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4 Faculty Twinning Key Findings: + Successes and - Challenges 4 Faculty Twinning Ch â¢ Approached as a â¢ No incentives/compensation for University of Rwanda reciprocal partnership faculty participation; unclear communication about with U.S. institution roles and expectations; and competing priorities for (USI) faculty who had University of Rwanda faculty experience in the â¢ Some unsuitable or unqualified USI faculty who did region and/or were not meet experience requirements or technical needs from the region â¢ Insufficient transfer of teaching skills from USI faculty â¢ Increased skills in to Rwandan faculty management of academic curricula â¢ Insufficient resources and unclear expectations and programs among Rwandan actors and USIs affected processes related to issuing contract, recruitment, and onboarding + - Capacity building in the Human Resources for Health (HRH) Program occurred through a number of activities, including the creation of the Aca- demic Consortium, discussed in Chapter 3, comprising U.S. institutions (USIs) that would conduct mentoring or âtwinningâ1 with University of Rwanda faculty (CDC, 2012; MOH, 2011b, 2012, 2014, 2016). Although twinning was a key mechanism by which the HRH Program intended to 1â The World Health Organization defines twinning as a formal, two-way exchange and col- laboration between two organizations (WHO, 2001). 109
110 EVALUATION OF PEPFARâS CONTRIBUTION TO RWANDA build Rwandan health professional educatorsâ capacity, the 2011 Program proposal makes only two mentions of the practice, one in reference to building leadership teaching capacity, with specific reference to obstetrics and gynecology, and the other in relation to research capacity, whereby a Rwandan principal investigator would be twinned with a foreign co- principal investigator (MOH, 2011a). In practice, the HRH Program launched and supported 22 training pro- grams across health cadres and specialties, through 16 to 25 participating USIs that collectively deployed about 100 faculty members each year to twin with University of Rwanda faculty members (see Figure 3-6 for a time line showing participating USIs). Twinning under the HRH Program was individual, focus- ing on one-to-one faculty relationships, with the aim of the USI faculty build- ing University of Rwanda capacity in teaching and clinical care. Although some USIs, such as Harvard Medical School, had longstanding partnerships in Rwanda, most were selected for their specialties and their commitment to recruiting high-quality professionals to stay in Rwanda for extended periods. Many USI âfacultyâ members were independent contractors, hired for this specific, time-limited twinning assignment, and many had not worked at the USI previously. Most of these contractors were based in the United States; others were based regionally, such as in Botswana and Kenya. These characteristics of USI faculty twins would prove important for the mixed outcomes of the twinning process, as confirmed in the literature (Cancedda et al., 2018; MOH, 2016; Ndenga et al., 2016) and in qualitative data collected throughout this evaluation. Overall, although most respondents agreed that the first few years of twinning activities faced challenges, by 2019, USI and University of Rwanda faculty and HRH students all reported a mix of successes and challenges. Twinning was designed as a departure from historically short-term visits (Binagwaho et al., 2013; MOH, 2011a) and was intended not only to promote teaching skills (as well as skills within clinical specialties) to Rwandans, but also to foster mutually beneficial academic partnerships beyond the 7-year HRH Program (Cancedda et al., 2017, 2018; Ndenga et al., 2016). As one respondent noted: Additionally, HRH helped people to open eyes about partnerships. There were people who have had professional exchangesâthose are connections. So, [the] HRH [Program] helped Rwandans to open eyes and to make connection in other countries, especially in the United States. So, that was not a bad thing. (Former HRH Student in Surgery) Faculty spanning a variety of health-related disciplines (such as medi- cine, dentistry, nursing and midwifery, and health management) began
