoming the Director of the Epidemiology Unit at the Ministry of Health.
Originally from the English-speaking Bluefields region of Nicaragua, Dr. Natalia Largaespada-Beer began her career in the Nicaraguan Ministry of Health. Later, after graduating from medical school, she served two years in the country’s rural interior, where she participated in “mobiles”a clinic that travels to the most remote areas on mules and horses for 15 days at a time to provide medical care. During one trip, a woman approached on foot, alone, eight months pregnant, covered in mud, and exhausted. “Are you sick?” Dr. Beer asked her. She wasn’t. She explained that it would be two months before the clinic came by again and she needed malaria medication in case something happened before then. The woman walked 10 hours for this essential medicine. Dr. Beer knew there must be a better way. She decided to go into public health, to work to change the system. She worked in the Nicaraguan health system for 10 years, primarily in the Maternal-Child Health (MCH) Department. Two years ago the Belizean Ministry of Health contracted her to be the Director of MCH. Part of her job is in the PMTCT program.
While in Junior College, Mrs. Erika Goldson-McGregor studied in preparation for law school. However, in her final semester her life changedshe became pregnant. “That changed my whole outlook on life,” Erika explained. “My whole future plans with regards to pursuing my studies had to be put on hold. I wanted to care for my child so I just had to find any job.” She started out as an X-ray technician at a private hospital, then applied for the job of Public Health Inspector. “That’s how I got into the system,” Erika explained. “When I was doing my training, one of the components was in Health Education, and I loved it! As a Health Inspector you have to do health education as well, but it is limited to environmental health issues. As a Health Educator it was the whole scope of things and I felt I could make more impact in my country.” Erika’s particular interests are in family and maternal health, HIV/AIDS, and nutrition. After training in Health Education at the University of the West Indies, Erika became a Health Educator in 1998, and later the Coordinator of the Health Education Unit in the Central Region. In addition to her current position, Erika works on the national level in health promotion, is active with the National AIDS Program (working closely with Dr. Edwards), and volunteers for a local organization (the Alliance Against AIDS) that provides support for HIV+ people and their families.
Addressing Their Challenge
Teams enrolled in the VLDP select a challenge that their organization faces. They are expected to work on this challenge as a team, and ultimately find a solution. Teams follow the program modules, learning practical leadership skills and using that knowledge to tackle their challenge. As part of the Belizean PMTCT program, newborns need to be tested to verify their HIV status. Because antibodies from an HIV+ mother transfer to her infant regardless of whether the virus is transmitted, testing requires a more sophisticated approach: DNA testing through the use of a Polymerase Chain Reaction (PCR) machine to test for the presence of HIV DNA. Previously, samples had been sent to Honduras. “There were many many problems,” Dr. Edwards said of the process. “Samples would be lost. You have to store those samples for sometimes a long time in proper conditions or they will spoil. Also, it’s hard to get blood from a newborn baby. Many times when we sent a sample, we were told they were inappropriate… So that entails going out and trying to find those kids again. It becomes very, very challenging.” In 2003, fewer than 25 percent of newborns were successfully tested. As their challenge, the Belize team chose to increase the DNA HIV testing in newborns of HIV+ women from 22.4 to 100 percent by performing all of the tests in country. “This needed the most urgent attention,” explained Erika. “We had discussed it before but the VLDP actually got us mobilized to complete it.” Completing this challenge would also provide long-term financial benefits. According to Dr. Beer, “the PCR testing we send out now is $250 for one sample; once the lab is set up it will cost us $25 per sample.”
Once the challenge had been identified, the team needed to overcome more practical concerns associated with staying on schedule. The VLDP requires teams to meet in person once every two weeks. In addition to demanding schedules, each member of the team was in a different place at different times. Erika lives and works in Belize City. Dr. Edwards also lives in Belize City, but drives nearly 50 miles most days to the Ministry of Health office in the capital city of Belmopan. Dr. Beer lives and works in Belmopan, but doesn’t have a car. The Belize team chose to meet mainly on weekendswith Dr. Beer taking the 90-minute bus ride into Belize City. Everyone noted how much they enjoyed the daily facilitator emails, how it kept them motivated throughout the 12 weeks. Facilitators serve to guide participants, provide feedback, and keep them on schedule. In addition, Erika acted as a facilitator within the team during the programkeeping on top of things and keeping her team on track: “I always made sure to read the modules and then call the team the next day to remind them: ‘did you read your things?’If I’m doing something I want to do it good.”
