The Neyang Health Initiative

More than half of the world’s population cannot obtain essential health services (WHO, 2017).  Primary healthcare is notoriously hard to access in developing nations and it is even more difficult for those living in rural areas.  For decades there have been multiple attempts to solve this problem.  Traditional international healthcare aid models have proven to be less effective than once predicted: often temporary, inefficient, and disempowering to the very people they were intended to assist.  This model fails because it treats the symptoms of this health crises, not its cause:  a lack of healthcare infrastructure.  The main areas in need of improvement for those living in the last mile involve rural healthcare human resource development and local primary care delivery.

Worldwide, over a billion people will never see a health worker during their lifetime (WHO, 2017).  Today, more than 60% of the African population live in rural areas far removed from healthcare providers (Amzat & Razum, 2018).  People living in remote places in Africa face considerable challenges receiving even basic health care. Obstacles confronting those living in remote areas include: 

• Difficulties traveling to the nearest health facility
• Lack of trained healthcare professionals
• High cost of treatment and transportation
• Stigma associated with disease itself

All these issues make it difficult, if not impossible, for people in rural communities to access lifesaving services.

The combined effects of distance and poverty means that many die needlessly from preventable or treatable diseases.  Infectious diseases, such as tuberculosis, HIV/AIDS, hepatitis B and C, pneumonia, diarrhea, and malaria spread unchecked.  Chronic diseases, such as hypertension, diabetes, malnutrition, and cancer remain untreated with devastating consequences.  Complications during childbirth destroy lives, families, and communities.

Cameroon

Cameroon is located in Sub-Saharan Africa, a region that carries about one third of the world’s disease burden (Njinji, 2012). More than 25 million people live in Cameroon and, although it is the 24th largest country by land mass, it is one of the least densely populated countries in the world (World Population Review, 2019).  “Out of the entire population, 24% live in poverty, and 55% of those in poverty live in rural communities. [There] are two causes of poverty in Cameroon and reasons for the gap between rural and urban poverty are a lack of infrastructure and an education system that fails to develop alongside shifting labor needs” (Borgen, 2018).  

Cameroon, a former colony of Britain, Germany, and France, is among the 50 poorest countries of the world.  The system of government is essentially half French speaking (Francophone) and English speaking (Anglophone) with separate systems of education and juris prudence depending on the predominant language of the area.  The Anglophone conflict is an outgrowth of perceived social injustice. 

Some of the cultural challenges stem from systemic gender discrimination, domestic violence, poverty, stigma associated with disease, tribalism, government corruption and resource diversion.  A further complicating issue arises from steady streams of refugees from neighboring countries.  There are growing numbers of displaced people living throughout rural Cameroon.

The most pressing problem in front of us lies in Cameroon’s rural medical deserts. Remote Cameroon has essentially no access to long-term and localized primary care.  This is a bifurcated problem. 

First, Cameroon has a medical professional shortage.  ‌Cameroon’s national doctor-patient ratio is 1:50,000 (Sina, 2020). While the WHO recommends a nurse/midwife-patient ratio of 1:120, Cameroon’s ratio is 1:1,300.  This leads to a crisis for the 43% of Cameroonians living in remote communities, where the ratios are even higher.  In rural areas, life expectancy remains well below the global average at 54 yrs.  Access to basic medical care is often 20-40 kilometers (12-25 miles) away.

Second, most medical professionals vacate rural areas for better prospects abroad or in the nation’s cities.  According to the Cameroon Economic Update, “It is in the self-interest of health care personnel to work in an urban setting, where their clients have higher salaries and their own chances for professional advancement are greater than in rural areas.  Whatever their social condition, Cameroonians pay a high price for care that is often deficient and perpetuates the cycle of poverty.”

According to the Journal of Global Health Reports, “bearing in mind the current doctor patient ratios and the difficulties to get doctors into rural areas, until we get there, nurses will be and are providing most of the Primary Health Care services” (Michaels, et al., 2018).

Traditional solutions to the rural healthcare gap are often fraught with problems; they are too short-term, engage only in “reactive” care, and lack connection and trust with the local community.  

In rural low-resourced areas of the world, the current healthcare system is essentially centralized, requiring a sick or injured person to travel to a medical clinic, usually in an urban area.  Within an urban context this is a reasonable expectation and optimizes economies of scale.  But for those living in remote areas, distance is often an insurmountable impediment to receiving any care, especially during emergencies and labor and delivery. 