FACULTY TWINNING 111 arriving and teaching in late 2012 from Academic Consortium institutions (see Chapter 3 for details on the Consortium) to support the 22 train- ing programs (Cancedda et al., 2018). However, not all programs were launched in the same year, reflecting implementation issues with procure- ment and shifting Ministry of Health (MOH) funding priorities. The initial range of programs included rapid skills upgrading for cadres such as nurses and midwives, targeted boosting of the production of health professionals, and the establishment of specialties and disciplines such as dental surgery and health management. The midterm review confirmed, as did respondents discussing program management in this evaluation, that the goals of the twinningâto improve the teaching and clinical spe- cialty skills of Rwandan facultyâwere well understood at a senior management level from the beginning â¦ [but] this vision was not trickled down to the faculty and administrative units (e.g., schools, departments) who were meant to drive the model. (MOH, 2016) This illuminates an important finding: The HRH Programâs twinning approach had a strong vision but lacked operational cohesion in efforts to realize that vision. This was particularly due to two challenges, first in clearly defining the USI faculty contractorsâ scopes of work, and then in communicating the scope of the relationship to the University of Rwanda. USI faculty filled multiple roles during the twinning program, as the midterm review also notes; there was an expectation that USI faculty would have dual roles as sole faculty members in new specialties and as mentors to the first cohort of trainees (MOH, 2016). From the perspective of HRH Program trainees, this expectation came to fruition. They reported that their main mentors and teachers were USI faculty, and the trainees ex- pressed strong appreciation for the education they had received from these individuals. Indeed, throughout data collection, when interviewees referred to âHRH faculty,â they were consistently referring to USI faculty, rather than Rwandan faculty from the University of Rwanda: So, I actually started to know much about HRH when I was ro- tating in [obstetrics and gynecology]. So, thatâs where I met some doctors from [the] U.S. They were so eager to teach us. Since that time then, up to when Iâeven now, weâre still communicating (84, HRH Program Trainee, Pediatrics) HRH trainees reported the USI faculty membersâ biggest contribu- tion was in their direct training and professional support of University of Rwanda students, followed by providing clinical services, and, less consis-
112 EVALUATION OF PEPFARâS CONTRIBUTION TO RWANDA tently, in building the capacity of University of Rwanda faculty to teach in these new specialties. Chapters 5 and 6 discuss in more detail the benefits of the USI facultyâs teaching and mentorship on specific outcomes for HRH trainees and the University of Rwanda more broadly. SUCCESSES OF TWINNING University of Rwanda respondents, USI faculty, and HRH trainees all reported important positive outcomes resulting from twinning relation- ships, including the approach to twinning as a partnership, rather than a mentorâprotÃ©gÃ© relationship. The longer duration of USI faculty engage- ment (1-year contracts versus a more typical 3-month rotation) was noted as a key success factor; one USI faculty member (16) reported that the longer stay showed âa sense of commitment to a departmentâ that helped foster more productive relationships. There is some evidence that being twinned in programs with established University of Rwanda faculty (nurs- ing, pediatrics, and internal medicine) generated more effective twinning relationships than newer programs with fewer Rwandan faculty, such as the Master of Hospital and Healthcare Administration (MHA) program. Respondents also noted positive twinning outcomes related to increased skills in the management of academic curricula, and the value of having committed USI faculty not only from U.S.-based institutions, but also from the Eastern and Southern African regions, as well as others with experience working in the region.2 This latter factor supported twinning relationships grounded in the cultural humility necessary to form strong relationships between twinned faculty members. Notably, USI faculty who were already in Rwanda and had established relationships there before the start of the HRH Program reported easier transitions into their partnerships with Uni- versity of Rwanda faculty. Program Management Skills University of Rwanda staff most often mentioned transferring program management skills between individually twinned USI faculty and University of Rwanda faculty, resulting in improvements in University of Rwanda facultiesâ skills related to their departmentsâ and residency programsâ or- ganizational structures and processes. They cited specific improvements in planning classes and replacing instructors on leave, scheduling residencies, and organizing internal department structures and external events and con- 2â For example, some USIs were able to hire staff from outside of the United States to be twins, whereas other universities had restrictions on hiring only individuals from their home states.
