Operational research on implementation of tuberculosis guidelines in
Mozambique
Brouwer, M.A.
Publication date
2015
Document Version
Final published version
Link to publication
Citation for published version (APA):
Brouwer, M. A. (2015). Operational research on implementation of tuberculosis guidelines in
Mozambique.
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Acknowledgements!
My! statement! that! I! was! doing! a! PhD! for! fun! in! my! spare! time! was! often! met! by! surprise! by! fellow! participants!of!the!graduate!school!courses.!Although!I!had!my!moments!of!doubt,!conducting!the!research! for!this!thesis!has!been!fun!and!a!great!learning!experience.!Part!of!the!fun!and!the!learning!was!because!I! worked!together!with!many!nice!and!knowledgeable!people!to!whom!I!am!very!grateful.! First!I!would!like!to!thank!my!coPpromotor!Frank!van!Leth.!Without!your!support!I!would!not!have!managed! to!finalise!this!thesis.!We!started!talking!research!and!a!PhD!long!before!I!formally!started!(often!at!Union! conferences! on! the! way! back! at! Gare! du! Nord).! From! protocol! development! to! the! publication! of! the! results,! you! helped! with! almost! every! step.! You! happily! did! most! of! the! more! complicated! statistical! analysis,!and!showed!me!how!to!use!Zotero,!which!I!have!used!ever!since.!Not!only!did!we!talk!research! related! themes! when! we! met,! but! also! other! aspects! of! life! such! as! good! books,! films,! dance! shows! to! name!just!a!few.!The!manner!in!which!you!supported!me!is!the!way!I!now!try!to!support!others.!Most!of! your!support!towards!the!work!in!this!thesis!you!did!in!your!spare!time.!A!visit!to!Scotland!to!taste!some! samples!of!the!Scottish!water!of!life!is!my!way!of!thanking!you.!The!sample!size!still!needs!to!be!calculated.! I!started!out!the!doctorate!trajectory!with!Martien!Borgdorff!as!promotor,!who!could!not!see!it!through!to! the!end!because!of!his!move!abroad.!Frank!Cobelens!succeeded!as!my!promotor.!Thank!you!both!for!your! stimulating!support!in!my!research!and!writing.!
I! thank! the! members! of! the! committee! for! their! willingness! to! evaluate! my! thesis.! I! find! it! particularly! special!that!professor!Johan!Groothoff,!who!made!me!aware!of!the!importance!of!public!health!in!my!very! first!year!at!medical!school!and!who!coPauthored!my!first!scientific!publication!many!years!ago,!is!part!of! the!committee.!!
I!also!thank!my!coPresearchers!in!Mozambique!for!all!their!support.!Agradeço!a!estimada!Doutora!Paula!
Samo! Gudo,! que! na! ocasião! do! primeiro! estudo! era! chefe! do! Programa! Nacional! da! Tuberculose.! O! seu! suporte! foi! crucial! e! nossos! encontros! e! discussões! foram! produtivos! e! agradáveis.! Agradeço! a! caríssima! Doutora!Eliana!Coelho,!!com!quem!trabalhei!lado!a!lado!no!segundo!estudo.!Juntas!escrevemos!o!protocolo,! visitamos! as! províncias! de! Manica,! Sofala! e! Tete! para! conduzir! os! grupos! focais! e! juntas! também! analisamos!as!transcrições.!Eliana,!aprendi!muito!consigo.!Meus!sinceros!agradecimentos!a!outros!colegas! que! ajudaram! nessa! empreitada! em! Moçambique:! obrigada! a! Dra.! Carla! das! Dores! Mosse,! Dr.! Isaías! Manuel! Ramiro,! Dr.! Riaz! Mubarak,! Dra.! Paula! Perdigão,! Sr.! Chalice! Magé! Simbe,! Sra.! Elisa! Luís,! Sr.! Lino! Sixpense!e!Sr.!Tino!João!dos!Santos.!Ao!agradecer!nominalmente!a!esses!colegas,!corro!o!risco!de!esquecer! alguém,!e!por!isso,!peço!desculpas!antecipadamente.!
I! thank! all! the! people! who! helped! with! the! data! collection.! Agradeço! aos! seguintes! colegas:! Sra.! Celina!