The other typical approach to address healthcare needs in remote areas has to do with "outreach", whereby a medical team with supplies go to a village and provides care for a discrete period.  These are centralized "outward traveling" events often referred to as “medical missions.”  Sometimes these teams visit every few months, or annually, or only once.  Although well-intentioned, outreach events are essentially inefficient with low returns and high expenditure of human and material resources inconsistently meeting the needs of a very small number of people.  These missions offer no opportunity for follow up, and no understanding of an individual’s medical history.

Currently, the rural nursing talent pool in Cameroon is untapped because even when these nurses can afford the tuition, they cannot afford to live in an urban area.  Therefore, many never become nurses.  Other than having nursing students move to urban education centers, there are no opportunities for healthcare human resources potential to be developed.  Once nurses move to an urban area, they will likely remain away.  

The centralized model lacks the knowledge, capacity, or time to grasp the nuanced complexities of unique communities, let alone address these issues within the plan of care competently.

We know right now that healthcare access in rural Cameroon is virtually non-existent.  We know that people are dying needlessly from easily preventable illness, that maternal and infant mortality rates are rising, and that the next infectious disease emergency is just around the corner.  We know that there is very little data to demonstrate the efficacy of providing healthcare to people who have none – because right now there is no one to design the study and gather the data there.  

Amzat, J. & Razum, O. (2018). Towards a Sociology of Health Discourse in Africa, Rural Health in Africa, pp 109-124.  Retrieved from  https://link.springer.com/chapter/10.1007/978-3-319-61672-8_8   and available on google books: https://scholar.google.com/scholar?q=towards+a+sociology+of+health+discourse+in+africa&hl=en&as_sdt=0&as_vis=1&oi=scholart

Borgen Project. (2018).  Understanding the Causes of Poverty in Cameroon.  Retrieved from https://borgenproject.org/causes-of-poverty-in-cameroon/

Michael, J., et al,(2018).  Lest we forget, primary health care in Sub-Saharan Africa is nurse led. Is this reflected in the current health systems strengthening undertakings and initiatives?  Retrieved from https://www.joghr.org/article/11943-lest-we-forget-primary-health-care-in-sub-saharan-africa-is-nurse-led-is-this-reflected-in-the-current-health-systems-strengthening-undertakings-and

Njinji, R. (2012). The Need is so Great. D+C E+Z.  Retrieved from https://www.dandc.eu/en/article/cameroon-too-many-nurses-and-doctors-lack-perspective

Sina, K., (2020).  Public Health : Over 35000 health care workers needed.  Retrieved from https://www.crtv.cm/2020/07/public-health-over-35000-health-care-workers-needed/#:~:text=Cameroon's%20doctor%2Dpatient%20ratio%20is,doctor%20per%2050%2C%20000%20persons%20.

WHO, (2013).  Better Access to Health Care for all Cameroonians.  Retrieved from https://www.worldbank.org/en/country/cameroon/publication/better-health-care-access-for-all-cameroonians

World Health Organization. (2017).  World Bank and WHO: Half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses.  Retrieved from https://www.who.int/news-room/detail/13-12-2017-world-bank-and-who-half-the-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses

World Population Review (2019). Cameroon Population 2019.  Retrieved from http://worldpopulationreview.com/countries/cameroon-population/  

Essentially, St. Leonard’s solution sustainably addresses the  lack of healthcare infrastructure in rural Cameroonian communities by:

• Recruiting and educating nursing students where they live (in remote communities) and then
• Incorporating new nurses as part of network of community-based primary healthcare providers in their home villages.

The Neyang Health Initiative simultaneously expands rural nursing human resources and remote primary care delivery led by nurses.  The two elements of the Neyang Health Initiative are Neyang Health Academy (NHA) and Neyang Rural Primary Health Partners (NRPHP). Neyang Health Initiative provides the infrastructure necessary to move rural nursing class cohorts into remote professional collegial networks.

