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See logframe attached

1. REASON FOR INTERVENTION …………………………………………………………………………………………………………………………………………………… 2

1.1 Operational context in the field …………………………………………………………………………………………………………………………………. 2 a) Low coverage and in unstable contexts b) Decentralisation of HIV/TB care (task-shifting) & development of innovative care strategies c) Comprehensive needs for HIV/TB care as well as a wider range of conditions. d) Insufficient focused care for patients with advanced disease e) Areas of HIV/AIDS care neglected in all settings f) Antimicrobial Resistance (AMR) g) Mentoring to support the implementation of the MSF “light approach” strategy h) Generally poor levels of care for children

1.2 Learning context in the field …………………………………………………………………………………………………………………………………………. 4

a) The limited support given to existing HIV/TB field training activities b) Continuity/links from classroom training to application in the workplace (transfer) c) Monitoring and evaluation of the impact of trainings d) Access to training for field staff e) Self-education modalities

2. SAMU LEARNING RESPONSE, 2017 …………………………………………………………………………………………………………………………………….. 6

2.1 Objectives ………………………………………………………………………………………………………………………………………………………………………………. 6 2.2 Axes of intervention ………………………………………………………………………………………………………………………………………………………… 6

2.2.1 To provide and support HIV/TB–related trainings to MSF missions …………………………………………. 6 a) In all contexts b) Adapted to each level of need c) With HIV/TB programmatic and/or technical content and within multidisciplinary themes d) Ensuring a wide variety of training approaches e) In both English and French

2.2.2 To provide pedagogical technical expertise and support ……………………………...................................... 11 a) Provide technical/pedagogical support at all levels of the training cycle b) Provide a Training of Trainers (ToT) course c) Focus on Mentoring skills

2.2.3 To develop and manage the sharing and dissemination of SAMU resources ……………........... 13 a) Context b) Production, editing and management of SAMU resources c) SAMU Website as the main medium for sharing resources

2.2.4 To develop a Monitoring and Evaluation system for all SAMU trainings ……………………………… 15

2.2.5 To reinforce communication, networking and partnership …………………………………………………………. 15 a) Communication b) Networking and partnership

3. OTHER AREA OF WORK …………………………………………………………………………………………………....………………………………………................ 17

SAMU contribution and involvement in the OCB Medical Education project

4. RESOURCES ……………………………………………………………………………………………………………………………………………………………………………………. 18

PROJECT DOCUMENT Southern Africa Medical Unit (SAMU)

Learning Unit

2017

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1. REASON FOR INTERVENTION

1.1 Operational context in field

Support to field operations on HIV/TB remains the SAMU core objective, and in this regard, it is important for the SAMU learning unit to define its plan of action in response to operational ambitions and problems/difficulties/challenges encountered by field operations. It should not be seen separately from any other SAMU activities as the SAMU support is a continuum between direct technical and strategic support from SAMU HIV/TB experts (focal person) and ongoing training activities. This Training Unit action plan falls into the 2017 global SAMU strategic vision and action plan. The proposed 2017 plan of action and choices for intervention are founded on the contextual elements identified below (not in order of priority). a) Increased need for HIV/TB trainings in integrated projects in low coverage and in unstable

contexts It is now universally accepted within MSF operations that HIV/TB care needs to be integrated into projects where HIV/TB are not the main axis of intervention. The main challenge remains ACCESS to HIV/TB care. It was recommended that the scale-up be catalysed by adapting what has been learnt from "vertical programmes". In these countries, the political situation and the limited capacity of the national health system often makes the concrete implementation of this integration very challenging so it is now a clear operational intention in all MSF OCs to support this integration process. This becomes even more difficult in emergency settings and displaced people situations. Operational Prospects, OCB takes a clear position reaffirming that, in the existing missions (CAR, Guinea and DRC) in low coverage countries, we need to take a longer term view, considering the situation as a humanitarian emergency where very little governmental capacity exists to plan shared responsibility and hand-over. For MSF field staff who do not always have the necessary knowledge and experience in care of HIV and/or HIV/TB co-infected patients, this is still perceived as “too complicated”. As an HIV/TB Unit with a wide range of experience in various contexts, SAMU has an important role to play in giving strategic and technical support in these contexts. Training activities are an important leverage to contribute to this ambition.

b) There is an increasing move towards decentralisation of HIV/TB care (task-shifting) and

development of innovative care strategies Over the past few years the global trend for HIV programs has been a progressive shifting of the burden of HIV management away from central hospitals into the district hospitals and primary health care clinics. With this shift comes a growing need to increase the capacity and competence of staff to handle this. In addition there are many other innovative approaches to care being rolled out that need to be developed or supported through learning/trainings activities (community-based approach (testing, linkage & retention in care), early ART initiation, new preventative strategies, etc)

The proposed action plan will give special attention to training demands from low coverage and unstable countries.

An important axis of intervention described in this action plan aims at supporting decentralisation of care at primary health care level, and innovative implementation approaches

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c) More comprehensive needs for HIV/TB care as well as a wider range of conditions.