FACULTY TWINNING 113 ferences, in addition to the in-person support they received in supervising postgraduates: [In terms of] skills transfer with the twinning model â¦ for instance, the School of Nursing â¦ organized a first group [to attend] the national conference with the HRH Program. Before that, we didnât have that experience. It is not going to be lost â¦ the skills in terms of planning, working together, and training coursesâso there are so many things that I can count that are going to be sustained even after the Program. (81, University of Rwanda Faculty in Nursing) [F]or some of them [the programs supported through the HRH Program], faculty were well positioned in Rwanda now to think about a new idea or an existing course and have better pedagogi- cal skillsâ¦. You know, better skills to think through, like have you develop[ed] a syllabus for a new topic or have you taken a course that seems stale and revamp[ed] it. I definitely think there are more faculty here that can do that in certain programsâ¦. I donât think there is more physical infrastructure, but I think the teaching infra- structure is better. (64, USI Faculty in Public Health) Some respondents highlighted the importance of helping with rotation plans. One discussed a sustained rotation plan and evaluation plan for the pediatrics program: [T]hey did [a] table of rotation, which would be helping even in further yearsâ¦. And itâs become easier when you have to plan the rotation of residents to follow that the exams before, and it was also helpful to see how they organize the evaluation toolsâ¦. Be- fore, people were really evaluated subjectively, which is not profes- sional. And they tried to make it more objective â¦ they also helped us making some modulesâ¦. And to categorize a plan to teaching, depending on the field. In pediatrics, it is like general medicine on children then you have to know what way and about cardiologyâ¦. So, they [are] trying to specify which field was the required [one] to learn before becoming a pediatrician. It was very good. (85, University of Rwanda Former Student in Pediatrics) Successes from Sustained Twinning Relationships Many University of Rwanda and USI faculty discussed the sustained relationships the twinning process created, such as ongoing mentorship, increased University of Rwanda faculty publications, support in curriculum
114 EVALUATION OF PEPFARâS CONTRIBUTION TO RWANDA development, and increased partnerships between the University of Rwanda and USIs (see Chapters 5 and 6 for details). [There are many] things that we have achieved, including that twin- ning period or using the twinning model. One of the things that have been a success was the writing. As I am talking with my twin, especially we wrote book chapters together on simulation. That is successful. That was great for me. (80, University of Rwanda Faculty in Nursing) USI faculty reported that their twinning experiences contributed to Uni- versity of Rwanda faculty membersâ professional development in a variety of ways, most evident in the University of Rwanda twins who subsequently led new departments established by the HRH Program. For example, USI faculty in surgery, obstetrics and gynecology, and nursing all reported that their Rwandan twins had taken over the departments. Some USI faculty also highlighted unexpected effects, including their twins taking curricula regionwide and establishing sustained partnerships with USIs: Heâs introduced broad technical skills in [redacted] curriculum, which has then expanded, and [heâs] now going Africa-wide with it. So, a lot of really cool things came out, not just for Rwandaâs [redacted] education but for quality improvement â¦ for the conti- nent, thanks to that partnership. (83, USI Faculty) Finally, I think, beyond just training in medical, there have been long-lasting friendships and exchange[s] â¦ between Rwanda and different universities in the United States. This went beyond the program itselfâ¦. [As] one example, there is one [USI] faculty, who came and â¦ when he returned, â¦ he supervised two, now he has three Ph.D. students, who are completing statistics and epidemiol- ogy research in HIV, hepatitis, and drug resistance â¦ and this was not originally planned for HRH, for him to do this kind of train- ing. He was sharing his time in the School of Public Health teach- ings, research and also working with statistics in RBC [Rwandan Biomedical Center]â¦. This is what I call beyond Ph.D. scope, no, beyond HRH scope. There have been other benefits, other continu- ation of linking or bridging Rwanda to the world and universities in the United States. (01, Government of Rwanda HRH Program Administrator) USI faculty also reported some unexpected and lasting outcomes for USIs that participated in the HRH Program. This included USI staff whose