Joaquim,! Sr.! Eugénio! Alberto! Anselmo! e! Sr.! Nelson! Chico! Mafione! que! colheram! os! dados! do! primeiro! estudo.! Obrigada! a! Sr.! Pedro! Tenente! pela! ajuda! no! manuseio! dos! dados.! E! aos! seguintes! colegas! que! colheram! os! dados! do! segundo! estudo,! meu! agradecimento:! Sr.! Francisco! António,! Sr.! Manuel! Armando! Cumba,! Sra.! Elisa! Luís,! Sr.! Modesto! Pedro! Mafaledzomba,! Sr.! Nelson! Chico! Mafione! e! Sr.! Tino! João! dos! Santos.!!
For!the!data!collection!in!Uganda,!I!thank!Annet!Nakaweesa!and!Michael!Mukiibi.!Another!person!without! whom! I! would! not! have! managed! the! study! in! Uganda! is! Achilles! Katamba! at! Makerere! University! in! Kampala.!He!provided!the!necessary!material,!supported!the!data!collectors,!was!available!for!discussions! and!helped!with!the!formalities.!Thank!you!Achilles.!
I!thank!Health!Alliance!International!(HAI),!the!organisation!I!worked!for!in!Mozambique,!for!allowing!me!to! conduct!the!Mozambican!studies!in!this!thesis!as!part!of!their!activities.!I!also!thank!HAI!staff!for!assisting! me!after!I!left!Mozambique!with!inPcountry!communication.!
We!lived!in!Mozambique!for!four!years.!I!thank!all!our!friends!and!colleagues,!from!Mozambique!and!many! other! places! in! the! world,! for! giving! us! a! wonderful! time! over! there.! A! special! word! of! thanks! goes! to! Luciana,! who! is! a! friend! and! a! colleague! and! a! coPadvocate! for! improving! TB! infection! prevention! and! control.!Your!Brazilian!mother!tongue!was!really!helpful!when!my!knowledge!of!Portuguese!failed!me.! Diederike!was!the!one!‘calling’!me!to!Mozambique!in!the!first!place.!We!have!much!in!common:!same!birth! year,! study! in! Groningen! (you! were! ahead! of! me),! working! in! Zambia! (again! ahead! of! me),! stories! of! a! stolen!car,!research,!and!much!more.!You!proofread!many!of!the!papers!in!this!thesis.!Thank!you!and!may! we!continue!to!share!good!moments.! The!library!of!Tilburg!University!became!the!place!where!I!could!focus!on!my!research.!Without!distraction! from!the!Internet!and!phone!it!is!a!quiet!place!where!all!one!can!do!is!work.!The!library!possesses!several! useful!books!on!qualitative!research!and!statistical!analysis,!which!helped!with!those!parts.!I!liked!working! there!so!much!that!I!now!use!the!library!as!my!office!away!from!home.! Heleen!and!Wieneke,!thank!you!for!being!my!paranymphs.!Since!the!start!of!my!tropical!career!(Heleen)!en! my!tuberculosis!career!(Wieneke),!you!both!are!part!of!my!professional!life,!though!often!at!a!distance.!We! are!friends!as!well!as!colleagues!and!have!shared!many!good!moments!in!several!parts!of!the!world.!Wine! sampling! in! Enschede,! hill! walking! in! Scotland,! klaverjassen! in! the! Okavango! delta,! and! tasting! Ethiopian! food,!are!just!a!few!examples!of!the!global!fun!I!enjoyed!with!you.! I!thank!my!family.!My!mother,!long!deceased,!always!encouraged!me!to!become!an!independent!person.!I! dedicate!this!thesis!to!her.!My!father!taught!me!lots!of!useful!business!skills,!which!I!use!regularly!now!that! I!run!my!own!business.!My!brothers!have!encouraged!me!all!through!my!life!even!though!they!may!not!be! aware!of!it.!Thank!you!all.!! Paul,!how!would!I!have!managed!the!whole!project!without!you?!Not!only!your!rich!research!experience! assisted!my!work,!you!also!easily!found!the!missing!comma!in!my!R!syntax.!Much!more!importantly,!you! have!been!my!companion!on!life’s!journey!for!almost!two!decades.!May!this!journey!together!continue!for! many!years!to!come.!
!
!
!
Portfolio!