HIV/TB programs are often more complex requiring a more comprehensive, holistic approach. The scope of disease intervention is also wider (HIV/TB/DRTB/HepC/Chronic diseases) and intervention is across a broader range of disciplines (programmatic, Clinical, laboratory, patient support, M&E…)

d) Insufficient focused care for patients with advanced disease The patient with advanced disease has come under the spotlight again as evidence is showing that the numbers of patients presenting with low CD4 counts is relatively unchanged from many years ago. The mortality rate remains a concern and now, with new point-of-care rapid diagnostic tests available and with the bulk of these patients coming from patients failing their ARVs rather than being ART-naïve, new approaches to these patients need to be developed. As much as the need is there to address this issue in the OPD clinics, it is as important to ensure that the hospitals we are referring to are providing good quality of care for these patients. For this reason, along with the fact that other stakeholders and funders are minimally invested in the support of hospitals, MSF is increasingly engaging in these IPD environments.

e) Areas of HIV/AIDS care neglected in all settings:

There are several areas identified by MSF as priorities or where better focus should be addressed, in which trainings could be part of the response to this. For example:

– Key populations: CSWs and clients, PWID, MSM, prisoners, adolescents and young women)

Co-infection with hepatitis B and C

f) Rising concern globally regarding Antimicrobial Resistance (AMR) Anti-microbial resistance is a growing concern globally leaving virtually no area untouched in clinical medicine. This is no less true in the realm of HIV and TB where strategies are needed to contribute to the worldwide plans to address this problem

g) Increased use of mentoring to support the implementation of the MSF “light approach” strategy “Light Approach” has increasingly become MSF’s strategic operational approach to engagement in HIV/TB projects. It consists of progressively transferring some elements of clinical HIV/TB care to MoH and keeping only specific roles of technical support to MSF staff. With this implementation strategy, MSF Staff are often placed into a situation where they have to both “mentor” clinical staff in decentralised clinics (MoH) and supervise activities and programme outcomes of the project. They do not always feel adequately skilled to fulfil the dual roles of pedagogic and clinical/programme management responsibilities. The provision of supervision and mentoring is therefore frequently one of the main components of this light approach with a ‘dashboard’ of key indicators used to monitor improvements and identify key areas in need of extra support.

Importance to focus on a wider range of intervention to cover not only more illnesses but also a greater variety of disciplines

d), e), f), We should remain open to respond to possible learning needs in these new conditions and neglected population groups

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The paradox is that while it is a key operational orientation in most of HIV/TB vertical projects, the light approach can often be perceived as requiring “light resources”.

h) Generally poor levels of care for children

On the whole, clinicians lack confidence in dealing with children with HIV/TB and, in addition there is generally poor implementation of paediatric HIV/TB programmatic elements in the field. Data on paediatric outcomes in the clinics MSF supports demonstrates the impact of this. SAMU LU will continue to support the existing paediatric HIV/TB training needs in the different contexts in which it is needed There is also a lack of integration of paediatric HIV/TB diagnosis and management into projects focused on nutrition and a specific need being expressed for SAMU’s contribution to the HIV/TB training components of existing general paediatric and nutrition trainings in low coverage and in unstable contexts. SAMU plans to increase support on this with help from a MSF Khayelitsha-based paediatrician with whom there is already some collaboration.

1.2 Learning context in the field a) The limited support given to existing HIV/TB field training activities

At present although the HIV/TB training offered by SAMU and all MSF OCs are well documented, many HIV/TB trainings are still designed, organised and implemented in the field, by the field teams themselves, as part of the operational objectives and activities of their missions. These training responsibilities consume much time and energy for field staff who have to implement them over and above their programme management duties. These training activities however have the potential to be the most powerful in terms of learning transfer and impact as, being completely piloted by the team themselves in the field, they are best adapted to the specific learning needs. There are regular requests for support to optimise the outcomes of these trainings. The solution however is not to delegate this responsibility to an external unit (like SAMU) but for the mission to maintain ownership while drawing on SAMU for support in the development of their training programmes.

b) Poor continuity/links from classroom training to actual application in the workplace

(transfer) There is an ongoing concern by mission staff regarding the capacity of MSF to ensure the follow-up and implementation in the workplace of theoretical concepts and new knowledge acquired during training. This phase, called “transfer”, is important if what we aim at is the development of genuine hands-on competencies in the workplace. The challenge here is that people giving training (trainers) are frequently not the people supervising and managing staff & programmes in the field. This diversity of training and management “actors” increases the risk of losing coherence and continuity which in turn can hamper this “transfer” process.

The development of a specific support to field mentoring activities is a priority for SAMU and SAMU Learning Unit in 2017, within the continuity of all experiences accumulated in 2016.

An important axis of SAMU Learning Unit intervention in 2017 proposes to support field teams in the design, preparation and implementation of trainings along with contributions to pedagogy and learning methodologies.

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Providing on-site training is the best approach to keep all “actors” involved and to respond to specific needs of the project/mission. Mentoring remains the most powerful approach to link newly acquired knowledge and its transfer at work

c) Minimal monitoring and evaluation of the impact of trainings

With any training intervention comes the need for ongoing monitoring and evaluation to ensure and improve its effectiveness. Currently there is very little beyond the gathering of very basic post-course feedback so there is a need to develop more advanced processes for broader evaluation of our trainings. This applies especially to the development of qualitative indicators and for evaluating transfer and impact in the workplace.

d) Insufficient Access to training for field staff In the MSF projects in HIV/TB settings there is usually a reasonable number of staff, clinical and non-clinical, from both MSF and MoH who benefit from SAMU’s centralised trainings (in Cape Town). However, capacity in off-site courses in Cape Town is limited so SAMU LU intends to increase access to training for more staff by proposing more on-site trainings (in the mission), with adapted methodologies, especially those which allow closer proximity with the field. E-Learning and other learning tools will also play an important role to address this issue.

e) Increase needs and use of self-education modalities

There is a growing trend in global education towards a use of a variety of learning opportunities, falling under the banner of a “Personal Learning Environment (PLE)”. Within this is an increased focus on internet-based resources, specifically access to medical digital resources, access to forum, peer to peer platforms, webinar etc)

The MSF SAMU Learning Unit plan of action proposes to focus increasingly on on-site trainings with a mentoring focus as this maximises this transfer process.

