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Coming of age

ESTHER Germany celebrates a decade of partnerships between German universities and African hospitals

Laboratory in Battor Hospital

Direct, collaborative relationships between health institutions in the North and South are an effective way to build the capacity of health professionals and to improve health outcomes in low- and middle-income countries. What’s more, the benefits from such partnerships flow both directions. A look back at the first ten years of university and hospital partnerships under ESTHER Germany reveals the unique features of this innovative and relevant form of international cooperation.

Building bridges from Berlin to Butare

More than 6,000 kilometres and a world of differences separate the Charité University Hospital in Berlin and the University Teaching Hospital of Butare (CHUB), in southern Rwanda. Yet for the past five years, medical researchers and clinicians from the two institutions have worked together closely on a series of tangible projects to improve the quality of care which patients receive at this Rwandan referral hospital.

CHUB is a 500-bed facility which treats some 10,000 inpatients and 50,000 outpatients every year. Infection control is a top concern for hospital management and the current collaboration between Charité and CHUB tackles this problem head-on. Researchers at the two institutions have investigated the extent and spread of so-called ESBL bacteria, which can lead to antibiotic resistance, at the hospital and are seeking to reduce hospital-acquired infections by introducing a locally-produced alcohol-based handrub and training health workers in its regular use.

The long-term collaboration between Charité and CHUB is one of ten such partnerships organised under the auspices of ESTHER Germany, an initiative implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the Federal Ministry for Economic Cooperation and Development (BMZ).

Celebrating 10 years of joint efforts to improve health

On November 26 a special anniversary event was held at the BMZ to celebrate ESTHER Germany’s achievements. Representatives from the European ESTHER Alliance (of which ESTHER Germany is a part), GIZ and the ESTHER Germany Secretariat, and German universities involved in ESTHER partnerships came together to take stock of accomplishments and to look towards the future. 

They were welcomed by André Budick, from the BMZ division for health and population policy, who placed university and hospital partnerships into the broader context of German development cooperation in health. Budick praised the role of such partnerships in strengthening health systems in low- and middle-income countries – one of the primary goals of German assistance in the field of health. He also noted that ESTHER’s approach is well aligned with the goals of the BMZ Africa Initiative, which stresses the importance of twinning arrangements between German and African institutions and the need to increase the number of health experts in Africa.

In his opening remarks Dr Günther Taube, the head of Education, Health and Social Protection at GIZ, drew attention to the way ESTHER works in and with networks, effectively linking together various communities of experts, from scientists, researchers and clinicians working in higher education institutions to development practitioners. ‘This type of work is like building bridges,’ Taube explained, ‘and once you’ve built the bridges, you have the opportunity to cross rivers, overcome obstacles, and link islands.’ In this way, ESTHER’s work in building capacity for health care and research goes beyond ‘traditional’ development cooperation and into the realm of international cooperation. Moreover, the institutional partnerships established under ESTHER can readily be extended into other fields and serve as a basis for cooperating and developing capacities in teaching and higher education more broadly.

What is ESTHER?

ESTHER – Ensemble pour une Solidarité Thérapeutique Hospitalière en Réseau – was launched in France in 2002 as a way to strengthen the response to AIDS and related diseases in low- and middle-income countries. Since that time ESTHER has grown into the European ESTHER Alliance (EEA) which spans 12 member countries. According to Dr Farid Lamara, the General Secretary of the Alliance, its member countries collectively support some 550 health partnerships in 48 countries in Africa, Central and South America and Asia. While hospital twinning is still at its core, ESTHER’s institutional partnerships now span a range of capacity development approaches and have broadened their focus beyond HIV and AIDS to other global health issues.

Germany joined ESTHER in 2004 and, shortly thereafter, the ESTHER Germany Secretariat was established at GIZ. Reflecting back on the early years of the programme, Dr Brigitte Jordan-Harder, a Senior Technical Advisor with the ESTHER Germany Secretariat, recalls the feeling of starting something virtually from scratch. ‘This was totally new for us,’ she explained. ‘We had no experience running partnerships, no instruments to use and no sense of whether German institutions and partner country hospitals would even be interested in such cooperation.’