Curriculum!Vitae! 2011Ppresent:!Independent!consultant!! 2007P2010:!TB/HIV!advisor!to!National!TB!Control!Programme,!Mozambique! 1991P2006:!Medical!officer!in!The!Netherlands,!Zambia;!specialist!training!Public!Health;!TB!control!medical! officer!The!Netherlands,!addiction!services!medical!officer!Scotland! 1983P1991:!Rijksuniversiteit!Groningen,!Medical!School! ! Publications! !
van! Leth! F,! van! Crevel! R,! Brouwer! M.! Latent! tuberculosis! infection! as! a! target! for! tuberculosis! control.! Future!Microbiology.!In!press.!
Mbonze!N,!Tabala!M,!Wenzi!LK,!Bakoko!B,!Brouwer!M,!Creswell!J,!Van!Rie!A,!Behets!F,!Yotebieng!M.!Impact! of!Xpert!MTB/RIF!as!diagnostic!for!smearPnegative!presumptive!TB!cases!on!case!notification!in!Kinshasa,! DR!Congo.!Submitted.!
Nabukenya! MG,! Kawuma! HJS,! Brouwer! M,! Mudiope! P,! Vassall,! A.! Tuberculosis! retreatment! 'others'! in! comparison!with!classical!retreatment!cases!in!regional!hospitals,!Uganda.!Submitted.!
Brouwer!M,!Coelho!E,!Das!Dores!Mosse!C,!Van!Leth!F.!Implementation!of!Tuberculosis!Infection!Prevention!
and! Control! in! Mozambican! health! care! facilities.! International! Journal! of! Tuberculosis! and! Lung! Disease! 2015;!19!(1):!44P49.!
Brouwer! M,! Coelho! E,! Das! Dores! Mosse! C,! Brondi! L,! Winterton! L,! Van! Leth! F.! Health! care! Workers’!
Challenges! in! the! Implementation! of! Tuberculosis! Infection! Prevention! and! Control! Measures! in! Mozambique.!PLoS!One.!2014!Dec!15;!9!(12):!e114364.!
Blok! L,! Creswell! J,! Stevens! R,! Brouwer! M,! Ramis! O,! Weil! O,! Klatser! P,! Sahu! S,! Bakker! M.! A! pragmatic! approach!to!measuring,!monitoring!and!evaluating!interventions!for!improved!tuberculosis!case!detection.! International!Health!2014,!Aug!6.!
Creswell! J,! Codlin! AJ,! Andre! E,! Micek! MA,! Bedru! A,! Carter! EJ,! Yadav! RPP,! Mosneaga! A,! Rai! B,! Banu! S,!
Brouwer! M,! Blok! L,! Sahu! S,! Ditiu! L.! Results! from! early! programmatic! implementation! of! Xpert! MTB/RIF!
testing!in!nine!countries.!BMC!Infectious!Diseases!2014,!14:!2.!
Brouwer! M,! Samo! Gudo! P,! Simbe! C,! Perdigão! P,! Van! Leth! F.! Benchmarking! to! assess! potential! underP
diagnosis!of!smearPnegative!and!extrapulmonary!tuberculosis.!A!case!study!from!Mozambique.!The!Open! Infectious!Diseases!Journal!2013,!7:!1P4.!
Brouwer! M,! Samo! Gudo! P,! Simbe! C,! Perdigão! P,! Van! Leth! F.! Are! routine! tuberculosis! programme! data!
suitable!to!report!on!antiretroviral!therapy!use!of!HIVPinfected!tuberculosis!patients?!BMC!Research!Notes! 2013,!6:!23.!
Brouwer!M,!Samo!Gudo!P,!Simbe!C,!Perdigão!P,!Van!Leth!F.!The!effect!of!Tuberculosis!and!antiretroviral!
treatment!on!CD4+!cell!count!response!in!HIVPpositive!Tuberculosis!patients!in!Mozambique.!BMC!Public! Health!2012,!12:!670.!