FACULTY TWINNING 115 contracts had not been renewed; when they moved to work in other coun- tries, many took the experiences and curricula they had gained through the HRH Program with them (16, USI Twinned Faculty in Obstetrics and Gynecology). USI faculty also talked about applying lessons from the HRH Program twinning experience in other countriesâ twinning programs. CHALLENGES WITH TWINNING Challenges with the twinning program identified during the midterm review were consistent with this evaluationâs data collection across USI faculty, University of Rwanda staff, program administrators, and other stakeholders. Challenges were attributed to a combination of factors and reported consistently across groups. Many respondents noted that although many of the challenges were magnified during the first few years of the HRH Program, there was some improvement as it continued. Gaps in Incentives and Clarity of Communication A main challenge reported was the lack of incentives and clear com- munication to University of Rwanda staff on the purpose and benefits of the HRH Program, which resulted in lack of participation by many in twinning. Many HRH trainees and USI faculty reported that University of Rwanda faculty did not have the time to commit to the twinning process, as many were already fully booked in their existing work, including the concur- rent rollout of online curricula. The midterm review similarly revealed a âlimited availability of Rwandan faculty to participate in twinning, due to competing clinical, administrative, and teaching responsibilities, as well as sheer faculty shortagesâ (MOH, 2016). HRH trainees and USI faculty reported other reasons why Rwandan faculty did not want to participate, most frequently citing poor communica- tion between the MOH and the Ministry of Education (MOE)âand then, between the MOE and its facultyâon the purpose, design, and added value of the HRH Program for University of Rwanda staff. Many University of Rwanda staff reported being surprised when the HRH Program was rolled out. As described in Chapter 3, the MOE was not actively engaged in the design of the HRH Program; the consequence of this was poor communi- cation during early implementation, although communication improved as the Program went on, as discussed below. In addition, there were no incentives for University of Rwanda faculty to participate; they received no additional compensation for participating in the Program, a fact that was amplified in USI faculty membersâ much higher salaries. Moreover, University of Rwanda faculty had many other responsibilities and commitments, and were called on by the MOH to per-
116 EVALUATION OF PEPFARâS CONTRIBUTION TO RWANDA form other functions outside of the educational setting. Respondents noted that University of Rwanda faculty had no agency in choosing whether they would be twinned, or with whom, as part of the HRH Program: Before they overcommitted â¦ they already had responsibil[ities] and you are not paid by the university to teach. So, now â¦ I de- cide to make you a teacher without asking you, because I employ you,â¦ there had to be the discussionsâyou know, we are trying to help the system, we are doing our best, you know we have limited resources and we have this opportunity we are going to manage it this way. I donât think, anyone took even one minute to invite peopleâmaybe over dinner and say: I am about to overcommit you, I know it may require 2 extra hours of your time and take 2 hours maybe away from your family, but this is what we got do to make our system strong. That never happened. (29, University of Rwanda Former Student in Internal Medicine) Mismatches in Expectations for Twinning Assignments There was also a mismatch of expectations and skills between USI and University of Rwanda faculty. The Government of Rwanda reported that many USIs did not provide qualified faculty, mostly (although not exclu- sively) referring to medical faculty, at the beginning of the Program: Over time, as we went on mentioning this challenge, the profiles changed and I think they would even send better people. (48, Gov- ernment of Rwanda HRH Program Administrator) USI and University of Rwanda faculty concurred, noting that the initial issue was that USIs were sending physician specialists who did not meet the experience requirements in terms of geographic experience or career stage (e.g., sending early-career USI faculty members to pair with senior University of Rwanda faculty), or who did not match the needed technical area or specialty. As one University of Rwanda faculty member reported, âthe mentorship I was expect[ing], I didnât have it as I expectedâ (80, University of Rwanda Twinned Faculty in Nursing). Other mismatched expectations related to scopes of work, divisions of labor, and cultural humility: U.S. faculty, Americans, need to have a huge dose of humility in terms of nothing works there the way it does here. So, if you have an American doctor who orders oxygen [and] it doesnât come, if it isnât on the floor, it isnât good or productive for the American to
FACULTY TWINNING 117 get angry and frustrated and take it out on the Rwandan staff who [took] the order. You have to figure out how to deal with those situations. (24, USI Faculty in Internal Medicine) [S]ome people who came with the HRH program were not deans, by [and] large. Very few people have been deans of school and thatâs just the nature of the system in [the] U.S. For example, my dean was twinned with an [American] who had been I think CPD [continuous professional development] in a hospital. Now, â¦ you can say there [were] some general features, in terms of leadership and management. The kind of leadership in mentoring or twin- ning that would be required for a dean of nursing in an African University that is growing very fast. (02, University of Rwanda Administrator) USIâUniversity of RwandaâMOH Relationships