Working on their challenge, Dr. Beer first called the Virology Laboratory of the National Autonomous University of Honduras, where Belize currently sends its samples, to ask what would be needed to do the tests themselves. At first the news seemed good: the PCR machine was not very expensive and the supplies and labor needed would only cost about $25 per test. After further research, however, the team discovered several additional pieces of necessary equipmentincluding an expensive cooling unit. Recruiting the assistance of Johani Lizama, Medical Technologist, of the National Laboratory in Belize, Dr. Beer went to Honduras to take a full inventory of the systems needed. Together they produced a cost estimate for all the equipment, supplies, and resources required. The cost estimate included funds for an additional 100 samples to be sent to Honduras to fill in gaps in service and cross check the results of their own machine once in operation.
Dr. Edwards and his team immediately set out to secure funding. Some funds were secured through the Pan American Health Organization, with additional money provided by the Ministry. There was still a sizeable gap, so Dr. Edwards decided to reach out to the business community. Two businessesthe First Caribbean International Bank and SOL Belize (formerly Shell Belize)came forward to help, marking a major achievement in public health for Belize.
One cost that was not included in the original estimate was the space to house the lab equipmentthe national lab was filled to capacity. Undaunted, the team contracted a local architectural firm to design plans and provide cost estimates for expanding the laboratory. New benefits popped upthe PCR machine has other capabilities, including sero-typing dengue fever and hepatitis C. The team’s efforts will result in an entire immunology department, ultimately saving the health system money andmost importantlysaving lives. The equipment and supplies necessary for the DNA HIV testing have now been procured, and the team is exploring funding options for lab expansion. Plans are in place for experts from Honduras to travel to Belize to train technicians in the use of the new equipment.
The VLDP Experience
“I’m telling you when I started doing the [VLDP] it helped me a lot,” Erika said of her experience. “It taught me how to deal with certain situations. It helped me develop coping mechanisms.” While working relationships had already existed within the team, Erika and Natalia had not worked together previously. “I got to know her much better, she’s a very dynamic woman. I felt that the whole program brought us closer together.”
The effects of the VLDP resonated with Dr. Edwards. When he started at the Epidemiology Unit in 2001 it had a staff of three. He has since expanded the department to a staff of more than eight. Dr. Edwards described the situation he was in: “you look around and think ‘what am I supposed to do with all these people?’ There is so much work to be done, how can you organize yourself to be most effective in getting from them what you need to achieve. All these different personalities, all the perceptions, all the values, all the ethicstrying to gear all of these together to get what you really need is a major challenge. But what the course really didespecially with mewas to learn a lot of patience and to be able to have a listening ear. Everybody has something to say and contribute. By listening and allowing people to be empowered, they feel a part of the process. When they feel part of the process they are better able to contribute instead of being behind someone [who says] ‘this is what you do, this is what you need to do!’ The course really helped to do that. To be able to understand how to better manage the individuals, demonstrating leadership in an indirect fashion to get what you really need to get, instead of being authoritative and being a dictator and such.
“To be honest, many times before I was that kind of person, because it was easy to say ‘I need you to do this, this, this, and this.’ But if you don’t understand how you’re going to contribute to something, you’re going to go through the motions and just get it done. You’re not going to go that extra mile and appreciate what you’re doing and how it fits into the big picture. I did not have leadership qualities in that sense that you get people together to work as a team, and the course has really helped me to do that.
“People now come in and ask ‘what would you like to get done?’ ‘I heard you were doing this workshop, I’d like to be a part of it.’ People are coming forward to be a part of a process. I remember a colleague calling and saying ‘Dr. Edwards, I hear you are doing a study at the prison.’ I said ‘yes, but we are doing it Saturdays and Sundays.’ And she said: ‘and?’ If you look at the history of the public sectoryou get to work at 8:15 and at 4:50 you are ready to leave! And here you have someone calling up and saying: ‘I want to be a part of that team that you have.’”
Since completing the VLDP, the Belize team has expressed an interest in replicating the program themselvesto run their own VLDP for their own people, facilitated by the pioneer members. One specific need would be to provide leadership training to the senior-level regional managers, to aid in the health system’s decentralization process. What’s clear is that the Ministry of Health recognizes that only through strong leaderslike Paul, Natalia, and Erikacan the greatest impact throughout the health system be achieved.
"We had discussed [the challenge] before but the VLDP actually got us mobilized to complete it."
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