Necessity to integrate training M&E component in all training initiatives or project developed, and to this end, to draw on the OCB and OCG L&D unit experiences.

Need to propose and to develop various training and learning implementation approaches, aiming at increasing larger access to MSF/MoH staff to trainings and learning opportunities

Need to develop, catalogue and facilitate access to a wide variety of learning resources, especially via the SAMU website

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2. REASON FOR INTERVENTION1

2.1 Objectives

General Objective In MSF projects having medical activities related to HIV and TB, to contribute to the achievement of operational objectives and the development of staff

Specific Objective MSF field projects, HQs and all MSF partners access and use quality learning opportunities in HIV/TB at programmatic and technical levels

2.2 Axes of Intervention2

The proposed plan of action focuses on 3 main axes of intervention:

2.2.1 To provide and support HIV/TB-related training for MSF missions 2.2.2 To provide pedagogical technical expertise and support 2.2.3 To develop and manage the sharing and dissemination of SAMU resources

Two additional and transversal working axes will support and complement our interventions: 2.2.4 To develop a Monitoring and Evaluation systems for all SAMU trainings 2.2.5 To reinforce communication, networking and partnership in the development and

implementation of our learning activities

2.2.1 To provide and support HIV/TB–related trainings to MSF missions

The core activity of SAMU is to support HIV/TB activities in the field. The main axis of intervention of the SAMU training unit is therefore the provision of training in HIV/TB-related service provision:

a) In all contexts b) Adapted to each level of need c) With HIV/TB programmatic and/or technical content and within multidisciplinary themes d) Ensuring a wide variety of training approaches e) In both English and French

a) In all contexts

SAMU’s training offer extends to vertical or integrated programmes in projects in all prevalence settings and coverage contexts, high and low, as well as in unstable contexts, whenever HIV/TB is part of the operational objectives of the mission. An important priority from SAMU and all OCs is to give special attention to all training requests from missions/projects implementing integrated HIV care in unstable and low prevalence contexts. MSF missions or projects which are not officially within the SAMU country portfolios, including OCG, are welcome to make requests for training. SAMU will assess them carefully in order to try and attend to the need.

1 No proposed training activity should ever exist by itself, “just to make SAMU learning unit busy” (Catalogue

approach). All training interventions should be developed in the context of clear operational positioning and priorities within a mission/project.

2 Described as “expected results” in the attached logframe

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Important note: SAMU can support a training request in the country only if it is part of a full operational response with the capacity to implement HIV/TB care (staff, drugs, equipment). A training cannot be seen as the starting point of such an operational response but rather as an early implementation step in the process. If all other conditions and prerequisites are not met for implementing HIV/TB activities in the project we will recommend postponing a training until they are.

b) Adapted to each level of need

The capacity to respond to all MSF operational contexts implies the ability to offer training at various levels of need. The 2017 plan of action proposes exactly this, with training offers at a variety of levels, ranging from basic to more advanced courses as well as workshops for highly experienced staff. Although we know that core topics will probably be common to all trainings, experience has shown that it is not practical to design a standard “one size fits all” training package. For example, the level of training required (from basic to advanced) varies from one context to another, so SAMU will use a core training package which it will adapt based on a needs analysis prior to the training. This is particularly relevant for all on-site trainings. On-site training is the preferred approach to ensure a tailor-made training adapted to the working context and the level of participants.

c) With HIV/TB programmatic and/or technical content and within multidisciplinary themes3

Within SAMU’s overarching strategic and technical HIV/TB support to MSF programmes, the learning unit plan of action for 2017 offers comprehensive courses that cover technical (clinical, patient support, lab etc) and programmatic topics. Distinction between technical/clinical and programmatic topics will not be as compartmentalised as it is in words. They are obviously closely interconnected but we intentionally want to maintain flexibility to develop “tailor-made” trainings with the appropriate mix of programmatic and technical components depending on the context and the target group. In addition, the response to HIV/TB requires a comprehensive multidisciplinary approach so at times there may be a need for a more focused training offer such as clinical DR TB or patient & community support (PCS). In this regard SAMU LU can support other thematic trainings in 2017 if pertinent and responding to a clear need. Other examples would be in the realms of laboratory, M&E or operational research. A special focus will be given this year in providing AMR training to the SAMU medical team. Other areas for potential trainings are addressing the needs of key population groups as well as an identified area of poor clinical competence, the management of the patient with a high viral load.

d) Ensuring a wide variety of training approaches:

Considering the various constraints within field missions in ensuring access to training for their staff, as well as the need to apply adult learning principles, it is important for SAMU LU to propose a variety of training approaches. Ideally these should involve those that promote a constant interplay between theory and practice. Our emphasis will always be towards investment in learning opportunities in the actual workplace, where we believe there is the best opportunity for “transfer” of knowledge into competencies and thus the place for the most effective learning. We therefore propose:

Off-site and on-site training Mentoring Bedside teaching E-Learning (internet-based training)

3 Some concern has been expressed that organising these specific thematic trainings might reinforce the fallacy that

the HIV/TB response needs specialized units (ie. Paediatrics, PMTCT). It needs to be stated that whilst a training may focus on a specialised area, the intention is to further equip clinicians to be more competent generalists with abilities in specialised niches of care. This will be clearly stated each time we support such a training initiative.