and Coordination USIâUniversity of Rwanda Relationships and Recruitment Successes in recruiting University of Rwanda faculty varied by specialty. Some new programs, such as the MHA, struggled to recruit sufficient Rwandan faculty to twin with USI faculty. There is some evidence that twinning worked better in more established departments, such as the Mas- ter of Science in Nursing (MSN), which had more staff to twin with USI faculty. For specialty programs with challenges in twinning, this resulted in select instances where USI faculty ended up without a twin once they ar- rived in Rwanda, and instead spent their contracts teaching and providing clinical services. The following discussion compares the MHA and MSN twinning experiences, with a more comprehensive comparison of the pro- grams in Table 5-1. Graduates from the first MSN cohort were reportedly filtering back to the University of Rwanda, and MSN graduates were seen as motivated to stay at the university because their advanced degrees had more relevance in academia than in direct patient care. By comparison, it was difficult to engage Rwandan faculty in the delivery of the MHA curriculum: [T]heir entire careers in public health and asking them to shift to hospital management is a completely different career move. So, a lot of faculty, they just donât want to do this program. Eventually, we had to move the program from the School of Public Health to the School of Health Sciences. We met the same problem. Itâs just the University of Rwanda, they donât have a lot of resources to hire new faculty â¦ specifically for hospital management. So,
118 EVALUATION OF PEPFARâS CONTRIBUTION TO RWANDA everybody was doing whatever they [had] been doing, plus this program. Time-wise, one it was a problem and two whether theyâre interest[ed] â¦ to actually shift into a different career is a different story. (15, USI Faculty in the MHA Program) In the MHA program, and in others, the result was that USI faculty taught students, rather than training faculty to become better teachers. In the emergency medicine residency program, for example, USI faculty had to primarily train students because there were no existing faculty and the first pool of Rwandan faculty recruits were not ready until year 6 of the HRH Program (MOH, 2016). In the MSN program overall, there were positive reports regarding the skills of USI faculty, many of whom were regionally based, and reports of good twinning relationships, despite some cultural challenges. It also seems that the Rwandan faculty took on more responsibility as USI staff began to wind down in 2017: From the first cohort, which is quite different from the second, the U.S. staff were the primary one[s] who were teaching us, but currently, as the number was reduced â¦ now Rwandan staff [are] working, but with the collaboration of available staff from [the] USA. (62, University of Rwanda, Former Student in Nursing) One respondent reported a very positive working relationship with a USI faculty twin who was engaged in the MHA program during the third cohort. Another faculty member from Ethiopia came to Kigali for the sec- ond half of the third cohort, and was reportedly very experienced, âbecause they had the same MHA program in Ethiopiaâ (81, University of Rwanda Faculty in the MHA Program). These respondents also reported shared learning between USI and Rwandan faculty. Also in the MHA program, however, some USI faculty who went to Rwanda for the summer were seen as âworse than our own faculty,â in that they did not support students, did not have the answers to studentsâ questions, and were unable to provide helpful feedback on dissertations (50, University of Rwanda Administrator of Public Health and the MHA Program). USIâMOH Challenges USI faculty and administration confirmed many of these challenges in recruitment, administration, and onboarding of USI facultyâa good num- ber of which the midterm review also documents:
FACULTY TWINNING 119 â¢ Difficulty finding physician subspecialists available for the 8-week period required by medical curricula (especially for dentistry, radi- ology, pathology, and ear/nose/throat specialties); â¢ Delays in funding and contract renewals that delayed or hin- dered recruiting the necessary physician specialists requested by the MOH, as well as time lines in conflict with U.S. academic calendars; â¢ Lack of funding for HRH Program advertising and human re- sources for recruitment; â¢ Insufficient salaries to attract midcareer, senior, or physician spe- cialist USI faculty, resulting in the recruitment of early- or late- career professionals (MOH, 2016); and â¢ USIs perceived the cost of losing their own faculty as too high, precluding certain staff from participating as twins (MOH, 2016). Finally, all respondents reported a lack of regular monitoring of the twinned pairs. Anecdotal reports indicated that the Government of Rwanda initially conducted exit interviews with twins, but the lack of consistent monitoring of these relationships challenged the HRH Programâs ability to learn what was working and what was not, and adapt in real time to improve management and implementation of the twinning process. CONCLUSIONS Twinning has been suggested as an effective and collaborative approach to empowering health care professionals in low-resource settings, although it is necessary to gain