This new educational model and system for care is St. Leonard’s is poised to begin the Neyang Health Initiative. St. Leonard's will leverage current information technology capacity, the robust wi-fi networks currently available in even the most isolated areas of rural Cameroon, educational e-learning platforms,  electronic medical records, and develop a professional communication network.  This model lays the foundation to make ‌lasting‌ ‌change‌ by ‌meaningfully‌ ‌improving‌ ‌people’s‌ ‌health and communities’ prospects,‌ ‌no‌ ‌matter how‌ remote they may be.  By recruiting‌ ‌and‌ ‌training‌ ‌local‌ ‌nurses, eliminating educational barriers, utilizing hybrid learning with a global web-based ‌platform, and empowering rural nurses as primary care providers while simultaneously connecting them across geographic distance and professional specialties, St. Leonard’s Neyang Health Initiative establishes healthcare ‌access‌ ‌for‌ ‌people‌ ‌who‌ ‌had none.  For each new nurse, a healthcare desert becomes an oasis.

The Neyang Health Academy (NHA) is a ‌new,‌ ‌hybrid model of learner-centered nursing education, bringing the classroom to rural students for the first time.  The majority of the nursing coursework is online, while developing clinical skills and evaluating competencies are conducted at least once per semester either at the urban St. Leonard’s compound in Limbe or with visiting clinical nurse educators in the students’ home communities.  This format eliminates the most common obstacles preventing rural potential students from pursuing nursing, such as the increased cost of living in urban centers and responsibilities at home.  We are dedicated to offering affordable and accessible nursing education to meet the needs of these students.

The Neyang Rural Primary Health Partners (NRPHP) consists of rural nursing school graduates linked to urban and transdisciplinary resources.  Neyang Health Initiative staff provide NRPHP nurses the necessary infrastructure, mentorship, and transdisciplinary collaboration to bring their localities primary care - assisting in moving novice nurses into experts.  Because these nurses operate within their home communities, they serve as a trusted link between disparate groups and avoid cultural, linguistic, and tribal obstacles experienced by other initiatives.  These primary care nurses will provide long-term care in their communities throughout their careers.

The implications of the Neyang Health Initiative go beyond improving local health.  Its structure addresses social determinants of health, such as poverty, physical accessibility, language, tribal and gender inequalities in a just and equitable manner.  By providing previously inaccessible educational and employment opportunities to potential nurses, we help close the professional health human resource gap and financially empower remote nurses.  Improved healthcare access enhances local health and leads to improved economic conditions in villages. 

By using technology, expanding the number of nurses, and bringing care directly to people in their communities, we avoid most of the obstacles experienced by other programs that have attempted to expand rural access in hard-to-reach places.  We will develop and leverage an untapped pool of potential nurses.  This allows local talent to remain, afford an education at the local cost of living, and incentivizes nurses to stay in local communities rather than move away for better urban wages.  It increases the economic empowerment of women.  It is very flexible, allowing us to be “additive” rather than competitive with existing programs. For example, nurses can provide the structure, consistent global nursing standards, and leadership necessary to expand and support a vibrant and sustainable Community Health Worker (CHW) paraprofessional model, rather than compete with it.  This allows the model to scale quickly in a sustainable manner.

Educating student nurses where they live, in remote villages in Cameroon, shifts the current centralized healthcare system to one of sustainable decentralized primary care into currently unserved areas.  We believe our new two-pronged model is an advance over the alternatives for several reasons, because it:

• Cost effectively expands service to populations currently without care,
• Develops new nurses in low resourced areas,
• Leverages global nursing standards,
• Embeds professional nurses within the communities they serve,
• Delivers nurse-led primary care collaboratively with transdisciplinary care teams,
• Addresses urgent and emergent issues with timeliness,
• Positions local nurses to lead, train, direct, and monitor paraprofessionals,
• Expands healthcare capacity and delivery evolving from within the community itself,
• Fosters culturally competent and person-centered care and,
• Improves local health which leads to improved local economies,

Perhaps most importantly, this is the only organic, progressively expanding, and sustainable model elevating nurses and distributing community-based care beginning in Cameroon.  With each new class of ~50 graduating nurses, ~50 previously unserved villages will become an oasis of professional primary community-based care.  Our vision is to move from success to success and grow each year, thereby expanding to ever-widening rural communities throughout Cameroon, neighboring countries, and beyond.

Our approach is both novel and transformational because it is based on inclusive nurse leadership, training, and delivery to bring quality primary healthcare closer to all no matter how far away a person might be, and indeed, will contribute to the global fight against emergent and re-emergent infectious diseases.  The urban-rural gap in care persists despite decades-long global amelioration efforts and continues to impede epidemic responses.  We are committed to closing this gap.