Many months of hard work went into developing systems, procedures, selection criteria and contract designs. At the same time, staff at the ESTHER Secretariat worked through health-related professional associations across Germany, spreading the word about the chance to collaborate with hospitals in German Development Cooperation partner countries.

Interest in the approach grew slowly at first, and then more rapidly. By 2014, ESTHER Germany was supporting ten partnerships in seven sub-Saharan African countries (Cameroon, Ethiopia, Ghana, Malawi, Rwanda, Tanzania, and Uganda), as well as one ‘South-South’ partnership between hospitals in Cameroon and Tanzania. The focus of the partnerships ranges from management of antiretroviral treatment and adherence counselling to cervical cancer screening and maternal and neonatal health.

Driven by partner country needs, oriented on practical results

Yvonne Schönemann, Coordinator of the ESTHER Germany Secretariat, shared with those present the key findings from an independent evaluation of the European ESTHER Alliance undertaken in 2012. The study found that the strength of the ESTHER model lies in partnerships’ responsiveness to local needs, a long-term approach which builds trust and capacity, and direct peer-to-peer learning. 

Indeed, the university and hospital partnerships supported by ESTHER Germany, while differing in their details, all share a common commitment to addressing relevant, practical challenges, from tackling infection control to establishing cancer registries and extending screenings for cervical cancer. And they do this through multi-year projects jointly designed and implemented by researchers and medical professionals from both institutions. Most importantly, the results of the partnerships are directly and immediately applicable for partner hospitals and the patients they serve.

[Hier sagen, was auf dem Bild ist]

Amrei Krings of the Gynecology Clinic at Charite University Medicine, Berlin, trains Hansen Benjamin Tetteh, a laboratory technician from Ghana’s Catholic Hospital Battor, in running diagnostic tests. © Andreas Kaufmann, Charité

Amrei Krings, a PhD student at the Clinic for Gynaecology at Charité, in Berlin, described how she and Dr Andreas Kaufmann are working with a team at the Catholic Hospital in Battor, Ghana, to extend testing for the Human Papilloma Virus (HPV) among women through the use of a simple self-sampling device. Despite the logistical challenges involved in setting up laboratory facilities in Battor, and the unexpected insolvency of the company which produced the self-sampling device, the partnership has continued to make steady progress and the main intervention, in which 2000 women in the community will be tested for HPV, is slated to start in the first half of 2015.  ‘Motivation and ownership of the local partners is the key to success,’ explained Krings. Dr Kofi Effah, the gynaecologist with whom they are working in Battor, spent a year training in a clinic in Berlin and went back to Ghana committed to making HPV screening more widely available. ‘They are pushing us to do more and to find new opportunities,’ Krings said.

In his presentation Dr Jean-Jacques Akamba, the ESTHER Coordinator in Cameroon, described how existing ESTHER partnerships have been mobilised in support of Ebola preparedness measures. After the current Ebola outbreak spread to Nigeria earlier this year, the Cameroonian government requested assistance from ESTHER to build the capacity of health personnel in five regions, to work with local health officials to develop Ebola protocols, to prepare isolation rooms in hospitals and to reinforce hospital hygiene measures. Existing ESTHER partnerships with French and German universities have served as a springboard for quick action.

Harnessing the power of networks

ESTHER Germany – itself a network – is linked to many other networks and initiatives which open up opportunities for its members to connect with others. Through the European ESTHER Alliance, German-supported ESTHER partnerships can link with work being undertaken by ESTHER in the other 11 member countries. Relationships with the European Commission, the European and Developing Countries Clinical Trials Partnership (EDCTP), and the World Health Organization’s Division for Tropical Disease Research, among others, open the door for the exchange of experiences and financing of joint research projects.

