Zimbabwe meets Glasgow meets Malawi – an international odyssey in global oral health

I am delighted that this guest post has been written by Cleopatra Matanhire, a dentist from Zimbabwe who recently completed a Master’s degree in Global Health at the University of Glasgow.

For her research project, undertaken in part-fulfilment of her master’s degree, Cleopatra undertook a case study of the work underway by the Oral Health Policy Task Force, established by the Ministry of Health in Malawi.

Cleopatra was able to visit Malawi in October 2021, allowing her to attend a meeting of the Ministry of Health Technical Working Group when it considered the draft policy and to meet key personnel from the Ministry, the Dental Association of Malawi and the Kamuzu University of Health Sciences.

This account, based on a diary of Cleopatra’s visit to Malawi, gives a flavour of her experiences as as she visited the ‘Warm Heart of Africa’.

Monday 4 October 2021

After several weeks of the journey to Malawi being postponed, finally it materialises today, the 4th of October 2021. The story of how this happened emanates from a self-initiated introduction that I made to the University of Glasgow (U of G) dental team on my arrival in Glasgow for my MSc Global Health Studies. Even though I was enrolled in a different College, I had hoped to learn as much as I could about the accomplished and renowned work the U of G Dental School was doing in the world, especially in Africa. In my reading, I had come across the MalDent Project in Malawi and Bwiza Childsmile Initiative in Rwanda that U of G was involved in. Little did I know that I would end up doing my Master’s thesis on one of the projects.

Sometime in October 2020 I had a virtual meeting with Professor Jeremy Bagg and Professor Lorna Macpherson at Glasgow Dental School. I informed them of my willingness to learn as much as I could about their work, especially in dental public health. Instantly they asked what I planned to do my dissertation on, which was oral health policy related work, and our worlds aligned. One of the MalDent Project goals was to develop a national oral health policy for Malawi.

This was it, it ticked all the boxes, a dentistry related project, African context and if possible, on oral health policy. I had hit the jackpot!

What followed was months’ worth of preparation, reading, meetings and more familiarization with the MalDent Project. I settled on the title Developing Oral Health Policy in Africa: Case Study of Malawi. All of my project had to be done online as a result of the COVID 19 pandemic, but I sought to go visit Malawi physically and contextualise my research. Which is the purpose of this trip.

As I departed from Harare International Airport I wasn’t sure what to expect. One thing for certain though, I knew I would be intrigued by the journey as all things to do with developing oral health, especially in Africa, get me excited.  I was expectant to learn from the hard work the Malawi team had put in. I was fortunate to have been invited as a physical observer to the Oral Health Policy Taskforce meeting with the Technical Working Group (TWG) of the Malawi Ministry of Health, when Draft 11 of the policy was to be considered for sign off.  My journey would start in Lilongwe, where the TWG meeting was to take place and then I would proceed to Blantyre. A busy but interesting itinerary was laid out for me by the Malawian team.

Tuesday 5 October 2021

We hit the ground running. I would be in the company of Dr Peter Chimimba (MalDent Project lead in Malawi) and Dr James Mchenga (academic lead at the new dental school). Both James and Peter are Oral and Maxillofacial Surgeons (OMFS), in fact the only two OMFS in Malawi. On the schedule lined up for us in Lilongwe were a tour of Kamuzu Central Hospital, a visit to the Kamuzu University of Health Sciences (KUHeS) Lilongwe campus (formerly known as University of Malawi College of Medicine), a meeting with a Dental Association of Malawi representative and attendance at the Ministry of Health Technical Working Group meeting where the national oral health policy document was being discussed in depth. All this and more were achieved.

James Mchenga, myself, Peter Chimimba at KUHES Lilongwe Campus

The tour of Kamuzu Central Hospital was very interesting. The quality of services rendered by the currently available manpower is impressive.  Because for a long time there hasn’t been a dental school in Malawi, dental therapists’ scope of practice goes above and beyond the typical expectation. The therapists man rural health centres and district hospital facilities mostly on their own, undertaking maxillofacial procedures such as cyst enucleations and intermaxillary fixations.