Samo!Gudo!P,!Cuna!Z,!Coelho!E,!Maungate!S,!Borroni!E,!Miotto!P,!Ahmadova!S,!Brouwer!M,!Migliori!GB,! Zignol! M,! Cirillo! DM.! Is! MDRPTB! on! the! growth! in! Mozambique?! Results! of! a! national! drug! resistance! survey.!Eur!Respir!J!2011!38:!222P224.! Brouwer!MA,!Keizer!ST.!Tuberculose!bij!asielzoekers.!Screening!bij!binnenkomst,!een!belangrijke!bijdrage! aan!de!bestrijding.!Infectieziekten!Bulletin!2003;!14!(2):!46P50.! Brouwer!MA,!Linden!PJQ!van!der.!De!acardiacus:!bekend!doch!weinig!gezien.!Nederlands!Tijdschrift!voor! Obstetrie!en!Gynaecologie!1999;!112:!212P3.! Brouwer!MA.!Caesarean!Section:!a!different!approach.!Tropical!Doctor!1998;!28!(3):!182P3.! Brouwer!MA,!Groothoff!JW,!Mooyaart!EL,!Terpstra!S.!Het!vaststellen!van!de!behoefte!aan!zorg.!De!MRP scan!als!voorbeeld.!Medisch!Contact!1991;!46:!750!–!752.! ! Conference!proceedings!! Poster!presentation.!Brouwer!M,!Coelho!E,!das!Dores!Mosse!C,!Brondi!L,!van!Leth,!F.!Tuberculosis!infection! control! and! prevention! in! Mozambique:! a! gap! between! daily! practice! and! guidelines.! 45th! World! Conference!on!Lung!Health!of!the!International!Union!Against!Tuberculosis!and!Lung!Disease,!2014.!
Oral!presentation.!Langa!E,!Brouwer!M,!Coelho!E,!Rahman!H,!Bossemeyer!D,!Brondi!L.!TB!infection!control! evaluations!leading!to!changes!in!guidelines!and!policies!in!Mozambique,!43rd!World!Conference!on!Lung! Health!of!the!international!Journal!of!Tuberculosis!and!Lung!Disease,!2012.!
Electronic!poster.!Brouwer!M,!Samo!Gudo!P,!Simbe!C,!Perdigão!P.!Is!median!CD4+!TPcell!an!indicator!for! underPdiagnosis! of! some! forms! of! Tuberculosis! in! Mozambique?! International! AIDS! Society! Conference,! 2010.!
Oral!presentation.!Brouwer!M,!Samo!Gudo!P,!Simbe!C,!Perdigão!P.!Implementation!of!TB/HIV!activities!and! follow!up!of!HIV!positive!TB!patients!in!Mozambique.!2nd!South!African!TB!Conference,!2010.!
Oral!presentation.!Brouwer!M,!Samo!Gudo!P,!Simbe!C,!Perdigão!P,!Van!Leth!F.!ART!use!determines!CD4+!TP cell! response! during! and! after! Tuberculosis! treatment! in! HIV! positive! TB! patients! in! Mozambique.! Oral! Presentation!at!4th!International!Workshop!on!HIV!Treatment,!Pathogenesis!and!Prevention!Research!in! Resource!limited!Settings,!2010.! Oral!presentation.!Scardigli!A,!Samo!Gudo!P,!Brouwer!M.!Coordination!between!TB!and!HIV!services!for!the! coPinfected!TB!patient:!a!real!challenge.!40th!World!Conference!on!Lung!Health!of!the!international!Journal! of!Tuberculosis!and!Lung!Disease,!2009.! Poster!presentation.!Brouwer!MA,!Meijer!W.!Tuberculosis!screening!of!prisoners!in!the!Netherlands.!3rd! Congress! of! Lung! Health! of! the! International! Union! Against! Tuberculosis! and! Lung! Disease,! European! Region,!2004.!
Poster!presentation.!Brouwer!MA,!Post!PN.!INH!treatment!in!tuberculin!surveys:!a!decision!analysis.!33rd! World!Conference!on!Lung!Health!of!the!International!Union!Against!Tuberculosis!and!Lung!Disease,!2002.!
!
Postgraduate+Courses++ + Academic+Medical+Centre+Graduate+School:+ Advanced!Topics!in!Clinical!Epidemiology,!2014! Computing!in!R,!2014! Project!Management,!2013! Basic!Course!Practical!Biostatistics,!2012! Clinical!Epidemiology,!2012! Infectious!Diseases,!2012! Scientific!Writing!in!English!for!Publication,!2012! Crash!course,!2011! Expert!Management!of!Medical!Literature:!PubMed,!2011! ! Other:+ DRLTB!Consultant!Training!Course.!World!Health!Organization,!2011!
WHO! Training! course! on! implementing! the! new! Stop! TB! Strategy:! MDR/XDR,! TB/HIV,! PPM,! Infection! control!and!more.!WHO!collaborating!Centre,!Italy,!2009!