When care is provided within a nurse-led community-oriented primary care model, local health and community partners have a true seat at the table to address their own local needs.  Whereas the centralized and outreach approaches foster an externally dependent system of care that fail to enhance the capacity of local communities to address their own needs from within.

We will leverage this potential as nursing students are recruited from these remote areas, educated while living in their homes, and then as graduates create a self-sustaining and expanding primary healthcare infrastructure within their own villages linked to a broader transdisciplinary support network. 

This people-centered model provides the foundation for culturally adept primary healthcare evolving from within the community itself to enhance quality of life.  Under the auspices of St. Leonard's, the blended nursing school educates students and feeds primary care nurses into remote communities.  This builds nursing competency and capacity leading to enhanced community self-efficacy while optimizing health outcomes within a cost-effective framework.

We are convinced that this model is not only innovative and achievable; but will be successful beyond what we can currently conceive.  In short, we see the Neyang Health Initiative as contributing to global health, creating educational opportunities and jobs, reducing poverty, increasing economic stability and productivity, improving gender equality, and fostering peaceful development.

We know right now that healthcare access in rural Cameroon is virtually non-existent.  We know that people are dying needlessly from easily preventable illness, that maternal and infant mortality rates are rising, and that the next infectious disease emergency is just around the corner.  We know that there is very little data to demonstrate the efficacy of providing healthcare to people who have none – because right now there is no one to design the study and gather the data there.  

Everyone deserves healthcare no matter how far they live from a medical center.  At least a billion people worldwide cannot access even the most basic care and die from preventable/treatable disease.  Most of the 11M people in rural Cameroon live in a medical desert. On average, St. Leonard's sees 220 patients a month in the urban medical clinic in Limbe.  Most deaths are seen in children less than 5 years old due to severe anemia from poorly treated malaria.  Each month five children come to the clinic at end stage disease and die within 20 minutes of arrival, and three children will already be dead upon arrival at the clinic – and this occurs within an urban medical clinic context.  The unwitnessed misery occurring in remote Cameroon and sub-Saharan Africa is beyond comprehension.  We are driven by a moral imperative to rectify such ongoing, unspeakable tragedy. 

Dr. Leontine Kouemou Sinda, MS, PhD, PA, is the Founder/CEO of Saint Leonard Health and Research Foundation – Limbe, Cameroon

• Dr. Sinda is on the faculty of Bengono Toure University, holds a PhD in Infectious Diseases from the Faculty of Medicine and Biomedical Sciences, is a licensed Physician Assistant, has a Master’s in International Cooperation and Humanitarian Action, and recently received a second PhD in Microbiology.
• Dr. Sinda has built and expanded St. Leonard's.  This new distributed healthcare model, Neyang Health Initiative, continuously evolves to meet the needs of her community and beyond.  She has demonstrated innovation and expanding capacity in successively meeting the challenges in Limbe, Cameroon, by creating a medical clinic, then an infectious disease research laboratory (and a second site in the capitol city Yaounde), and then an urban nursing school.  And throughout it all, Dr. Sinda continued to run rural medical outreach clinics. 
• Recognizing that each individual has knowledge, skills, talents, and capacity that can enrich us all, Dr. Sinda’s team has built a feedback loop between urban, rural, and tribal community members, across specialties to create partners into all her work in order to enhance inclusion, diversity of perspective, quality communication and continuous improvement.
• Her humanitarian activities include:
  • Advocacy for peace and human rights. 
  • Empowering rural women and girls and addressing gender inequality and violence
  • Fostering a healthy and safe environment for sustainable development,
  • Sensitizing rural communities to prevent the spread of COVID-19 during outreach events
  • Promoting education and primary healthcare for all,
• Her clinical activities include conducting nosocomial MRSA and antimicrobial resistance research.  Dr. Sinda joined the vaccine research team at the University of Buea and published an article “Assessment of Vaccine Hesitancy to a COVID-19 Vaccine in Cameroonian Adults and Its Global Implication” (February 2021).

• 

• As a woman living in Cameroon, Dr. Sinda has been facing entrenched systemic gender discrimination as do most women and girls in Africa, and yet she has navigated through this with determination, grace, and dignity.  She believes that Africa is facing issues of poverty and as such there is an urgent need for positive changes.  The advocacy for primary health care for all, peace, human rights, and social change does not go without challenges.  She sees these challenges as opportunities and uses them as aspirations that drive her to take humanitarian actions for sustainable development in Cameroon and Africa.
• Dr. Sinda continues to meet with St. Leonard's Advisory Board and a team of medical advisors and business leaders.  They stand ready to support her in this fundamental expansion to St. Leonard's.