Myself and Austin Mnthambala, Principal Dental Specialist at Kamuzu Central Hospital Dental Department

At Kamuzu Central Hospital I was impressed to see Registered General Nurses running the Dental Department’s infection control and equipment sterilization – I was informed they had been requested from the Central Sterile Supply Department (CSSD). This was particularly interesting as Malawi does not have qualified dental nurses or dental surgery assistants but had managed to plug the gap with an appropriate standard. I also had the privilege of meeting Mr Edgar Mthunzi, a dental therapist with further training in general anaesthetics. He was preparing for retirement, but I was rather impressed – never in my mind had I imagined that the local cases that were being conducted under GA were being undertaken with the anaesthetist having a dentistry background. This was a brilliant solution for the context and he had worked in this capacity for many years. In fact, the gentleman had worked with one of my colleagues from Zimbabwe during his training to qualify as an OMFS. I had to have a photo taken with him! I thought of our Dental Therapy students back home in Zimbabwe and how this would be a great example for career diversification and growth within the dentistry profession, if one is willing.

Mr Edgar Mthunzi and myself

During the trip, James and Peter would share with me their career journey and life stories which were so interesting. Later, that day we met with Dr Wiston Mukiwa, who I had been privileged to interview on-line for my master’s research project. Wiston has been practising for more than four decades. He had the privilege of serving as Principal Secretary in the Ministry of Health and Chief Dental Surgeon of Malawi earlier in his career. I spent the afternoon in the company of the three, as they narrated the journey of Dentistry as a profession in Malawi, from when there were only three dental practitioners to the present day. I was in awe of the accomplishments they had made, including the involvement of private practitioners in the development of the new National Oral Health Policy. The biggest takeaway from the afternoon discussions was that you only need a few dedicated, committed people to do the job. We agreed to work on strengthening collaborations as Regional dental associations and dental schools.

James Mchenga, myself, Wiston Mukiwa & Peter Chimimba

Wednesday 6 October 2021

Today the Ministry of Health meeting was held. Two new policy documents were being discussed – the National Oral Health Policy and the Emergency and Critical Care Strategy. Though we were physically at the Crossroads Hotel in Lilongwe, most of the participants logged in virtually on the Zoom platform. At the meeting I got an opportunity to meet Dr Jones Masiye (Deputy Director Clinical Services – NCDIs and Mental Health) from the Ministry of Health and Dr Martha Chipanda (the newly appointed National Oral Health Coordinator). Dr Dube, the Chief of Health Services and a specialist paediatrician, brought the house to order and led with poise. In fact, what surprised me the most was how well versed she was with both policies and specialties, having clearly reviewed the draft documentation thoroughly. She had an intriguing depth of oral health intersectionality with other health disciplines, referencing relevant previous projects and documentation that had been run within the Ministry of Health, decades prior. She proved to have a wealth of knowledge and offered wise suggestions of what needed to be improved.

I couldn’t help but think, this is what we need in African countries – homegrown, innovative and contextually relevant solutions to the health challenges: eradication of the silo approach and integration of health services.

There were even discussions to incorporate oral health into emergency services. At the hospital the previous day it had been indicated that most of the surgical cases were Road Traffic Accidents (especially with motorbikes being on the rise as public transportation in Malawi), followed by tumours.

With James, Jones, Peter and Martha at the Crossroads Hotel for the TWG meeting
James, Jones and Peter during a break in proceedings at the TWG meeting

Thursday 7 October 2021

Today we travelled to Blantyre by road. James made a great tour guide, helping me discover more about Malawi. He even showed me the area where my mother’s paternal roots and heritage originate from, before migrating to Zimbabwe. This was really a life defining moment, as I always wanted to appreciate the land of my forefathers in Malawi, Ntcheu!

Coming home to Ntcheu- my mother’s paternal roots!

After a 5-hour road trip we arrived in Blantyre. No time was wasted as we went straight to the Queen Elizabeth Hospital. We toured the Dental Department and the rest of Queen Elizabeth Hospital. I had the privilege of seeing Mercy James Paediatric Hospital, a specialty facility that Madonna, in collaboration with various benefactors, built and named in honour of her daughter who she adopted from Malawi.