+
Teaching:+
Supply!Chain!Management!with!a!focus!on!TB,!The!UNION,!2013!&!2014!
TB! infection! control:! training! for! managers! at! the! national! and! subnational! levels.! WHO! collaborating! Centre,!Italy,!2009! ! Contribution+to+guidelines:+ Ministério)de)Saúde,)Direcção)Nacional)de)Saúde)Pública,)Programa)Nacional)de)Controlo)da)Tuberculose.) Política)e)Plano)Nacional)de)Controlo)da)Infecção)para)a)Tuberculose)em)Unidades)Sanitárias)e)ambientes) conglomerados)de)Moçambique.!2010.! Ministério)de)Saúde,)Direcção)Nacional)de)Saúde)Pública,)Programa)Nacional)de)Controlo)da)Tuberculose.) Manual)de)Diagnóstico)e)Tratamento)de)Tuberculose)Resistente)e)MultiGDroga)Resistente.!2009.!
Commissie) voor) Praktische) Tuberculosebestrijding.) KNCV) Tuberculosefonds.) Handboek) TBCGbestrijding) Nederland.!2008.!
Affiliations! and! contributions! of! co:
authors!
Chapter! 2! The! effect! of! Tuberculosis! and! antiretroviral! treatment! on! CD4+! cell! count! response! in! HIVP positive!Tuberculosis!patients!in!Mozambique.!!
Chapter!3!Are!routine!tuberculosis!programme!data!suitable!to!report!on!antiretroviral!therapy!use!of!HIVP infected!tuberculosis!patients?!!
Chapter! 4! Benchmarking! to! assess! potential! underPdiagnosis! of! smearPnegative! and! extrapulmonary! tuberculosis.!A!case!study!from!Mozambique.!!
For!chapter!2!–!4!the!coPauthors!are:!
Paula!Samu!Gudo!(PSG)!P!Ministry!of!Health,!National!TB!Control!Programme,!Maputo,!Mozambique! Chalice!Magé!Simbe!(CMS)!P!Ministry!of!Health,!Provincial!Directorate,!Manica,!Mozambique!! Paula!Perdigão!(PP)!P!Independent!chest!physician,!Maputo,!Mozambique!
Frank! van! Leth!(FL)! P! Department! of! Global! Health,! Academic! Medical! Center,! University! of! Amsterdam,! Amsterdam,!The!Netherlands;!KNCV!Tuberculosis!Foundation,!Den!Haag,!The!Netherlands!
Miranda!Brouwer!(MB),!PSG,!PP!and!FL!conceived!the!study;!MB,!PSG!and!CMS!developed!the!study!tools;! MB!and!CMS!coordinated!the!data!collection;!MB,!PSG,!PP!and!FL!analysed!the!data.!MB!drafted!the!first! versions! of! the! manuscripts,! and! all! coPauthors! provided! comments! and! suggestions! towards! the! final! manuscripts.! Chapter!5!Health!care!Workers’!Challenges!in!the!Implementation!of!Tuberculosis!Infection!Prevention!and! Control!Measures!in!Mozambique.!! Eliana!Coelho!(EC)!P!Ministry!of!Health,!National!TB!Control!Programme,!Maputo,!Mozambique!! Carla!das!Dores!Mosse!(CDM)!P!Ministry!of!Health,!Provincial!Directorate,!Tete,!Mozambique! Luciana!Brondi!(LB)!P!Independent!Consultant,!Edinburgh,!United!Kingdom! Laura!Winterton!(LW)!P!Social!Anthropology,!University!of!Edinburgh,!United!Kingdom!
Frank! van! Leth! (FL)! P! Department! of! Global! Health,! Academic! Medical! Center,! University! of! Amsterdam,! Amsterdam,!The!Netherlands!
Miranda!Brouwer!(MB),!EC!and!FL!conceived!the!study;!MB,!EC!and!LB!developed!the!study!tools;!MB!and! EC!conduced!the!focus!group!discussions;!MB,!EC,!CDM,!LB!and!LW!analysed!the!data.!MB!drafted!the!first! version! of! the! manuscript,! and! all! coPauthors! provided! comments! and! suggestions! towards! the! final! manuscript.!
Chapter! 6! Implementation! of! Tuberculosis! Infection! Prevention! and! Control! in! Mozambican! health! care! facilities.!!