As Dr Günther Taube mentioned in his opening comments, networks are like bridges. As German universities involved in ESTHER partnerships learn about one another’s work, they often see opportunities to apply innovative ideas from one country to other country contexts. Discussions are currently underway, for example, about the possibility to extend the HPV testing methodology being used in Ghana to ESTHER partnerships in Ethiopia and Tanzania.

Mutual learning…

The Medical Center at the University of Rostock was one of the first German institutions to come on board with ESTHER Germany. Dr Christoph Hemmer, a specialist in tropical medicine who attended the anniversary event in Berlin, has been involved in a partnership with the Limbe Provincial Hospital in Cameroon since 2008. What initially attracted him to the idea of the partnership?  ‘I wanted to get involved with a fascinating project,’ he recalled, ‘and to have direct involvement with tropical medicine. I saw it as a chance to learn something, and to teach something.’

Hemmer is of the view that German institutions benefit from the ESTHER partnerships as much as their African partners do. Not least, it provides German medical students with the opportunity to learn how medicine is done under very different conditions than those to which they are accustomed. ‘This scheme allows students to see new things, to hone their clinical skills by learning to take good histories, doing subtle clinical exams and weighing what they know about the frequency and likelihood of conditions to make a differential diagnosis.’

[Hier sagen, was auf dem Bild ist]

Prof. Dirk Vordermark © GIZ / Kilian Günther

Professor Dirk Vordermark from the University Clinic at Martin Luther University Halle, which partners with Addis Ababa University in Ethiopia, agreed. He noted that a dozen medical students from Halle have now done field work in Ethiopia, gathering data on the incidence of gynaecological cancers in urban and rural areas. ‘From the point of view of the medical faculty, this type of project is highly attractive because it contributes to our general research interests in epidemiology,’ he said.  

…and a broader perspective

Another benefit of the ESTHER model has to do with the way it brings experts from a variety of disciplines together, with a common purpose. Professor Frank Mockenhaupt, who heads the partnership with Butare, Rwanda on behalf of the Institute for Tropical Medicine and International Health at Charité, appreciates the fact that ESTHER makes it possible for German universities to pursue joint projects with African partners. ‘It gives people like me and others a taste of cooperation work. It’s not pure research – it’s a different taste that enters into our fields and it’s interesting.’

Dr Andreas Kaufmann, an immunologist at the Gynaecology Clinic at Charité, echoed this sentiment: ‘A really valuable thing about ESTHER is that it brings together combinations of people who wouldn’t otherwise meet. It’s easy to go to conferences and meet with people with similar backgrounds and expertise. Though involvement with ESTHER, we gain a much wider perspective.’

The way forward for ESTHER

With considerable achievements already behind it, ESTHER Germany is heading confidently into its second decade. Interest from German universities continues to grow and many practical lessons have been learned about how to build and maintain successful partnerships.

Beyond this, ESTHER has demonstrated the relevance and effectiveness of the university and hospital partnership approach. It provides a robust framework for bringing together expertise from clinical, research and development communities and, as such, effectively complements other, more traditional forms of development cooperation. While such partnerships on their own cannot strengthen health systems at the scale which is needed, they are highly effective as a way to test out innovative ideas and to positively impact health service delivery.

To be sure, there are challenges to address and areas which could be improved. Broader institutional commitment from German universities – beyond the extraordinary efforts of the individual researchers and clinicians who drive the partnerships – would lend greater weight to and enhance the sustainability of ESTHER partnerships. A lack of continuous funding is another obstacle for ESTHER partnerships to surmount.

These and other issues will require attention as ESTHER Germany moves into ‘adolescence,’ but the future of the initiative looks bright. André Budick from the BMZ put his finger on the essence of ESTHER when he reminded those at the anniversary event of the following African proverb: ‘If you want to go fast, go alone. But if you want to go far, go together.’

Here’s to another 10 years of fruitful ESTHER partnerships!

More on ESTHER

See also: The European ESTHER Alliance Web page

BMZ glossary

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