 Advisory Board Members include:

• Sokem Ngale Mborh – Director – Magistrate 
• Leontine Kouemou Sinda – Member – Infectious disease specialist / humanitarian
• Medong Adel Noel – Member – Economist
• Mbimenyuy Bomki Cynthia – Member – Clinical Researcher
• Sara-Ana Rodriguez – Spain – Member – Lecturer/humanitarian
• Dr. Fokoue Fabrice – Member – Medical Doctor
• Dr. Sinda Freud Taylor – Member - PharmD
• Kathleen Russell –  US Representative - Nurse Educator/Strategist

Other assistance received from:

• Julia McNamara – Global Executive – Business Advisor
• Professor Koulla Shiro Sinata
• Twamba Charles
• Elvice Sahadio – YiWu Waco Cargo 
• Dr. Jean M Bouquet DO, FAWM - Cure Cervical Cancer, Inc.
• Ariel Russell – Special communications / anthropologist

UBA Africa Day Conversations:

Dr. Sinda was invited to participate in the convening of global leaders in May 2021 bringing together some of Africa's foremost policymakers to showcase the best of Africa while exploring the continent's reimagined relationship with the world.  She has shared the Neyang Health Initiative proposal with panel participants.

Dr. Sinda has presented privately and publicly to the following individuals, all of whom expressed support for the Neyang Health Initiative:

• Minister of Public Health (Yaounde, Cameroon) – Manaouda Malachie
• The President of Scientific Council for Public Health Emergency, Formal Secretary General of Public Health (Yaounde, Cameroon) – Professor Koulla Shiro Sinata
• The King of Wabane Community (Bemnbu Village) / Sentaor – Lekunze Nembo
• The Mayor of Limbe II City Council – Ndive Koka Ngale
• US Ambassador (Yaounde, Cameroon) – Vernelle Trim FitzPatrick
• United Nations Development Program Director (Yaounde, Cameroon) – Jean-Luc Stalon

Partners with St. Leonard's in Cameroon include:

• The Barre Tchamba Foundation (have provided outreach grants to St. Leonard's)
• The American University of St. Vincent School of Medicine
• Volunteers 4 Africa
• Cure Cervical Cancer – Dr. Jean M Bouquet DO, FAWM
• YiWu Waco Cargo -  Elvice Sahadio 

Last Mile Health (LMH) -

• 2019 - Dr. Sinda and Ms. Russell participated in the LMH Community Health Academy’s first Leadership Training for Strengthening Community Worker Programs.
• We have consulted with LMH to further our collective impact and possibly develop a more formalized collaboration or Memorandum of Understanding. 

Atleat One University –

• We are exploring a partnership to offer a Bachelor of Nursing Science four-year option for students having graduated with a three-year nursing degree.

Kathleen Russell, MSN Ed, RN – US Representative, Nursing Education and Strategy Advisor to Saint Leonard Health and Research Foundation

Kathleen Russell has been an active advisor and collaborator with Dr. Sinda for the last three years to develop and expand the reach of healthcare to the most remote and vulnerable populations in Cameroon in the most sustainable manner possible.  She assisted in re-framing the centralized care delivery model to one that shifts to an organic distributed model -  the Neyang Health Initiative. 

As a nurse, Ms. Russell has been involved in strategic planning, development, and educating across healthcare and administrative teams for 15 years.  Recognizing her organization faced high case manager staffing turnover along with low quality and compliance rates, she proposed new best practices with educational initiatives as part of the continuous improvement process.  By utilizing MS Excel and web-based platforms to enhance professional support, clinician capacity, and quality compliance the initiative estimated $1.2M ROI and a doubling of nurse retention rates.  At a start-up home health agency, she created organizational policies, protocols, quality procedures, and nursing competencies with special vulnerable populations training modules.  Within a community-based context, she furthered these cost-effective improvement processes through in-person, e-learning, blended education, and simulation approaches.

Back story:  How we got to where we are

Our innovative model was developed using “Backward Design” methodology rather than traditional approaches to problem solving. We kept our end goal in mind as we worked backwards to identify the steps necessary to get there.  Rather than getting stuck in the weeds, we wanted to look up at the horizon and take the long view of what we wanted to be. 