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- Off-site and on-site trainings4 This is one of the strongest added values of SAMU, something that we want to use our flexibility and proximity to the field to continue in 2017. Proposing both on-site and off-site trainings allows us to respond to the double needs of contributing to the achievement of operational objectives of the missions as well as the development of individual competencies in the field. The combination of on-site and off-site trainings helps to maintain a healthy balance as they each have specific benefits.

Benefits of on-site training in the field: We can propose “tailor made trainings” adapted to specific contexts and operational objectives of

a mission or a project. We can also adapt it to the level and experience of staff. An important pre-condition is the training need analysis prior implementation.

We can adapt the training to respond to the local MSF-MoH partners’ existing working dynamics in the national HIV/TB response.

We can use the national/regional context specificities and data to illustrate challenges faced and possible ways to overcome them (clinically and programmatically).

We avoid disconnection between the learning process and context of the project/mission

We use the country context and field work as a learning place.

We link reflection and learning arising from the trainings with the feasibility of their transfer into the work place (from theory to practice). An on-site training gives a better chance for positive impact on quality of care and operations.

We increase access to training for many more staff members, especially the national team who represent 90% of MSF’s workforce capacity.

Benefits of off-site training: People from a variety of operational contexts are able to benefit from a centralised pool of experts

within the Cape Town context (eg local experts in clinical management), also working with greater diagnostic and treatment resources. This allows a higher level of training for those who need it.

We are able to reach specific target groups of participants such as coordinators or people with specialised activities who, as a group, would not constitute the critical mass required to justify an on-site training in their respective countries.

In programmatic trainings a forum is created for participants to benefit from networking with people from a variety of contexts

We create or maintain synergies within the MSF movement between missions, OCs, the HIV/TB technical department and working groups.

Whilst current off-site trainings are conducted only in Cape Town, other venues (countries) can be considered when they provide added value. (eg. Senegal for French speaking trainings, Kampala for East Africa countries)

- Mentoring

Direct Clinical Mentoring (Dr. Rosie Burton): Founded on the belief that the best learning happens in the actual workplace, we see mentoring activities as the most efficient approach for transferring theoretical learning into improved practice in the workplace. Most of the SAMU trainings mentioned above (on- and off-site) are implemented using mainly a “classroom” model. They aim to incorporate some case-based work, often at the actual bedside, but this is limited by the time constraints of a short course. We would like to offer a far more comprehensive approach to on-site learning by linking these trainings with prolonged post-course bedside or out-patient teaching (several weeks) by a SAMU HIV/TB specialist clinician. With this approach, we strongly address the challenge that most of the training activities are facing today: to better accompany and ensure the application of learning at work (transfer).

4 Off-site: commonly called “centralised” training, conducted in a central location targeting participants from a variety

of contexts On-site: commonly called “decentralised” training, implemented on-site (in a mission/project), targets a group of staff usually in the same mission and it respond to specific context and operational needs of the mission.

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This hands-on teaching can also be seen as a stand-alone approach when needed, not necessarily needing to follow a formal training course. By having an HIV/TB specialist, we also address the increasing need to develop MSF staff in clinical skills for patients presenting with advanced disease, mainly at IPD level. Infection control and AMR are also areas where MSF wants to focus more. This role was taken by Dr Rosie Burton for the first time in 2016 and will be renewed in 2017.

Support mentoring programmes implemented by field teams (Dr. Sylvie Jonckhere) Over the past several years the global trend for HIV programs has been a progressive shifting of the burden of HIV management away from the more central hospitals into the district hospitals and primary care clinics. With this shift comes a growing need to increase the capacity and competence of staff to handle this. MSF’s strategic operational approach to engagement in HIV/TB projects was also to support this decentralisation with a “Light Approach”. This consists of progressively transferring some elements of clinical HIV/TB care to MoH and keeping only specific roles of technical support to MoH staff, commonly described as “mentoring” support. For this reason we have significant number of MSF projects that are providing clinical mentoring as part of decentralisation of care and/or light approach strategies. In these projects, MSF staff are placed into a situation where they have to both “mentor” clinical MoH staff (to increase skills) in decentralised MoH clinics and supervise their activities and medical programme outcomes. They often do not always feel adequately skilled to fulfil the dual roles of pedagogic and clinical/programme management responsibilities. Implementing a mentoring programme requires specific approaches within programmatic and technical frameworks that are not only time-consuming but can be resource-intensive, and requiring a specific skill set. Facing such massive demand for support, the provision of a full time position dedicated to this activity has been accepted for 2017. This will be held by Dr Sylvie Jonckhere. She will be able to stay several weeks in the field and provide support to MSF field mentoring teams in:

- Upgrading their HIV/TB clinical skills - Design and develop the mentoring programme at programmatic level (Objectives, framing, and

planning) - Upgrade their pedagogic & mentoring skills (how to mentor someone)

Whilst Rosie and Sylvie have quite similar academic profiles personally they have distinctly different job profiles at present. It must be emphasised that Sylvie’s role in 2017, and hopefully in 2018, is primarily one of facilitating the mentoring programs. - Bedside teaching

When Dr. Rosie is working in a project one of her key training methodologies is the use of a working ward round as a vehicle for training local staff. In addition, hospital visits in which trainees review selected in-patients and then discuss the conditions at the bedside are a key component of our face to face trainings. These are a routine component of the Cape Town advanced course and where time allows are incorporated into the on-site trainings

- E-Learning

SAMU no longer provides a basic HIV course but a full e-Learning training package is now available for clinicians with little to no experience in HIV management, particularly to support integration of HIV/TB care into routine programmes. It is designed to provide clinicians with the necessary theoretical knowledge for starting to consult in HIV/TB clinics, ideally under initial clinical oversight. This course is scheduled for full launch in January 2017.

