ESP (SPH) Kinshasa/Tulane Future directions

1. ESP (SPH) Kinshasa/TulaneFuture directions ESP 1988

2. About Payson • An interdisciplinary center for education, research and service, the Payson Center is international in its focus. • It is dedicated to education, bringing undergraduate, master’s and doctoral programs in international development to students from the United States, Africa, Latin America and Asia. • It is involved in critical research and programs to improve sustainable human development. • And it is focused on using information technology in all those arenas to bring innovative solutions to global problems.

3. Technology Transfer • Sustainable development in a global economy • Consumers knowledge Producers knowledge • Consumers IT Producers IT

4. Dr. William E. Bertrand, Ph.D. is Co-Director of the CDMHA and also director of the Payson Center for International Development and Technology Transfer at Tulane University. Dr. Bertrand has served as Vice President of Institutional Planning, Research and Innovation at Tulane University. He holds an endowed chair in public health and has served as Chair of the Department of Epidemiology and Biostatistics and Chair and Founder of the Dept. of International Health. He has been involved in the study of disasters and the disaster to development continuum since the mid 1970’s. He became one of the early users of information technology in the social and health sciences and has maintained this interest to date. Dr. Bertrand pioneered the use of microcomputers in Africa in the early 1980’s by setting up one of the first computer based surveillance and information systems in Niger and in other Central African Countries. Based on a model he developed and pilot tested in the early 1980’s in Bolivia Dr. Bertrand was one of the developers of the USAID Famine Early Warning System which has operated for nearly 15 years now as an effective early warning information system predicting disasters in Africa. He has been one of the first to apply information technology to higher education in the United States and abroad. Dr. Bertrand has served as consultant to such organizations as the World Bank, USAID, the InterAmerican Development Bank, Kenya’s Ministry of Health and the Haitian School of Public Health. In addition, he has done substantial research in the field of public health in Latin America and Africa, in areas of disease and nutritional surveillance, health policy and planning and the integration of new information technology into the social sector. Dr. Eamon M. Kelly, Ph.D. has served as a member of the Center’s Governing Board. As a senior executive, former university president, and currently Chairman of the National Science Board (the governing board of the National Science Foundation) and Professor, Payson Center, Dr. Kelly has extensive policy formulation, policy implementation and strategic management experience. Complementing this is his substantive involvement in the arena of international development, primarily in the America’s and Africa. Beginning with his career as Officer-in-Charge for the Office of Social Development within the Ford Foundation, he coordinated and supervised innovative programs, employing analytical models, for the development of economically advantageous programs to address obstacles to social development. In 1979, Kelly joined the administration of Tulane as Executive Vice President, and within the year was appointed as interim president. In 1981, he was chosen to serve as the 13th president of the university. During his tenure at Tulane, he was credited with leading Tulane into an unprecedented period of growth. Today, Tulane has become a leading institution for the study of environmental, international, and urban programs. He has served on numerous governing and advisory boards and has received presidential appointments several times to public service, the most recent being Chair of the National Science Board. Dr. Kelly is formally trained in economics. He received his doctoral degree in economics from Columbia University in 1965. Leadership

5. Social and Economic Development

6. Disaster and Development Management • Prevention, Preparedness, Mitigation, Response, Recovery saves lives and alleviates suffering Reduce need for external assistance Achieve sustainable broad-based improvement in people’s living conditions Social and Economic Development

7. Training, education and behavioral change Achieve sustainable broad-based improvement in people’s living conditions Social and Economic Development

8. Knowledge Base Skills Base • Intervention Phases • Prevention • Preparedness • Mitigation • Response • Recovery Disasters Disaster Cycle Underdevelopment Framework for disaster interventions X

9. ESP (SPH) Kinshasa/Tulane

10. Unique Strengths • The KSPH has a highly trained faculty, which comprise a diverse range of public health areas of expertise. It includes the largest number of post graduate trained professionals in all of Africa, including South Africa; • Both the faculty and administration of the School are strongly motivated to continue the excellent training heretofore provided; • The KSPH has extensive experience in health research and in project management; • The School has a strong history of collaboration with the Health Zones and the national health programs; • Long history of cooperation exists with funders (USAID, EU), UN agencies (WHO, UNFPA, UNDP), American and European Universities (Tulane, Ulg, ULB), national and international NGO’s (Basics, IRC, SANRU, Fométro, OXFAM), and Congolese government Ministries (Public Health, Environment, Education); • The School has been able to sustain itself during harsh political and economic times and has both the experience and the will to serve as a model for other Congolese health sector institutions.