First, we began framing and identifying the results we wanted to achieve.  Although our vision was bold and vast, we were undeterred by the scope of this “big idea.”  And that is…. “Health, peace and justice for Africa.”

Next, we went about gathering evidence to support the desired results – our goals – and sought input from established and emerging partners who could potentially be affected by any initiative we undertook.  Throughout this entire phase, we continuously explored the unique role and perspective of nursing leadership in driving transformational change.   We analyzed what had and had not worked and why.  We investigated new and evolving approaches.   In Africa primary healthcare is already led by nurses and will continue to be so into the foreseeable future.  This informed our decision to view the development of our model through a nursing lens.  By rigorously adhering to the American Nurses Association (ANA) Core Values of Nursing, the Ethical Principles of Nursing, and the Code of Ethics for Nurses (ANA, 2015), we knew we would be aligning ourselves with best practices.  From this information we were able to identify both the pathway we needed to follow and what we would need to avoid in order to stay true to the long view.  What emerged were our guiding principles:

Patient-Centered

• We are committed to each rural person - from the individual to the entire population
• From a macroscopic perspective, potential rural nurses are also our patients
• Our focus is on identifying and developing the capacity for new primary healthcare nurses

Accessible

• Decentralized
• Nursing education develops healthcare resources where students live
• Primary care optimizes the health where people live

Sustainable

• Continuously providing primary care

Empowering

• Enhancing local health
• Improving local economies with improved health
• Developing local nursing (typically female) capacity

Holistic

• Respecting the inherent dignity, worth and unique attributes of every person
• Delivering culturally/spiritually/linguistically appropriate care within each social context

Organic

• Expanding and scalable growth adjusting to increasing capacity
• Continuously reviewing and refining approaches to best meet the needs of communities
• Developing “Centers for Nursing Education” as we evolve

Justice

• Social Determinants of Health related to:
  • Distance and poverty
  • Gender-based issues of discrimination,
  • violence
  • lack of reproductive healthcare

Our end-point focuses and organizes the knowledge acquired during the Backward Design process.   The result is the creation of a new model –

The Neyang Health Initiative: 

Locally trained and empowered nurses embedded within their rural communities delivering primary care beginning in Cameroon.

The supports needed to advance the Neyang Health Initiative are beyond the scope of St. Leonard's nonprofit ability to supply.  Although the clinic in Limbe provides fee for service healthcare and students  pay tuition fees at the nursing school, this revenue source is inadequate to acquire the infrastructure necessary to create the remote nursing school and eMAR/network.  

There are a host of monetary and non-monetary supports which would  be of great assistance to us, especially over time, such as: 

• acquiring a soft and hard technology suitable to rugged rural tropical climate with intermittent electrical supply, such as:
  • Software to support rural wi-fi dependent nursing education through a platform
  • Software to support electronic medical records and transdisciplinary professional collaboration
  • Electrical equipment to support IT devices
  • Lap Top/Tablet Computers and cell phones
  • Printer - Laser
  • ongoing remote telephonic IT supports for field nurses/students
  • solar power supplies
• mentoring, partnering
• establishing an administration process, 
• financial accounting system, 
• navigating the grant process, 

A few of the unique needs specific to this endeavor involve creating a safe and healthy environment for the students in urban Limbe.  Since students will be traveling from remote locations to the school 1-3 times per year, facilities need to be enhance.  Chief amongst these improvements involve:

• Clean water
  • Drilling a bore hole
• Providing temporary shelter to accomodate 50 students during in-person clinical instruction and orientation.  Students will need to be housed in tents within a compound for safety on the property of St. Leonard's in Limbe.
  • Costs associated include:
    • Constructing a "compound wall" around the facility
    • Acquiring tents 
    • Enhancing sanitation (toilet/shower) capacity

There are four main elements unique to the Neyang Health Initiative and lay the foundation for catalytic growth.  These feature involve: 

• Utilizing hybrid/blended Distance Education for rural nursing students as part of the Neyang Health Academy;
• Creating an Integrated Network for Rural Primary Care Partners to foster connection and collaboration across geography and transdisciplinary care teams;
• Integrating an Electronic Medical Record to coordinate patient records, data and analysis; and
• Fostering Social Innovation of local based homegrown healthcare workers themselves and amongst the remote communities themselves

In addition to these elements, another feature specific only to Cameroon has  to do with leveraging currently vacant and remote medical clinics scattered across the country.  By incorporating these clinics into the growth plan of the Neyang Health Initiative, the rural medical clinics can serve as both 

• community-based healthcare centers for Neyang Rural Primary Health Partners and as
• "Centers for Education" for the clinical nursing educational component to be utilized by increasingly distant nursing students.

