Publication date: October 31, 2016
Hema Magge, MD, MS
Country Director, Ethiopia
Institute for Healthcare Improvement
Division of Global Health Equity, Brigham and Women’s Hospital
Division of General Pediatrics, Boston Children’s Hospital
Based in IHI’s first Africa office, in Addis Ababa, Ethiopia, Dr. Magge is leading a program funded by the Bill & Melinda Gates Foundation and the Margaret A. Cargill Philanthropies to reduce maternal and newborn mortality in Ethiopia. Over the next two-and-a-half years, IHI and its partners will support the Ethiopian Federal Ministry of Health in an ambitious agenda to rapidly close gaps in national health outcomes through the coordination of quality planning, quality assurance, and quality improvement.
Q: What led you to become a physician?
I always knew I wanted to work with children and families. And from an early age I felt strongly that every individual — regardless of where they’re born or how much money they have — every human being has a right to be healthy. This fundamental belief formed the basis of the social justice and human rights framework that has guided my career ever since.
I did my undergraduate degree at Harvard and majored in government because I wanted to understand how policies and politics can affect — positively and negatively — the health and wellbeing of families. After I graduated I spent a year in South Africa with a community-based health and human rights organization, working with a group of social workers who focused on preventing injuries in and violence toward children living in urban townships.
It was an amazing experience, being immersed with these workers in the field, talking to them and learning from them. It gave me such perspective in mapping out my journey, finding that match of my skills and interest with this vast scope of need.
I realized medicine was the best fit because it would give me a chance to work directly with children and families at a time when they are often the most vulnerable to illness; to understand their needs and identify gaps so I could then become their best advocate.
I went to medical school at the University of Pennsylvania, focusing on global health with a group of mentors in the Infectious Diseases Department. Through this connection I got the opportunity to work in Botswana, where I helped develop the university’s first medical student program in global health.
Q: What was your biggest take-away from medical school?
These early experiences sparked my passion for global health. The need is so critical. We have the data, we know that if you are born in a poor country, you are much more likely to die before the age of five than you are if you’re born in a rich country. This injustice is unacceptable. I felt compelled to work toward change.
I went to the University of California, San Francisco, for my pediatrics residency in the Global Health Clinical Scholar’s Program, and that’s when I first connected with Partners In Health (PIH). Like many others, I had long been inspired by PIH’s work to bring high-quality care to some of the hardest to reach areas worldwide using a social justice framework. Through a combination of luck and circumstance, after my residency I spent a month in Rwanda with PIH. It was my first trip to Africa as a physician. I got the bug.
Q: Why did you focus on health services research?
I knew that I wanted to pursue global health. But I realized I needed tools to be able to build and develop innovative solutions to gaps in care delivery — including the evaluation and research skills to rigorously evaluate any intervention we designed. I think too often in global health, because the scope is so large, we rush to implement programs without making sure they’re evidence-based and without the monitoring and evaluation component that ensures we learn what works and what doesn’t.
So, when I returned to Boston to complete a General Academic Pediatrics fellowship at Boston Medical Center, I also got my master’s degree in health services research at Boston University School of Public Health.
I was incredibly fortunate to be able to do my public health fellowship in Rwanda with PIH, supporting a clinical quality improvement nurse mentorship program they were introducing at frontline health facilities in three very rural districts. I got involved in both the program intervention design and the evaluation component, working with a strong Rwandan team.
This work gave me a terrific education in how to be a good partner. Rwanda has a remarkably strong Ministry of Health that guides and leads a strategic vision — a vision very much in line with PIH’s mission. So we had a strong partnership in which we could, together with local partners, design innovative approaches to meet the needs of their communities, rigorously evaluate them, and integrate these approaches into national plans and scale them when effective.
When my fellowship ended I was thrilled to be offered the position of Director of Pediatrics for PIH in Rwanda, with support from the Division of Global Health Equity at Brigham and Women’s Hospital. This allowed me to strengthen my work in Rwanda with academic operational research support, and work clinically in the US for short stints through Boston Children’s Hospital, to ensure that I was staying in touch with the highest standard of care.
