Strengthening Health Systems Abroad: A Student Perspective

By Grace H. Yoon, BA
MS candidate in Health Services and Systems Research
Class of 2020, Boston University School of Public Health

Over the past summer, I completed an 8-week summer internship at the Lesotho-Boston Health Alliance (LeBoHA) from mid-June to mid- August 2019 with the support of IHSIP and under the mentorship of Dr. Brian Jack.

I participated in two projects:

  1. Problem Solving for Better Health (PSBH)
  2. Tuberculosis (TB) process mapping

Both projects required travel across different districts in Lesotho. In total, I visited six regions: Mafeteng, Maseru, Leribe, Butha Buthe, Berea and Thaba Tseka.

Problem Solving For Better Health

PSBH is a three-day training initiative targeted towards current on-field healthcare workers in Lesotho to increase problem-solving capacity. The course requires all participants to develop a problem statement from their own work spaces, build an action plan to solve this specific problem in their department, and carry out their project proposal after they return from the workshop. The purpose of my evaluation project was to gather participant perspectives on the workshop and their progress with the original problem statements. I conducted 30 one-to-one interviews in 10 different healthcare facilities, ranging from full district health centers to neighborhood filter clinics. Our findings suggest that, overall, PSBH provides a critical new skillset to many junior and high-level managers and clinical staff that changed how participants think about their jobs. Difficulties expressed by the participants include not having enough time to conduct their PSBH projects and lack of cooperation from their work environments.

Afterwards, I conducted a total of 30 1:1 semi-structured qualitative interviews to assess the post-workshop thoughts and status of participants up to 1 year after their workshop date.

I found that most of the dedicated PSBH participants experienced symptoms of burn-out. Most of the trainees from the first year’s training cohort were in leadership positions, such as district health managers and nurse matrons. Most of the participants intrinsically understand the challenges facing Lesotho today. However, due to the high volume of small and large problems in the health environment, they are left feeling helpless. When participants join PSBH, they are initially overwhelmed by their tasks and responsibilities and frustrated by the countless challenges that have been avoided for a long time. Aside from providing critical staff with the practical skills of prioritizing and solving these problems systematically, the workshop itself is a highly energizing, motivational experience filled with helpful anecdotes, information sharing between department representatives, and even singing to raise morale. As I observed the PSBH workshop in Thaba Tseka, and learned from professionals supporting all facets of the system, I witnessed the value it brought to strengthening health services in Lesotho.

The results of the qualitative investigation of PSBH participants will be further organized and formally submitted for publication in a peer-reviewed academic journal as my Master’s degree graduation thesis requirement.  

A photo of St. James Hospital, in Lesotho
Pictured: St. James Hospital, in Lesotho. Photo by Grace Yoon.

Tuberculosis Process Mapping

Studying TB processes in resource-limited settings with the highest rate of cases in the world was an eye-opening experience. At the individual level, they maximize care with the limited support they have. In this environment, health care professionals may lack the capacity to step back from delivering urgent treatment to examine their systemic approach to care. As a research intern, I had the opportunity to examine Lesotho’s TB care at a system level.

I conducted about 40 interviews to gather data in the TB care processes across four different districts: Mafeteng, Berea, Leribe and Thaba Tseka. Most problems that the districts faced were not unique to each other. Shortage of human and monetary resources and lack of oversight over NGO sponsored support staff create many of the existing gaps in the current system. Several of the districts’ patient trackers and screeners illuminated challenges such as lack of transportation and lack of phone credits, which make it impossible for them to adequately do their job. Issues facing each of the hospitals visited involve stock outs of reagents for TB diagnostic labs and unfilled holes in TB-related staffing in the district. For example, while the government standard for TB staffing is to have one TB Coordinator for monitoring of surrounding clinics and at least one TB Officer to oversee TB care in the hospital, Mafeteng district hospital only has a TB Coordinator who is now burdened with the job of both TB Coordinator and Officer, preventing adequate monitoring and dissemination of TB care in the district.

The details of the TB process mapping data are currently being synthesized with the help of Dr. Jack’s research team at The Boston Medical Center and may be used to inform the development of a potential patient aid technology to improve the care coordination of TB in Lesotho.

Final Thoughts

I believe an interdisciplinary framework fits the mission of LeBoHA well. Expanding the human resources capacity of healthcare in Lesotho requires experts across all disciplines, not just doctors. I am very grateful for Dr. Jack’s and IHSIP’s support for me to complete this internship, and hope the Institute will continue to support the vision of LeBoHA in empowering the local healthcare workforce to make groundbreaking changes in the field. I believe this approach can lead to widespread impact throughout the country, if disseminated effectively. 

Although there is still much work to be done, I have great hope that the Lesotho health system can one day stand up on their own to ensure the health of their people.


About Grace H. Yoon, BA

Grace H. Yoon is a MSc student at the BU School of Public Health, with a focus on health services and systems. In addition to her studies, she supports research for the university and Boston Medical Center on maternal depression, telehealth, and safe injection sites. Before joining BU, Grace worked as a Qualitative Investigator at Tufts Medical Center. At Tufts, she supported research on patient & caregiver perspectives, cancer screening feasibility, screening social determinants of health for pediatric care. During undergraduate studies, she conducted comparative global health policy research in Hong Kong. Grace looks forward to expanding her work and pursuing doctoral education in the field.

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