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Among activities described in the attached logframe, two important one are planned for development in 2017:

– Evaluation of the perceived quality of the training and its impact on actual transfer from knowledge into skills and competencies in the consulting room.

– Paediatric HIV is comprehensively covered in the 2015 HIV/TB clinical guide but currently lacks an e-Learning module to support self-study. The development of this will not only provide a stand-alone self-study option but will also serve as a pre-learning module for clinical paediatric training courses

e) in both English and French:

In 2015 SAMU has widened its pool of experts and is now able to offer almost all its trainings, clinical and programmatic, in both French and English. This therefore increases access to training for a larger body of field workers. MSF currently has two missions in Mozambique (OCG and OCB), Portuguese-speaking and currently missing out on much of the training due to language constraints. In 2015 and 2016, successful clinical trainings were however completed in Maputo with translation support from the Brazil Medical Unit (BRAMU), paving the way for the development of trainings to support Portuguese projects as well.

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2.2.2 To provide pedagogical technical expertise and support

Training is often perceived as a once-off classroom event that achieves its objectives by the end of the course. We however like to promote the concept of lifelong learning with an ongoing interplay between classroom learning and application in the field. This is the essence of effective building of skills and competencies and their transfer into the workplace. Allied to this therefore, we see learning as a continuum where all supervisors, managers and coordinators within MSF, especially those in the field where the training is happening, have an important role to play. We still believe that there are a lot of missed opportunities and therefore possible ways to optimise all resources and energies used by MSF field teams in training activities. We therefore intend to provide training of trainers and pedagogical technical support to the field teams who implement the majority of HIV/TB training within the organisation, and enhance the role and contribution of field supervisors/coordinators in learning, through their daily management/supervision at work (formative supervision). This support can also be given by the SAMU LU to the SAMU team members when preparing and implementing a SAMU training.

a) Provide technical/pedagogical support at all levels of the training cycle

We can support all training activities as technical/pedagogical advisers. Support can be given at various levels and in any of the five steps of the training cycle (addie), according to the need expressed by the project/mission or by the SAMU team:

a) Training needs analysis b) Training design c) Training development d) Training implementation e) Training evaluation and follow up

This support will always be done in close collaboration with the mission as it is important that the field keeps the ownership and the coordination of all training activities.

a) Provide a Training of Trainers (ToT) course

Training people in the five steps mentioned above requires a five day course. If necessary, the course can be modified to focus on only a few steps according to the specific needs of the target group. We propose two ways of implementing this training:

On-site, in mission/project: This is the preferred means of implementation for us, as it enables the tailoring of the training as closely as possible to project/mission needs, better ensures transfer of learning from the classroom and widens access to training for the staff.

Off-site, in Kampala For specific individual needs, when an on-site training is not needed or required, interested parties are referred to a ToT in the OCG Kampala training centre. As part of an OCG/OCP/SAMU partnership, this training is organised twice a year (one in French, one in English) by OCG/OCP. The target group for ToT is not exclusively for HIV/TB clinical staff. All staff involved in designing and implementing trainings are encouraged to attend.

b) Provide ToT Mentoring and support to field mentoring programme implementation:

As developed above, mentoring is taking a significant place in the support given by SAMU to the field, and especially to MSF mentors. As much as the need exists to our mentors to be clinically above

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average in their clinical skills in order to be effective clinical mentors, there is also an important need to develop their “pedagogic” skills and capacity to accompany and create the best conditions for learning. In 2017, we would like to:

- Provide a course for the training of mentors (ToT mentoring) Drawing from the common foundation of the general ToT mentioned above (1,5days), this “ToT mentoring” aims at increasing capacities and knowledge in three key areas over approximately 3.5 days:

Designing an HIV/TB clinical mentoring programme Equipping a mentor with technical mentoring skills Designing the necessary tools to facilitate both of the above

- Provide mentoring programmatic and technical support The appointment of Sylvie as the mentoring MIO will enable us not only to provide more pedagogic and programmatic support in field mentoring activities but also to facilitate the actual transfer of these skills into the workplace. This will be done by her first giving a training as outlined above and then staying on for up to three weeks in the project to support the implementation of all that has been taught, both pedagogically and programmatically.

- Develop/document our experiences and practices in mentoring Along with Sylvie’s activities described above, she will also be finalising the programmatic clinical mentoring guideline and the toolkits whose full development is nearly complete.