11. Accomplishments in research Major research projects that are currently taking place at the ESP include: 1. Disease control: Malaria situation in the DRC 2. HIV/AIDS 3. Sanitation and Water Quality Monitoring 4. Evaluation of the hygienic, environmental condition and community behavior with regards to  sanitation in the Health Zone of Barumbu (Kinshasa) 5. Nutrition 6. Maternal and Child Health , University and Government of the DRC, and ESP 7. Disaster and Emergency Preparedness for Diseases for Disease in DRC 8. Global Positioning System (GPS) and Geographical Information System (GIS)

12. KSPH Mission The KSPH has 5 objectives, which cumulatively strive to improve the health of the Congolese people and promote development:1. Train and educate undergraduate and post-graduate health professionals in public health;2. Update the knowledge and skills of Congolese health professionals as needed to address health management priorities;3. Enhance disease surveillance, health research and operations research to gather and evaluate health data and programs in the DRC;4. Offer quality direct health services to the community including managing of maternal and child health services;5. Provide leadership and training on the use of information technology to the health program managers and policy makers in the DRC.

13. Health Context in DROC • After years of neglect and war, the government no longer pays salaries for workers, maintains basic equipment, stocks essential materials and medications, or encourages the training and retraining of health professionals. • With the collapse of the health sector and the generally desperate social and socio-economic situation, outbreaks of rare diseases, which were virtually eradicated have reappeared. Outbreaks of infectious diseases, including hemorrhagic fevers, monkey pox, measles, meningitis, pertussis and HIV are frequent. Other endemic and epidemic health problems such as polio, tuberculosis, malnutrition, and malaria, are commonplace. • Surveillance and organization of health data is weak doesn’t allow adequate responses. Hygiene is lacking and environmental conditions are catastrophic. • Emergencies due to various root causes often combined with natural disasters have been frequent and severe. • Maternal and infant mortalities have been increased. Concerning the maternal mortality, it has doubled within this last five years and happens to be one of the highest worldwide.

14. Development of KSPH • To address the situation, the leadership of the DRC (formerly Zaire) agreed to support the opening of the "Ecole de Santé Publique", as a Dept. of Public Health within the Faculty of Medicine at the University of Kinshasa. This project got underway in 1984 with the help of USAID and a consortium of American Universities coordinated by Tulane University in New Orleans. The School strives to produce Congolese health professionals with specific training in Public Health to manage health zones throughout the country, and to run the services and programs of the Ministry of Public Health (Minister de la Santé Publique). • The KSPH educates health professionals in the Congo through exposing medical students to public health via integrating courses in the medical school curriculum, through training personnel responsible for the management of health districts and other public health institutions, and through training of trainers in public health. It also conducts high quality research relevant to local needs and concerns

15. Historical Background Between 1986 and 1991, the KSPH produced five successive graduating classes of professionals with the degree "Diplôme en Santé Publique", which is roughly equivalent to a Master’s Degree (MPH). These graduates are post-graduate professionals with at least three years of experience working in health related institutions, which includes medical doctors, pharmacists, health administrators, social scientists and nurses. They receive training in public health methodology, health planning, health systems management and community health. In addition to training these categories of students, many graduates of the MPH program have gone on to complete their Doctoral studies in the United States or Europe. There are currently 10 doctoral level faculties member working at the KSPH.Financing for the KSPH was tenuous from the years 1991-1994 but due to the perseverance of the faculty and administration, the school was able to recommence activities in 1994. The KSPH has graduated a total of 288 students to date at the level of "Diplôme en Santé Publique". In addition, the KSPH has participated in and assisted in the training of 13 Ph.D. or near Ph.D. level degree individuals. All continue their relationship with the School although 2 are working full time with WHO and two with USAID.

16. Key Accomplishments • Key to the accomplishment of objectives during the last year has been the beginning of a new cohort of future faculty at the University within the Medical School and the Dept. of Public Health. • A total of 8 individuals have entered into a program leading to the Ph.D. in various specialties related to Public Health. Tulane has received approval and accreditation for offering a sandwich program whereby courses are given in Africa to this cohort of young professionals including three women. • The objective is to prepare a new generation of leaders and trainers of trainers for the DRC. In order to lower the costs for such training while at the same time encouraging intensive English as the language of instruction. Courses have been held in Nairobi, Kenya during the first year. • The results have been favorable in that the cost of providing the courses has been held to a low level while at the same time a good infrastructure and learning environment has been developed with the use of Tulane professors. • This year another three courses on English, Research Evaluation, and Learning How to Learn with Technology were offered in Nairobi. Tulane University has contributed to this effort by subsidizing the tuition for these courses by 50% and providing facilities and resources for achieving full accreditation for this sandwich program. In addition qualified members of the UNIKIN KSPH faculty have been approved as Tulane faculty members such that they are able to supervise and assist in the primarily DROC based training.

