An emergency of the scale and complexity of the Ebola outbreak required the many actors involved to step outside of their usual realms of operation and adopt new ways of working. Likewise, the global lack of expertise and experience in Ebola response demanded new approaches to coordination and knowledge sharing throughout the entire response cycle, from building and running Ebola Treatment Centres (ETCs) to training and deploying staff.
Due to the high risk nature of this response’s deployments, pre-departure trainings for healthcare workers (HCWs) deploying to the “red zones” of the ETCs were a priority. As part of the rollout of the UK’s response in Sierra Leone, the actors involved worked closely together to develop and deliver a centralised training programme for the deploying medical teams. The result was a programme of trainings that not only prepared participants for safe and successful deployments, but also contributed to the coherence of the UK response. The success of the coordination mechanisms used to develop and deliver this programme of pre-departure training can inform future large-scale rapid deployments to humanitarian emergencies.
This article draws on RedR UK’s experience of delivering 16 Ebola pre-deployment trainings since December 2014 to over 350 health care workers from the National Health Service (NHS), Foreign Medical Teams and research teams to prepare them for deployment to Sierra Leone as part of the UK’s Ebola response.
Government and NGO partnerships
The UK committed a £427 million package of direct support to Sierra Leone for containing, controlling and treating Ebola. This package included financial, material and human resources to build and supply six ETCs and provide teams of international healthcare workers (HCWs). To rollout and run this response, a wide network of actors was involved, with the UK’s Department for International Development (DfID) acting as the coordinating body. The UK’s Ministry of Defence (MoD) led the construction of the ETCs, which were each entrusted to an NGO to manage and run.
The governments of Norway, South Korea and Denmark partnered with Médecins du Monde, Emergency and GOAL to provide resources and Foreign Medical Teams to their ETCs in Moyamba, Freetown and Port Loko, respectively. British teams of medical volunteers from the UK’s NHS were recruited by UK-Med and deployed to the ETCs by International Medical Corps in Makeni and Save the Children International in Kerrytown. RedR UK delivered a centralised programme of five-day intensive pre-departure trainings in the UK for the deploying HCWs.
Successes of the centralised pre-departure training programme
Regardless of their background or destination, it was essential that the HCWs received training before entering the ETCs to work with Ebola patients. To coordinate between the different sending and receiving organisations, a two-step system of pre-departure training followed by further in-country training at the ETC was adopted. Centralising the pre-departure trainings acted as an additional coordinating mechanism for the complex response framework and had multiple benefits beyond requiring all HCWs deploying through the UK’s response mechanism to pass through the same first port of call.
First and foremost, centralised training was essential for developing a collective foundation of knowledge to the diverse groups of volunteers who came from different deploying countries and health care systems as well as a variety of occupations and specialities. Previous to this outbreak, Ebola was such a rare disease that very few people had much knowledge of the virus or experience in responding to it. The training ensured that the medical teams deployed with a shared understanding of the disease and the practices around medical case management as well as a solid grounding in the principles of working safely in the ETC, including the principles of the safe use of personal protective equipment. The standardised trainings enabled the partner organisations to have confidence in the level of knowledge HCWs would begin their in-country training with. Regardless of where the team was coming from and which ETC it was heading to, the HCWs were primed to be able to apply the principles they learnt in pre-departure training to the specific protocols of their centre when undergoing in-country training and mentorship.
Likewise, the trainings eased the transition of the HCWs from their work in high-resource, non-emergency environments at home to their work in low-resource, humanitarian emergency environments in the field. As few of the HCWs had experience working in the field, and even fewer had experience of humanitarian emergencies, the training played a key role in preparing the HCWs for humanitarian deployments. The training provided a strong understanding of the challenges that would be faced in the low-resource, high-risk environment of the Ebola response, but it also gave an overview of what it meant to be a humanitarian responder with an introduction to humanitarian principles and context. As the ETCs were run by humanitarian NGOs, the pre-departure trainings’ humanitarian focus built a bridge between the HCWs work for hospitals in their home countries, and the ETCs they would work at during their deployments.
Equally important, delegating the responsibility of delivering pre-departure training to a specialist training organisation allowed the partner organisations to focus their limited time and resources on the front-line elements of the response rather than on extensive pre-departure trainings. The trainings benefitted from RedR’s expertise as an international humanitarian NGO with extensive experience in providing training and other capacity building services to the humanitarian sector, while the NGOs were able to channel their capacity to providing direct support in-country.
The success of this centralised programme can in large part be attributed to the high level of coordination that took place throughout the development, planning, delivery and review of the pre-departure trainings. RedR was able to work through existing coordination mechanisms as well as implement new systems to engage stakeholders, connect with expertise, facilitate knowledge-sharing and monitor participant progress. The result was a training programme that was the product of a transparent and collaborative process and which responded to the needs of the deploying organisations and changes to the reality on the ground.