To meet the WHO recommended nurse to patient ratio of 1:120 for a rural population of 11M, we would need 91,000 nurses in total. 

In the modeling attached below, our initial goal will be 1:480 ratio of nurse to patients.  We utilized the Fibonacci Sequence to frame organic development of nurses and “Centers for Education” allowing the remote primary care program to grow in a sustainable manner.  The system underpinning this progressive expansion is achievable and readily replicable.  Externalities, such as additional resources, may be able to increase the rate of growth. 

It is important to view both the remote education and rural primary care initiatives as elements of a whole - because they are mutually dependent and reinforcing.  Essentially, neither program can develop or operate without the other. 

We are convinced that this model is not only innovative and achievable; but will be successful beyond what we can currently conceive.  In short, we see the Neyang Health Initiative as contributing to global health, creating jobs, reducing poverty, increasing economic stability and productivity, improving gender equality, and fostering peaceful development.

We know right now that healthcare access in rural Cameroon is virtually non-existent.  We know that people are dying needlessly from easily preventable illness, that maternal and infant mortality rates are rising, and that the next infectious disease emergency is just around the corner.  We know that there is very little data to demonstrate the efficacy of providing healthcare to people who have none – because right now there is no one to design the study and gather the data there.  We do know the impact of consistent provision of culturally competent community-based primary care led by nurses will be transformational.

 We anticipate many different layers of success stemming from this innovative healthcare system:

• Each class of NHA will have 50 nursing students,
  • Students who otherwise would not be trained
• As we graduate nurses from NHA they will transition to being NRPHP.
  • Each nurse will be providing primary care in one rural community,
    • Graduates who otherwise would have no professional skills.
  • Communities who previously had no healthcare access will now have access.
  • Year 1 = 25 graduates/rural communities
    • (Estimated half of the first class will graduate with a one-year nursing degree, and the other half will continue for a two-year nursing degree)
  • Year 2 = 50 graduates/rural communities,
  • Year 3 = 50 graduates/rural communities, etc.

IF each nurse has 500 patient visits each year, then …

• In year 2 – we have 12,500 visits, 
• In year 3 – we have 25,000 more patient visits,
• In year 4 – we have 25,000 more visits, etc.
• By year 5 = 87,500 total patient visits,
• By year 10 = 212,000 total patient visits.

• IF each nurse has 500 patient visits each year, then …
• Cumulatively ….

To augment the scope of our reach into increasingly remote areas, we will leverage existing unstaffed medical clinics scattered through rural Cameroon, and plan to have 3 new remote nurse training facilities within the first five years, and progressively expand annually.

Our step-by-step plan includes:

• Remote students will enroll in NHA.
• Remote students will graduate and obtain their nursing license, becoming part of NRPHP. 
  • They will begin working as nurses in their remote home communities.
• Quality of health is anticipated to improve in communities with embedded nurses.  These include:
  • Enhanced wellness through preventative, reproductive, and primary care in collaboration with telehealth teams.
  • Decreased maternal and infant mortality.
  • Increased immunizations.
  • Coordinated leadership during emergent outbreaks and epidemics.
• Nurses will receive income for services rendered and contribute to local economies.
• Nurses will be community role models influencing the perception of female competency and autonomy.

We are confident in our team’s capacity to move the Neyang Health Initiative into reality.  The feasibility analysis of our project had been done.  We have sensitized the population, developed our proposal, discussed strategies for its implementation with traditional and local leaders, governmental authorities, and some NGOs.