17. Key Accomplishments • The Foundation for the Support of Public Health in Africa, which has always had a primary focus on the KSPH, is working with the Directors of the School to continue to provide a stable and dedicated financial base outside of the DRC. • The foundation has succeeded this year in donating two vehicles, 9 computers and a considerable quantity of supplies and furniture. • In 2001-2, we expect the foundation will be more active in raising money and supporting KSPH and has already programmed the donation of two more vehicles.

18. Key Accomplishments • In addition to the training, the faculty and students have been able to complete, during this same period of time, numerous research studies and have conducted many short courses for working professionals in the Congo. • Research activities have been conducted in diverse areas including the following: health systems management, water quality, malaria prevention, HIV/AIDS sero-prevalence, attitudes toward behavior change related to HIV/AIDS, immunizations, nutrition, and child health. • The continuation of training in the Congo has been particularly noteworthy during the last year because of the ongoing conflict related issues making any activity in Kinshasa costly and difficult.

19. Key Accomplishments • In terms of short courses, over 270 participants of different professional levels have been trained intensively in diverse content areas, including professionals from other disciplines and other countries in the region. • During the last year over 100 professions were trained in short-term courses related to various aspects of USAID strategic objectives. • For a review of the specific results of various courses offered in Nairobi and the Kinshasa are available on the KSPH Web site (www.espkin.org).

20. ESP (SPH) Kinshasa/TulaneFuture directions

21. Initiatives and Opportunities for SPH Kinshasa/Tulane • Center for Behavior Change • Center for study of conflict and disasters (complex emergencies) • Payson technology and outreach training in HIV/AIDS and health at local level

22. Overview of the Epidemic • 34 million adults and children are living with HIV/AIDS worldwide • 71% of these cases were from Sub-Saharan Africa • HIV is the second leading causes of Disability-Adjusted Life-Years (DALYs) worldwide • HIV accounted for 20% of the total DALYs in Sub-Saharan Africa Sources: (UNAIDS, 2000; Michaud, Murray & Bloom, 2001)

23. HIV/AIDS and Other Infectious Disease Objective: HIV transmission and the impact of the HIV/AIDS pandemic reduced through behavioral change at the organizational and individual level

24. Recent trends in HIV infection, 1996–2001 + 1 300% + 20% + 20% + 160% + 100% + 60% + 40% HIV prevalence in adults, end 2001 + 30% 15 – 39% 5 – 15% 1 – 5% 0.5 – 1.0% + 20% 0.1 – 0.5% 0.0 – 0.1% not available The global view of HIV, end 2001 Source:UNAIDS/WHO July 2002 outside region

25. Behavioral Change is Implicated in the USAID Comprehensive Approach O =Organizational Behavior Change I = Individual Behavior Change Prevention Ensure blood safety O Sexual risk reduction OI Condom social marketing OI Treat other sexually transmitted diseases Voluntary counseling OI and testing Preventing mother-to- child transmission OI Surveillance and monitoring systems O Care and Mitigation Basic care and OI support for HIV infected persons Use of anti-retroviral drugs in introductory sites OI Support for orphans and vulnerable children O Other mitigation activities OI

26. Uganda’s Pursuit Of Three Behaviors • Delayed Sexual Debut • Sex Partner Reduction, and • Condom Use are complementary behaviors. • Uganda has pursued all three. • Data based • Proven success • Organizational Behavior Change at the Presidential level

27. HIV/AIDS Successes • At project level: • sustained reductions in risk behaviors >> less HIV transmission >> lower HIV & STD prevalence • At national level: • Preventing a major epidemic (Senegal, Phillippines, Indonesia) • Reducing an existing severe epidemic (Uganda, Thailand, Zambia, Dominican Republic, Cambodia)

28. HIV Seroprevalence (%) 50 1993 1994 1998 40 30 20 10 0 15-19 20-24 25-29 30-34 All Age HIV prevalence declines among females 15-19 in Lusaka, Zambia: 1993-1998

29. HIV/AIDS is a serious and real threat to development • HIV/AIDS has become the most serious threat to Africa’s health and socio-economic development--- it has spread at a far faster rate and has affected more segments of society than was previously recognized by many • Main modes of HIV transmission in Africa are health system related and sexual contacts.