Designing the trainings was an entirely collaborative process. Initial content was shared by Médecins Sans Frontières (MSF), the International Federation of Red Cross and Red Crescent Societies (IFRC) and the MoD. Further content and sessions were provided by RedR and InterHealth, as well as the Anthropology Platform, Sierra Leonean Diaspora Group, Ebola Waste Task Force and epidemiologist Dr. Tim Healing.
Stakeholders were involved in approving course content to promote buy-in and ensure their perspectives were considered and integrated into the trainings. Before the training programme was launched, the deploying organisations – along with other key stakeholders including the British Red Cross, the Department of Health and the MoD – had the opportunity to examine the original training agenda to review the proposal and suggest amendments. All were given the chance to comment on the proposed content, balance of session themes and objectives at course and session levels. Similarly, when a review of the course was conducted two months into the rollout of the programme, the NGO partners were again invited to give feedback.
Additionally, the agenda included time for NGOs to send representatives to the trainings to provide briefings to the teams deploying to their ETCs. This allowed the overall course content to remain centre-neutral, while still providing participants with the opportunity to hear from their deploying organisation. Similarly, time was made for representatives from UK-Med or team-leaders of the Foreign Medical Teams to brief participants as necessary.
Connecting with expertise
A hallmark of the pre-departure trainings was the amount of expertise present at each course. Training teams included experienced humanitarians, infection prevention control/logistics specialists and clinicians with experience from this response. Resource people for the training teams were identified through the RedR Associate Trainer pool and membership register, networking with other organisations responding to the crisis and former participants of the pre-departure trainings who had returned from their deployments. Similarly, expert sessions were delivered by an epidemiologist, InterHealth trainers and members of the Anthropology Platform and Sierra Leonean Diaspora Group to add extra depth.
Coordination allowed for information-sharing that was essential for keeping the training relevant and up-to-date with changes on the ground. Weekly staffing group meetings were held by DfID to enable discussion between DfID, RedR, UK-Med, the NGO partners and other stakeholders. These meetings gave the opportunity for those present to discuss arising issues, share updates and give situation reports on various parts of the response. The situation reports, in particular, were important for cross-checking that the trainings stayed relevant to the response and reflected changes in-country.
Monitoring participant growth
A participant competency framework was developed in partnership with the sending organisations to monitor participants’ learning and development of necessary behavioural competencies over the course of a training. The competency framework was integrated into the trainings, and a participant flagging procedure was in place to alert the sending organisations when concerns were raised about an individual’s display of characteristics contrary to the competencies.
Factors enabling coordination
In this response, the pre-departure training was not treated as a peripheral activity. Instead, because working safely in the ETCs required a meticulous understanding of principles and protocols, training was given top priority and was recognised as a cornerstone of the success of the deployments, and thus of the response. This perspective embedded training in the existing coordination systems of the response. For example, because training received a central focus, RedR was represented in the staffing group, which enabled a high level of coordination between RedR, DfID, the partner organisations and other stakeholders.
Additionally, the challenging nature of the Ebola crisis prompted the sector to take collective ownership of the response. Due to the general lack of experience and expertise in managing such a crisis, the sector came together without the usual competitiveness and instead relied on each other to find the way forward. In a sense, the sector was learning together and the resulting trust and openness made it easier to engage stakeholders throughout the training cycle, access and collaborate with expertise in the sector and develop feedback loops that connected the training to the changes on the ground.
Factors challenging coordination
Challenges were faced in implementing the variety of coordination mechanisms throughout the full cycle of training. Coordination was particularly difficult when the training was first being designed and rolled out. In these early stages, the entire sector was over-worked and under-resourced, which made it hard to access and engage partners at the time when their input was required. Short time frames exacerbated this challenge because there was little flexibility in the schedule, with delays in coordinating with partners potentially leading to bigger delays in implementing components of the training programme. This was particularly problematic in the set-up phase of the trainings when delays would have set back deployments and, ultimately, ETC openings.
In addition, uncertainty or an outright lack of information in the face of a continuously changing situation on the ground also challenged the coordination of the training. For example, even when partners were available and willing to collaborate, they often did not have the information to do so at the capacity level required.
It is widely recognised that coordination is essential to delivering an effective humanitarian response. The effective implementation of coordination mechanisms throughout the development and delivery of the UK’s centralised programme of Ebola pre-departure trainings demonstrates how a high level of collaboration can benefit a complex response framework. To date, RedR has delivered 16 pre-departure trainings for over 350 HCWs. Participants of these trainings have deployed to all six of the UK-funded ETCs as part of UK-Med deployments, Danish, Norwegian, and South Korean foreign medical teams and Oxford research teams. Centralising the programme of pre-departure trainings played a strong role in bringing these diverse groups together under a coherent deployment framework, and coordinating between the different stakeholders ensured that the programme remained relevant to the needs of the response.
Shelby Fields has worked with RedR UK since the fall of 2012, with positions in the International Programmes and UK/Europe Region departments. She has 3 years of experience in event and project coordination, including logistical and financial management of ECHO- and DfID-funded projects. Since November 2014, Shelby has been the Project Coordinator for RedR’s DfID-funded Pre-departure Ebola Response Training Project. (Shelby.firstname.lastname@example.org)