The Mercy James Centre for Paediatric Surgery and Intensive Care

In there were benefactors close to my global health academic journey: the Beit trust who had sponsored my postgraduate studies at the University of Glasgow and NHS Greater Glasgow and Clyde, who were a frequent find in our studies and whose staff we interacted with a lot.

The benefactors listed inside the Mercy James Centre

The highlight of the afternoon was James preparing his theatre list for the following day. I was present for all the case reviews. I was yet again impressed as dental therapy interns that had clerked the patients presented the patients, including differentials and provisional diagnosis, surgical and treatment management plans. What stood out was the early age of presentation of patients with benign and malignant tumors of the maxillofacial region – more than 4 of the cases were patients less than 24 years of age; some were even in their teens. A minority of the cases were trauma cases, the injuries having been sustained in road traffic accidents and assault cases. The staff helped me appreciate that the patients had travelled far and wide to be able to access these particular oral health services.

From the Hospital, we headed to Kamuzu University of Health Sciences Blantyre Campus. A quick tour of the institution helped me realise the outstanding work the Malawi and Glasgow team have been putting in equipping and establishing a world class dental training facility. Even though we had had an extremely busy and exhaustive day, it was productive and ended on an extremely high note!

Newly equipped Dental Department at Queen Elizabeth Hospital

Friday 8 October 2021

Friday commenced with a debriefing session with Peter and James at KUHES Blantyre Campus for the week’s activities and more. We ended our meet and said our goodbyes to each other and the other MalDent team members.

Annie Mwapasa (MalDent Administrator) and myself at KUHES Blantyre campus moments before departure.

Aboard the return flight from Blantyre to Lilongwe my official itinerary was complete, with everything done and dusted. It was time to carry out in-depth personal reflections of my visit.

My reflections …

Though it is clear Malawi’s oral health workforce is inadequate, it is highly specialized. In Blantyre at Queen Elizabeth Central Hospital I spent the afternoon yesterday with Dr Mchenga and his team of dental therapy interns attending to the theatre list for the following day. The knowledge the interns had of OMFS was the standard of BDS finalists / interns. They even gave provisional diagnoses and treatment plans.

Prior to that I had been informed that due to the similar challenge of the Oral Healthcare Worker shortage, Dental Therapists are equipped in districts to perform minor surgical procedures such as inter-maxillary fixation, enucleations and the like.

For me, there is an emerging story to be told here. I reflect on home and realise that contrary to Malawi we have a large oral health workforce, but it is now concentrated in the urban areas, whilst the remote parts of the country are unserved.  Most recently the BDS program has been restructured to become longer and internship for foreign trained dentists extended. The African region faces a clear shortage of practitioners, but the regulatory authorities continue to tighten training policies and increase the timeline to produce a Practitioner. It made me think, what is the motivation for these decisions? Are the decision makers informed of the situation on the ground? Do they consult oral health experts prior to imposing these decisions? Do they consider the plight of the candidates who take up the training who now have to invest 8-10 years of their time into undergraduate degree training without pay? At present, there already is a massive exodus of health practitioners. Where will we stand in a decade from now on oral health service delivery? In the meantime, the oral disease burden increases and lives are at risk.

Lessons from the visit to Malawi

Oral Healthcare Worker shortage is no excuse for not delivering services.  Existent health workforce can be capacitated within the required field. Dental Surgery Assistants are non-existent in Malawi, but Central Hospital Dental Departments have RGNs from CSSDs manning infection control, disinfection and sterilization. Meeting a dental therapist who had pursued further training in anesthetics and worked in house with the OMFS was another revelation – a career path for a dental therapist that I had never thought of.

We need to think again about workforce models, because the traditional norms in developed countries do not work for low- and middle-income countries. In reality, there is now a realisation that they don’t work well for developed countries either, particularly as the need to address sustainability and planetary health has become an urgent imperative. There is an opportunity for countries like Malawi and Zimbabwe to develop and lead the way on new ways of working. I am excited to be part of it!

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