- Participate in the reflection and development of the mentoring approach within MSF organisation/movement We want to contribute to and benefit from the varied experience and competencies within OCB/OCG especially on all initiatives aiming at clarifying concepts of mentoring and supervision and in developing frameworks and tools. We see in the mentoring experience gained by MSF OCB/Norway, as well in the technical expertise of the OCB L&D unit, real complementary resources and added value to what we are trying to develop in our HIV/TB mentoring programs. Collaboration with our colleagues will continue during 2017

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2.2.3 To develop & manage the sharing and dissemination of SAMU resources

a) Context

The growth of SAMU has more than tripled in the past five years. As a result, this HIV/TB unit has developed stronger and wider domains of support in a variety of areas: clinical & programmatic, M&E, operational research, patient & community support activities, laboratory, pharmacy and of course training and learning. More globally, the level of production of medical and advocacy resources from the MSF movement (AAU units, Access campaign, DNDI etc) and also from external actors (WHO, UNAIDS, UNITAID) has reached an impressive level. Furthermore, these new resources are constantly being developed and existing ones updated While L&D (Learning and development) and knowledge management5 responsibilities are usually separate entities in most of MSF office settings, in SAMU, these two domains fall under the Learninig unit. Our objective is to ensure that field teams have timely access to correct and updated HIV/TB information & resources. Currently there are considerable resources available that can be categorised as follows:

- Produced and edited by SAMU

- Produced and edited by MSF HIV/TB entities within the movement (access campaign, AAU, etc)

- Produced and edited by partners or other actors when relevant for MSF programs (WHO, MoH,

UNAIDS etc.)

- Generated by peer-to-peer networks and forums

This leads us to reflect on our capacity and means to produce, develop, maintain and disseminate all of these resources. In 2017, no major investment will be done in the “peer to peer resources” activities. Indeed, the focus will be done on the 2 others group of resources, for which the workload can be structured into 2 categories of activity:

5 We rather say information and resources sharing system, as knowledge management is a broader concept and largely addressed by specific units in most of the OC’s

SAMU HIV/TB RESOURCES - clinical guideline - IPD clinical algorithms - reports and toolkits - leaflets, flipchart,

posters - training resources and

materials - training videos

OTHER HIV/TB MSF RESOURCES - TB/HIV literature - publications - articles - Specific MSF project reports &

toolkits (eg. Khayelitsha)

OTHER HIV/TB EXTERNAL RESOURCES - WHO guidelines - UNITAID, UNAIDS publications - articles / abstracts

PEER to PEER RESOURCES * - blogs - forums, webinars - exchanges field to field

(* Largely under-developed)

1. The production, editing and management of the storage of all printed SAMU resources + other MSF HIV/TB publications

2. The management of all the IT processes for their dissemination through the SAMU website (online)

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b) Production, editing and management of SAMU resources

In 2017, an important objective will be the updating of the MSF HIV clinical guide (2015), English version, followed by its translation into French. The SAMU Learning unit will coordinate this process. This represents a massive time investment and level of engagement with the SAMU medical team. In addition to this guide, we will also finalise the development of in-patient clinical algorithms, a set of guidelines for the management of common conditions seen in hospital emergency units and wards. As these are conditions that invariably present initially in the out-patient clinics it is important that these are not only well referenced in the MSF HIV/TB clinical guide for those who are able to refer to hospitals but also available to clinicians in settings where limited options exist for such referrals The last main activity will be to ensure that all printed resources related to HIV/TB (SAMU, MSF, External partners) are well recorded, stored and distributed. This work has been largely underestimated and was below expectation last year. A new admin position dedicated to SAMU Learning unit has been accepted for 2017. Part of the responsibility of this job function will be to administer all these resources.

c) SAMU Website as the main medium for sharing resources The SAMU website is a major medium to ensure that field staff and partners can access HIV/TB resources. A significant investment was made in 2016 to review and design a new SAMU website. The objective is to have a better interface system that is more logical and user-friendly. This process was far longer than expected in 2016 so we aim to launch the new website early 2017. - Technical functionality:

As SAMU does not have in-house competencies in web design and management, an important challenge was to find an external provider who could help us to upgrade and maintain this website. Contact has been made with one provider (Rogerwilco), whose services are also used by MSF-SA. We hope to finalise an agreement and work with this company in 2017. Their role will be to ensure all aspects of the technical functionality and development of the website.

- Curation of resources

The question on the relevance and pertinence of posting or not posting documents is also important, in order to stay focused on providing field support rather than becoming a storage for all HIV/TB documents. Maintaining the accuracy and relevance of all posted documents requires the oversight of a curator. This will be done by Helen Bygrave and Olivier, to ensure the timeous removal or updating of outdated documents and the posting of all relevant new ones.

- Monitoring and Evaluation of all our web-based activities:

This year, we will set up a process for the M&E of website usage in order to better see the use and impact of such media for SAMU and for field teams.

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2.2.4 To develop a Monitoring and Evaluation system for all SAMU trainings

Training is a core value of the MSF movement worldwide with consequent investment of considerable time and resources in it. There is however very limited monitoring and evaluation of the actual outcomes. This is not an easy task but is nevertheless one that must be engaged with more actively to ensure that programmes actually achieve the objectives for which the training is being given. It is our intention to invest focused time on this M&E in 2017 in collaboration with the OCB training unit and MSF Canada (for e-training), as this is currently one of our common key focus areas. In the first few months of 2017 we have contracted the services of Dr Colla McDonlad, a retired professor of medicine with extensive experience in internet-based learning and its evaluation. Dr McDonald will use a variety of methodologies to evaluate not only the experience of the learning aspects of the training but also the impact of transfer of learning into the consulting rooms

2.2.5 To reinforce communication, networking and partnership

Functionally and hierarchically under OCB and MSF Southern Africa partner section, SAMU remains an intersectional unit where all trainings are open to all MSF OCs. With the size and the complexity of the MSF movement, networking and communication plays an important role. The challenge for the SAMU learning unit is to fit into the channels of communication and decision making in each of the OCs. Concretely we will develop a networking and communication strategy to ensure:

That all SAMU training activities are known, widely used and appropriately integrated into the five MSF OCs training opportunities.