So I moved to Rwanda, and for the next four years, I continued working with communities and leaders in the public sector, at all levels of the health system, to identify gaps in care in the rural district hospitals, prioritize core needs — using data we were gathering as well as global evidence — and work together to find solutions to address these needs.
Q: What brought you to IHI from Rwanda?
Working in neonatal and newborn health, I saw that we have solutions to the problems. We’ve known what to do for many years; the breakdown is primarily in the delivery. Evidence-based interventions are not being delivered at the scale or quality they need to be, especially with the poorest of the poor. That led me to quality improvement (QI), which offered my PIH team a set of methods to help bridge the gap between knowledge and practice.
As we were designing our maternal neonatal survival intervention, I had a sense that Learning Collaboratives could be an innovative approach to accelerate change. I had read about Collaboratives but wanted to learn how to run them. So I thought, well, you’ve got to learn from the best.
A PIH colleague connected me with Pierre [Barker, IHI Chief Global Partnerships and Programs Officer], who connected me with Sodzi [Sodzi-Tettey, MD, MPH, IHI Executive Director, Africa Region], who at the time was leading Project Fives Alive! (PFA) in Ghana.
In 2013, I traveled with a PIH colleague to Northern Ghana and met with Sodzi and other PFA staff, and really dug into the nuts and bolts of how their model works and the challenges they faced. I left that experience feeling that this is a kindred organization where people are working intensely, at rapid speed and enormous effort, because they feel the urgency of the work; they know it’s critical to saving lives and improving the health and wellbeing of families.
This started a conversation, and we continued to stay in touch with the PFA team. Over time we learned from each other; my team traveled to Ghana, and Sodzi’s team came to Rwanda to understand the different implementation experiences. We shared valuable insights. Ultimately, my PIH group achieved significant success in Rwanda; we developed effective approaches in 25 facilities. This led me to think about scale: how do we do this in hundreds of facilities, in other countries, in other settings?
Around this time, Pierre and Nneka [Mobisson-Etuk, MD, former IHI Executive Director, Africa Region] approached me about the IHI opportunity in Ethiopia. It felt like a perfect opportunity to build on all of the experience and knowledge my PIH team and IHI’s Africa teams had gained and apply it on a large scale across Ethiopia.
Q: What is the focus of IHI’s work in Ethiopia?
Our focus is in the critical area of maternal and newborn survival, demonstrating the impact of quality improvement approaches to accelerate the achievement of the Ethiopian Ministry of Health’s ambitious goals for reducing maternal and neonatal mortality.
We are working with the Ministry to help them achieve their mission of making quality improvement part of the norm, part of the routine; integrating an emphasis on providing high-quality, respectful care to every single patient in every single facility.
It means we’ll be reaching all levels — the front line, the community health worker, nurses, midwives, and doctors in rural facilities — and building skills in improvement: the ability to test a change, identify what’s working, what’s not, make adjustments, develop solutions, introduce them and test more… the heart of a PDSA cycle.
In the first year we’ll begin working in four districts, but then quickly expand into 25, iterating on the model and continuing to improve it. We’re going to implement in a rigorous way to develop a scalable intervention strategy. Once we demonstrate that this works, that it improves the quality of care and ultimately saves lives, we’ll have evidence to support scale-up nationally.
Q: What are some challenges you see ahead?
In order to do this work well, I fundamentally believe you have to understand at a deep level the needs of a community and then design your system to help meet those needs. You can’t try to force communities to adjust to what your system provides. In a complex country with a huge population and huge land mass, there’s a tremendous amount of variation. That’s going to be challenging, to understand what are the needs in specific areas and ensure we design solutions that can be adjusted and adapted to any setting.
Q: What are you most excited about?
I’m excited by the quality improvement approach. It’s not a pill, not a prescriptive intervention. It’s a set of guiding principles and skills that enable and strengthen and help health care providers and managers to be able to own their challenges and own their solutions.
What I’m most excited about in Ethiopia is the opportunity to support the Ministry of Health in designing system-level solutions to improving the lives of children and families. That’s really the ultimate goal.