clarity on the concept before conducting a rigorous impact evaluation. A recent analysis of peer-reviewed publications on twin- ning projects in global health (Rwanda was not included in the sample) found definitional variation, but identified four attributes of twinning: reci- procity, personal relationship building, a dynamic process, and involvement of two named organizations across cultures. From the concept analysis, the following definition of twinning was generated: âa cross-cultural, reciprocal process where two groups of people work together to achieve joint goalsâ (CadÃ©e et al., 2016), pointing to a relationship at an institutional level. Twinning programs can also be used to strengthen professional medical associations in low- and middle-income settings (Azimova et al., 2016). There are several examples of long-term institutional twinning that build teaching and research capacity. The partnership between Makerere University in Uganda and the Karolinska Institute in Sweden, which empha- sized strengthening research capacity, has graduated 40 doctoral students from Uganda since 2003, and more than 300 faculty and students have
120 EVALUATION OF PEPFARâS CONTRIBUTION TO RWANDA been a part of the exchange (Karolinska Institutet, 2018). Although that programâs focus was on a joint Ph.D. program, students spent a majority of their time in Uganda to ensure research remained focused on local is- sues, with the remainder spent in Sweden, where they enrolled in specialty courses (Sewankambo et al., 2015). The institutional partnership between Muhimbili University of Health and Allied Sciences in Tanzania and the University of California, San Fran- cisco (UCSF), Institute for Global Health Sciences focused on incorporating innovative teaching in curriculum, finding short-term solutions to faculty shortage, and increasing clinical exposure of medical students (Tache et al., 2008). These activities grew to shift from âmedical educationâ to âhealth professions educationâ and emphasized interprofessional teamwork. The partnership also benefited UCSF and focused on the institutionsâ shared challenges despite differing resources, such as large class sizes and more engagement with a wider range of stakeholders (Pallangyo et al., 2012). In contrast, the HRH Program twinned USI faculty and University of Rwanda faculty at an individual level, and experienced mixed results in twinning, mostly owing to varied experiences in design, management, and implementation across specialties. Strengths of the model include bringing external faculty and other experts via the memoranda of understanding (MOUs) with USIs, and gains in University of Rwanda staff membersâ capacity to manage and plan for new specialty programs and the increased number of students and residents who were flowing through the university and teaching hospitals. However, there was variation across programs, with Rwandan faculty in the MSN program, for example, demonstrating notably increased capacity. The reciprocal nature of twinning relationships was evident in some pairings of USI and Rwandan faculty, though not all, and was found to be more successful where interpersonal relationships had developed between twins. The formation of continued partnerships resulted in new publications and advancement in University of Rwanda facultyâs professional development. However, respondents reported a perceived lack of equality, which is key to reciprocal relationships, between USI faculty and Rwandan facultyâs compensation (CadÃ©e et al., 2018). Nonetheless, twinning did not meet its original objective of widespread teaching and clinical skills transfer between USI faculty and University of Rwanda faculty, in part because the original design lacked clarity on how to operationalize this unique model, which worked across 25 USIs and 22 programs. On both sides of the relationship (U.S. and Rwandan), lack of resources and time committed to setting up and then managing the initia- tive created challenges in issuing contracts, recruitment, and onboarding, affecting the overall success of the model. Furthermore, the lack of incen- tives to encourage University of Rwanda faculty to participate, given their other responsibilitiesâcombined with challenges due to cultural differences
FACULTY TWINNING 121 between the USI and University of Rwanda twinsâimpaired the modelâs sustained success. The result was the absence of a dynamic twinning pro- cess that allowed for tactical adjustments to improve implementation and likelihood of success. It is unclear whether learning generated from an Ethiopian twinning program supported by the Presidentâs Emergency Plan for AIDS Relief to bolster emergency medicine training was incorporated into the design and management of the HRH Program. In the first year of the Ethiopia project, courses were delivered by U.S. and South African instructors; during year 2, courses were co-taught by foreign and Ethiopian educators, during which time curricula were adapted to the local context; by the third year, capacity had been built in sufficient numbers of Ethiopian instructors to indepen- dently deliver the nine emergency medicine modules (Busse et al., 2013). Other twinning and partnership experiences could have offered insights into effective and productive collaborations, including identifying models outside of twinning that could have