That the SAMU learning unit is integrated into OCB and OCG L&D strategic plan and working dynamics.

That SAMU can benefit from resources and expertise within the MSF movement in order to implement its plan of action and achieve its objectives

a) Networking and partnership - OCG & OCB

OCG is a key partner contributing a full FTE which comprises 1/3 of the SAMU learning unit staff (Olivier). Roger Teck, is also part of the steering committee for the preparation and the implementation of the off-site (Cape Town) HIV/TB programmatic and DR-TB trainings as well as offering support in the planned paediatric training course being developed under the oversight of the PWG and OCG. As part of the contribution of OCG, SAMU will always facilitate access for OCG staff to SAMU trainings and, more globally, access for OCG missions/projects to SAMU training or pedagogic support. Any specific request for on-site training will be considered, illustrated by trainings approved and implemented in 2015/2016 for OCG (in Mozambique, Swaziland, and Myanmar) As part of the scale-up of our ToT implementation, we run our own on-site trainings in the projects and will continue to refer all individual requests for off-site training to the OCG/OCP ToT in Kampala (held twice a year).

More specifically, we see some common areas where both OCG and OCB are working in parallel and where SAMU learning unit could both contribute and benefit. Training quality chart, and transfer at workplace In line with our objective of improving our training M&E (with more qualitative outcomes) and to better invest in the transfer and training follow-up in the workplace, we are following with interest the work started by OCB and OCG training units on the revision of training quality standards (Genevieve Erken). This focuses, among other things, on defining a better system for analysing training needs, ensuring transfer and follow-up in the workplace and reinforcing the training role of field supervisors and coordinators.

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Clinical Mentoring The SAMU LU has already started the process of supporting clinical mentoring programs and trainings in the region, drawing on the good mentoring experiences in Zimbabwe, Lesotho, DRC and South Africa. With the increasing demand from the field to support their mentoring programmes, our exposure and experience in this domain, targeting mostly MoH clinical staff, is set to increase considerably in 2017. MSF Norway (OCB) and OCG have already made considerable headway in the development of mentoring programmes for a range of MSF managers in the field. Much work has been done in the development of tools as well as in the work on definition and clarification of the concepts of mentoring, supervision and formative supervision. There is much room for mutual collaboration and learning, and SAMU learning unit is willing to play a role in any initiative that might be created to share, mutualise and document these experiences at MSF movement level.

- Intersectional - AWG – TBWG – All OCs and MSF hub of expertise

By nature, all trainings supported by SAMU are open to all MSF operational centres. The programmatic course and DR-TB workshop are facilitated in collaboration with OCs, HIV/TB referents and AIDS/TB working group members.

- MSF Canada

We continue our fruitful collaboration with MSF Canada in the development and upgrading of the HIV/TB e-training basic course (see e-training activities described above). Terms and conditions of this partnership will be renewed in 2017 (MoU).

- MSF Khayelitsha

Several different paediatric trainings are being developed in collaboration with the MSF Khayelitsha project which has made its paediatric specialist available for 20 % of his time. Activities for 2017:

- Upgrading the paediatric chapter of the MSF clinical HIV/TB guide - Developing a paediatric module to complement the existing SAMU HIV/TB E-Learning basic course - Developing an intersectional paediatric training/workshop requested by the Paediatric Working

Group (PWG)

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3. OTHER AREA OF WORK

SAMU contribution and involvement in the OCB Medical Education project2

MSF OCB is in the process of establishing a healthcare academy in partnership with universities and professional institutions on different continents. Its focus is not only on professionalising and accrediting as much as possible of our existing trainings but also on augmenting the content to create diploma and in some instances, masters level tertiary level qualifications. Apart from ensuring good quality service provision in our projects it is also believed that accreditation and the ability to acquire a recognised diploma or masters qualification will both attract more staff to MSF and increase retention. In addition, MSF is willing to invest in the development of training facilities in the field, hospitals and clinics, where trainees will have opportunity for practical training in the field in the clinical workplace.

Extract from the Amendment to the 2014 – 2016 Operational Prospects, OCB Brussel, Medical Department

OCB has a clear intention to “increase significantly its ambitions around learning and development of MSF staff, in particular for (para-) medical professionals. The precise outlines of this new ambition are not entirely clear, but we agree on a series of general objectives that will be realised through a parallel initiative organised by OCB.

We want to further professionalise the MSF trainings and increase access to it for national staff. Through solid links in the academic world, we want to ensure that the MSF trainings receive official accreditation.

We want to develop a series of clinical trainings adapted for MSF needs in the field (OPD consultations for OPD, tropical paediatrics in IPD, general surgery and traumatology, etc.)

The greatest ambition is to create an MSF satellite that can have a clear academic status, this will function as a platform for the first 2 ambitions and will enlarge the MSF network and the perception of the organisation in many ways”

Extract from “Project Charter Writing of a Business Case - Medical Education”, MSF OCB Brussels General Direction, 2015

The possibility of investing in a “MSF academy” has been emerging and reemerging since decades. It is not a new idea; it is in fact the continued acknowledgement that the work we were and are doing in MSF had and still largely has no specific related training modules. It is clear that existing educational programs do not prepare enough for the specific field conditions during humanitarian crises. After a feasibility study into the possibility of an education project was commissioned by MSF and led by Dave Michalski the idea of investing in a medical school was brought to the board. The board was not able to decide on this and needed a larger buy-in from its members and other options to be studied. This led to the follow two motions being presented and accepted at the OCB Gathering June 2015: Motion 7: There is an urgent need to formalise, accredit and further develop medical and para-medical training and education in MSF for all staff, with a strong focus on national staff capacity. We ask the MSF-OCB to develop this as soon as possible based on identified priority needs, in a flexible and decentralised way build on networks. Motion 8: We ask MSF OCB to expand our mandate and to become an influential actor in medical education, with partners and scope to be defined, to challenge the for-profit and lucrative basis of existing medical profession and education and to put patient care and humanitarian ethos at the centre. In order to move forward, we now require a full Business Case.