30. Research Results on Common Interventions Based on Randomized Trials* * No Randomized Trial has been conducted to evaluate Social Marketing Program in Africa Setting

31. Behavioral Change is the PrimarySolution • Authors from both the Mwanza and Rakai studies suggested that the differences in the two study populations stage of HIV-1 epidemic could explain the differences in results seen between in the two trials (i.e., Rakai population had a more mature generalized stage of HIV-1 epidemic than the Mwanza population.) This implies that STD treatment may be only effective in reducing HIV seroprevalence in setting with low and moderate HIV-epidemics (Grosskurth et al, 2000). • Most of observational and randomized studies conducted as to date have shown that behavioral interventions is effective in reducing the rate of unprotected sex among adolescent and adult population. • Condom use reduces the infectivity of HIV by a minimum of between 90-95% (Perkinerton &Abramson, 1993). • Little information is available on whether behavioral intervention actually reduces HIV seroincidence at the population level

32. Research Results on Common Interventions Reference: (World Bank, 2000; Kumaranayake & Watts, 2000)

33. Benefit of Early Prevention This figure provides an illustration of the cost of providing comprehensive package of interventions for a typical Sub-Saharan African countries with per capita income of US$300 When the adult HIV prevalence rate is less than 5%, the annual cost of prevention, care, and treatment is about 1.3% of GDP, but once the HIV prevalence rate reaches 30%, the annual cost can reach 10% of GDP) Source: World Bank, 1997; UNAIDS, 1999

34. Payson technology and outreach training in HIV/AIDS and health at local level Training, education and behavioral change

35. Payson Technology: Building Knowledge Bases

36. Payson Technology • Shareware and open sourcesolutions: • TALM Toolkit, Linux, Open Office, GIS – Manifold • Knowledge bases: Greenstone Digital Libraries, PC-Isis Libraries • Human Sustainable Development Library • Considered one of the finest development libraries in existence • 1230 publications, 160 000 pages • English, French • All information is contained on a single standalone CD or via the web http://www.humanitylibraries.net • Created in Greenstone Digital Library software developed by the University of Waikato, NZ –Dept. Computer Science • Effective & Efficient (MG) • High academic recognition in digital libraries disciplines • Multi lingual (english, french, spanish, chinese, arabic) • Multi collections (text, pictures, audio, music, combination)

37. Payson technology:Rapid Courseware development using EClass and the TALM toolkit

38. Technology Assisted Learning Modules (TALM) Toolkit & E-Class: Sound pedagogical principals for instructional design • TALM toolkit for developing courses includes shareware software: • E-Class and tutorials • Image editors • Video editors • Sound Editors • Office • Internet tools & resources

39. Audience for E-Class • People (faculty, instructors, web designers) who want a user friendly, no-programming required method to developbasic training that can be posted online or distributed in a standalone CD.

40. Training in HIV/AIDS and infectious disease at local level Using Payson technologyand the SKC framework for lifelong learning

41. SKC Framework Skill Knowledge Competence • A multi-faceted, ordered, aggregate of facts, knowledge and skills, physical or motor, and cognitive. • A competency encompasses the proper execution of skills based upon the appropriate knowledge of facts and methods.

42. SKC Framework • SKC - Skills Knowledge Competence Framework for courseware design assumes: • Individual baseline assessment - Individually assessing the quality of the learner’s prior experience SKC. The learner should be assessed before learning, so that a list of SKC already present is produced, as well as a list of missing SKC. • Flexibility and menu-like approach - Courses are constructed from Modules which in turn are made up of Sections. Based on the SKC assessment, the learner can select from a list of sections, modules or courses to take. Since the smallest learning unit is Section, it can be shared by several modules and courses.

43. Lifelong learning • In a world where the quantity of data and information is exploding, driven by multiple factors mostly related to technology implementations, the single most important capacity an individual, or an organization should have, is the ability to learn rapidly from the experience and the experiments of others.

44. The first competency • Health professionals should have the ability to organize learning as a continual lifelong process without necessarily having the defining structure of a course or a professor.

45. HIV/AIDS training • Epidemiology (demography) and Biology (virology) aspects of HIV/AIDS • Methodology (biostatistics, qualitative and quantitative research methods) and Research ethics • Behavioral change at individual and community level (social sciences) • Individual and Organizational change and Policy formulation • Cross-Cultural and Cross-Gender communication (anthropological aspects) • Management (system thinking, strategic planning, program, project and change management, M&Evaluation, financial management etc.) • Health Economics • Law

46. Payson technology enables SKC lifelong learning • Knowledge bases and courseware software facilitates SKC lifelong learning in at least two ways: • By allowing the expert to produce courseware without technical assistance • By allowing the learner to access a portable knowledge base and IT enabled course wherever, whenever and whatever he/she selects.

47. Conclusions • Behavioral change interventions are the only intervention currently available that seem to have an impact of HIV transmission • Behavioral change interventions are effective in reducing the rate of unprotected sex based on both observational and randomized trials, and interventions in infectious disease control and conflict resolution. • Behavioral change interventions cost less than all currently available management and treatment regimens. • Individual and Organizational Behavior Change is the key