Eliana!Coelho!(EC)!P!Ministry!of!Health,!National!TB!Control!Programme,!Maputo,!Mozambique!! Carla!das!Dores!Mosse!(CDM)!P!Ministry!of!Health,!Provincial!Directorate,!Tete,!Mozambique!
Frank! van! Leth! (FL)! P! Department! of! Global! Health,! Academic! Medical! Center,! University! of! Amsterdam,! Amsterdam,!The!Netherlands!
Miranda!Brouwer!(MB),!EC!and!FL!conceived!the!study;!MB!and!EC!developed!the!study!tools;!MB,!EC,!CDM! and! FL! analysed! the! data.! MB! drafted! the! first! version! of! the! manuscript,! and! all! coPauthors! provided! comments!and!suggestions!towards!the!final!manuscript.!
About!the!author!
!
Miranda!Brouwer!was!born!in!Winschoten,!The!Netherlands.!She!attended!secondary!school!in!Haren!and! received!her!gymnasium!beta!diploma!in!1982.!After!a!gap!year!in!Switzerland,!she!started!medical!school! in!Groningen!in!1983.!She!wanted!to!do!her!practical!years!on!the!island!of!Curaçao,!but!a!lottery!decided! differently:! Diaconessen! hospital! Groningen.! An! overseas! alternative! presented! itself! in! the! form! of! an! elective!period!at!the!University!Teaching!Hospital!in!Lusaka,!Zambia!(1990).!This!was!a!decisive!step!in!her! career,!and!ever!since,!Zambia!and!Africa!have!been!close!to!her!heart.!!
After!graduating!from!medical!school,!Miranda!started!the!tropical!doctor!training!programme.!Equipped! with!obstetric!and!surgical!skills,!a!diploma!from!the!Royal!Tropical!Institute!on!tropical!diseases,!and!lots!of! enthusiasm!and!common!sense,!she!returned!to!Zambia!in!1994!to!work!at!Our!Lady’s!Hospital!Chilonga.! She! learned! to! provide! medical! services! under! challenging! circumstances! such! as! shortage! of! staff! and! materials,! power! cuts! and! lack! of! running! water.! Moreover,! she! practised! public! health! in! addition! to! clinical!medicine.!
Upon!returning!to!The!Netherlands!early!1998,!she!briefly!started!a!career!in!obstetrics!and!gynaecology,! but! decided! that! public! health! was! more! appealing.! In! 1999! the! opportunity! arose! to! join! the! Dutch! TB! control! world,! again! a! major! decisive! moment! in! Miranda's! career.! She! trained! as! a! TB! doctor! at! the! Municipal!Health!Services!in!Tilburg!and!the!Netherlands!School!of!Public!Health!in!Utrecht,!and!qualified! as!a!specialist!in!2001.!!
Going!overseas!had!great!attraction!and!in!2004!she!moved!to!Edinburgh,!Scotland.!She!worked!partPtime! as!medical!officer!in!the!homeless!addiction!team!in!Glasgow!and!in!the!remaining!time!Miranda!developed! the!first!TB!control!handbook!for!The!Netherlands.!
Africa! still! pulled! hard! and! when! in! 2006! the! request! ‘why! don’t! you! join! us’! came! from! a! friend! in! Mozambique,! she! learned! Portuguese! and! moved.! First! to! Chimoio! in! central! Mozambique! where! she! worked! with! the! provincial! TB! and! HIV! programmes! on! TB/HIV! collaboration! and! integration.! Later! she! moved! to! Maputo! and! assisted! the! National! TB! Programme! as! a! technical! advisor.! During! this! time! she! conducted!most!of!the!research!of!which!the!results!are!presented!in!this!thesis.!
In!2011!she!returned!to!Tilburg,!The!Netherlands.!She!started!her!own!consulting!agency!working!mainly!in! TB! and! HIV! high! burden! countries.! She! works! as! an! independent! consultant! supporting! TB! and! HIV! programmes,!as!well!as!the!wider!health!care!system!to!further!improve!their!activities.!She!works!with! large! international! organisations! and! small! local! organisations! and! enjoys! both.! She! supports! the! development! of! national! strategic! plans,! funding! proposals! and! policies! and! guidelines,! undertakes! research!projects!and!evaluates!numerous!projects.!She!would!like!to!continue!this!work!for!many!years!to! come.!