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SAMU is committed to contributing to this project, especially in the realm of HIV/TB by linking with the HIV/TB academic world and bringing MSF’s field experience. Currently our engagement is in providing local experience and access to local tertiary institutions and through this helping to mould an educational program that best addresses the project’s aims and ambitions. As the project develops and SAMU’s engagement increases, the need will arise for a dedicated resource to support this process. The Medical project steering committee agreed on the provision of a six month consultancy for 2017. The first phase of this development is the provision of a training course for, and the sponsoring of MSF staff to write the South African Colleges of Medicine’s HIV management diploma.

4. Resources It is important to mention that in terms of organisational set up and scope of work for all members of the team, we do not promote the specialisation of skills with, for example, someone exclusively in charge of mentoring activities, another in clinical trainings etc… We want to maintain a multi-expertise team able to support all training needs. However, with some important field needs (eg. support on mentoring and the training follow-up in the workplace) and the necessity to make the best use of each of our individuals’ expertise and strengths, we do not exclude the option that each member of the team be assigned to coordinate and implement more specific activities or dossiers.

4.1 Actual resources Olivier: Non-medical, pedagogical and project coordinator profile. In charge of SAMU L&D coordination Ian: Medical Doctor, clinical profile with pedagogical skills. In charge of Clinical trainings, e-Learning, Rosie: HIV/TB specialist, MIO clinical mentor for IPD care. Note: Rosie is still part of the SAMU medical team. Helen: Medical Doctor, website resources and programmatic training in Cape Town Jonathan: Paediatric doctor, support on MSF HIV/TB guideline and e-Learning

4.2 Development for 2017

In order to implement this 2017 plan of action and reach its expected outcomes, a new position of “mentoring and learning officer” has been accepted in order to support field clinical/programmatic mentoring programs at decentralisation/PHC level. With the increasing training activities, in addition to the resources sharing & management, we will also welcome a “learning unit manager” who will be in charge of the resource management and all administrative activities related to learnings. Overall, the SAMU learning unit will comprise 7 people, equivalent to 5,6 FTE (Rosie included). The breakdown of the main domains of responsibilities and activities are described as below.

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Proposed resources 2017 : New resources 2017

OLIVIER (100%) Pedagogic support & coordination of SAMU LU

(ENG/FR)

Overall SAMU learning unit management & Coordination:

- Strategic / vision development

- Trainings Implementation: planning, follow up and reporting

- Field Mentoring support activities

- SAMU training M&E

- Medical Resources sharing

- LU team management

Pedagogic technical support: - SAMU off-site Training (Cape Town) - SAMU On-Site trainings (in the field) - Ad hoc field HIV/TB training support (Non-

SAMU), on request

Communication, networking, partnership with MSF OC’s and external actors

Mentoring (on back up): - Pedagogic mentoring

support - ToT mentoring

ToT Generic On-site (back

up)

Dr. IAN (100%) Clinical & Pedagogic support

(ENG)

Clinical advanced training off-site (Cape town)

Clinical advanced training on-site

Mentoring (on Back up only): - Clinical mentoring support - Pedagogic mentoring support - ToT mentoring

SAMU web-based training: - Further development of the basic e-

Learning course - Development of additional web-based

training tools (eg disease specific videos)

Training resources production: - review & update of the MSF HIV/TB clinical

guide

SAMU Training M&E

20% clinical work to maintain clinical competencies

Dr. Rosie (100%) Clinical mentoring

support (IPD) (ENG/FR)

Clinical advanced training off-site (Cape Town)

Clinical advanced training on-site

Mentoring (Field, IPD Hospital) : - Clinical mentoring support - Pedagogic mentoring support

Clinical & learning resources production

- Guidelines updates - Algorithms - Clinical resources production

Other: Support Operational Research

and other Medical topics (under

the management of SAMU medical team coordinator)

Dr. Sylvie (100%) Mentors support

(PHC) (ENG/FR)

Mentoring (Field, PHC, decentralisation) : - Clinical and programmatic

mentoring support - Pedagogic mentoring support - ToT mentoring

Dr. Helen (40%) Prog. trainings & web based resources

(ENG)

On-site programmatic training (on request)

- Work on the curriculum and support its implementation

Off-site programmatic training (Cape Town)

- Part of the SAMU steering committee and support its implementation

SAMU web based Resources & information management

- Development of Medical “ hot topics” ( with evaluation to assess their utility by the field) and updating of guidelines and protocols

Scientific days

Dr. Jonathan (20%) Paediatric

(ENG)

Paediatric chapter revision in the MSF HIB/TB clinical guideline

Paediatric e-Learning module development (attached to the basic e-Learning course)

Paediatric dossier for the SAMU website (if any)

LU manager (100%) (ENG)

Support all SAMU administration on trainings planning, implementation and reporting

Coordination of SAMU

resources production - Editing of Guidelines &

Toolkits, articles, position papers, …

- SAMU website management

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