enabled Rwandan faculty to access USI faculty who were more advanced in their careers but could not physically be in Rwanda for extended periods. Additionally, the HRH Program did not seem to take into account what is needed or how to teach health professionals to be health profes- sional educators. Evidence indicates that courses designed specifically to build teaching skills can improve teaching confidence, effectiveness, and student outcomes (Brown and Wall, 2003; Godfrey et al., 2004; McLeod et al., 2008). During implementation, other challenges arose from lack of clear commu- nication from the MOH (and the MOE) to University of Rwanda staff (which did improve over time), and between the MOH and USIs. This resulted in mis- matched expectations and poor communication, cultural differences, and lack of coordination across specialties. A midwifery twinning project between the Netherlands and Sierra Leone identified 10 key steps to a twinning program, including evaluating organizational capacity; matching twins based on key criteria; creating avenues and opportunities for twins to communicate, bond, and âcreate joint storiesâ and joint projects; and celebrating achievements and successes to encourage ongoing twin relationships (CadÃ©e et al., 2013). Regular interinstitutional communication is also critical to share progress, dis- cuss challenges, and hold partners accountable (Busse et al., 2013). The HRH Program did not appear to incorporate these types of considerations into the planning and implementation process. The short duration of USI faculty stays in Rwanda was seen as another barrier to effective transfer of teaching and clinical skills, reinforcing the evidence that suggests long-term peer-to-peer support is necessary for effective twinning (Kelly et al., 2015). Where there were successes in management and implementation, these were driven more by individual commitments than longer-term institu-
122 EVALUATION OF PEPFARâS CONTRIBUTION TO RWANDA tional partnerships, especially among USI faculty who had already been in Rwanda or had a particular passion for making this program a success. They often took time out of their own schedules to manage overhead and internal communication issues. On the University of Rwanda side, individ- ual faculty members who had the time, background, and interest in a given specialty also committed to making it a success. Institutionally, despite the recognition that longer-term engagements strengthened twinning relation- ships, two related factors made longer-term commitments challenging: (1) MOUs were signed for only 1 year at a time; and (2) many USI faculty were contractors, not tied to a specific institution but only hired for that 1-year contract (see Chapter 3 for more detail on the contracting process). Many of the other successes of the HRH Program are attributed to the overall health professional institutional capacity, findings that are detailed in Chapter 5, and the increased production and capacity of HRH trainees, findings that are detailed in Chapters 6 and 7. REFERENCES Azimova, A., A. Abdraimova, G. Orozalieva, E. Muratlieva, O. Heller, L. Loutan, and D. Beran. 2016. Professional medical associations in low-income and middle-income countries. Lancet Global Health 4(9):e606âe607. Binagwaho, A., P. Kyamanywa, P. E. Farmer, T. Nuthulaganti, B. Umubyeyi, J. P. Nyemazi, S. D. Mugeni, A. Asiimwe, U. Ndagijimana, H. Lamphere McPherson, D. Ngirabega Jde, A. Sliney, A. Uwayezu, V. Rusanganwa, C. M. Wagner, C. T. Nutt, M. Eldon- Edington, C. Cancedda, I. C. Magaziner, and E. Goosby. 2013. The Human Resources for Health Program in Rwandaânew partnership. New England Journal of Medicine 369(21):2054â2059. Brown, N., and D. Wall. 2003. Teaching the consultant teachers in psychiatry: Experience in Birmingham. Medical Teacher 25(3):325â327. Busse, H., A. Azazh, S. Teklu, J. P. Tupesis, A. Woldetsadik, R. J. Wubben, and G. Tefera. 2013. Creating change through collaboration: A twinning partnership to strengthen emergency medicine at Addis Ababa University/Tikur Anbessa Specialized Hospitalâa model for international medical education partnerships. Academy of Emergency Medi- cine 20(12):1310â1318. CadÃ©e, F., H. Perdok, B. Sam, M. de Geus, and L. Kweekel. 2013. âTwin2twinâ an innovative method of empowering midwives to strengthen their professional midwifery organisa- tions. Midwifery 29(10):1145â1150. CadÃ©e, F., M. J. Nieuwenhuijze, A. L. Lagro-Janssen, and R. De Vries. 2016. The state of the art of twinning, a concept analysis of twinning in healthcare. Global Health 12(1):66. CadÃ©e, F., M. J. Nieuwenhuijze, A. L. M. Lagro-Janssen, and R. de Vries. 2018. From equity to power: Critical success factors for twinning between midwives, a Delphi study. Journal of Advanced Nursing 74(7):1573â1582. Cancedda, C., R. Riviello, K. Wilson, K. W. Scott, M. Tuteja, J. R. Barrow, B. Hedt-Gauthier, G. Bukhman, J. Scott, D. Milner, G. Raviola, B. Weissman, S. Smith, T. Nuthulaganti, C. D. McClain, B. E. Bierer, P. E. Farmer, A. E. Becker, A. Binagwaho, J. Rhatigan, and D. E. Golan. 2017. Building workforce capacity abroad while strengthening global health programs at home: Participation of seven Harvard-affiliated institutions in a health pro- fessional training initiative in Rwanda. Academic Medicine 92(5):649â658.
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