 Scalability:

• Once we have graduated the first two classes of nurses, refined our on-line and in-person educational system, and rolled out the rural primary care program, our innovation then becomes replicable.  We will scale the same nursing education and nurse-led primary care delivery model throughout the ten regions of Cameroon and to other African countries as well.
• As more and more students become nurses from further and further away from Limbe, we anticipate that new hubs as "Centers for Nursing Education" will evolve based on demand.
• Scattered throughout rural Cameroon are several completely unstaffed medical clinics built by the government in an effort to meet the challenge of remote healthcare.  These facilities could become staffed and functional in the future and serve as new bases for the delivery of primary care and “Centers for Nursing Education” for increasingly distant communities.
• The beauty of the Neyang Health Initiative is that it is designed to expand organically, and place newly minted nurses within their home communities.  These nurses are most familiar with local language, culture, religion, economics, and traditions.  The care they provide is person-centered within their social context.  This innovative system is infinitely fluid and translatable to virtually every community.
• Generally, nurses are women.  In a male dominated society, female autonomy and economic independence are rare phenomena.  As nurses, providing community-based primary care, they will charge and be compensated for services.

The Neyang Health Initiative (NHI) is part of the multi-year program designed to develop the healthcare human resources and progressively support rural primary healthcare led by nurses. 

• Once the initiative receives the necessary infrastructure supports, we would immediately begin to implement Phase I - Neyang Health Academy (NHA) - preparing for the remote nursing school roll out, beginning with obtaining the infrastructure supports necessary for water, student safety, and IT platform/equipment.  The following semester we will begin with the first batch of students.
• As we begin graduating and embedding nurses, we will move into Phase II - Neyang Rural Primary Health Partners (NRPHP) - embedding professional nurses within villages.  We would we need to obtain an Electronic Medical Record (EMR), Integrated Transdisciplinary Network Platform, vaccines, medications, and supplies. 
• As our capacity increases, we will move into Phase III – (Centers for Nursing Education) – progressively expanding new centers into increasingly remote areas.  Throughout all three phases we would benefit from mentoring from a host of subject matter experts.  The plan below illustrates the anticipated progression of our implementation.

• Phase I:  Neyang Health Academy (NHA) - Remote Nursing Education

  • Preparation
    

Anticipated Preparation Timeline:

• The immediate first steps will begin the semester prior to the start of the first class.  These steps are:
  • Acquiring the physical infrastructure (detailed in attached spreadsheet),
  • IT platform/equipment supports.
  • Drilling a water bore hole for clean water,
  • Erecting a temporary compound wall, so students can reside safely at the school in tents, etc.
  • Training nurse educators in using the global educational platform,
  • Enrolling 50 students, and orienting them in person at St. Leonard's

Annual Cycle of Education:

• There are multiple educational and work options available to students at every step throughout their education/professional pathway.  This approach provides students a higher degree of agency, flexibility, and autonomy according to their own unique circumstances.  The “gap-work-year” may be especially suited to lower income students who initially may be unable to afford the upfront tuition commitment of a three-year program.  There is also another benefit resulting from students selecting this option: we can place more nurses quicker within local communities while fostering a culture of continuous learning and professional development.

At the end of the 1st year of nursing school:

Some students will choose to begin practicing with a one-year degree

• “Nurse Aid” in Cameroon
  • (Similar to US Licensed Practical Nurse - LPN)

Once graduated, some of these one-year degree nurses will choose to:

• begin providing care in their local home communities.
• continue directly onward towards a two-year, three-year, or four-year nursing degree.
• take a “gap-work-year” in their local communities, while taking part-time prerequisite classes so they are prepared to enter the two-year “Nursing Assistant” (NA) or “National Diplomat” (ND) program.

During the 2nd year of nursing school:

• New students will enroll replacing the students recently graduated.
• The remainder of the two-year students will graduate nursing school
  • “Nursing Assistant” (NA) or “National Diplomat” (ND) in Cameroon
  • (Similar to US Associate Degree Registered Nurse - RN)
• Once graduated, some of these two-year degree nurses will choose to:
  • begin providing care in their local home communities.
  • continue directly onward towards a three-year or four-year nursing degree.
  • take a “gap-work-year” in their local communities, while taking part-time prerequisite classes so they are prepared to enter the three-year “State Registered Nurse” (SRN) or “Higher National Diplomat” (HND) program.

During the 3rd year of nursing school:

• New students will enroll replacing the students recently graduated.
• The remainder of the three-year students will graduate nursing school
  • “State Registered Nurse” (SRN) or “Higher National Diplomat” (HND) in Cameroon
    • (Similar to US Diploma RN)
• Once graduated, some of these some of these three-year degree nurses will choose to:
  • begin providing care in their local home communities.
  • continue onward towards a four-year nursing degree.
  • take a “gap-work-year” in their local communities, while taking part-time prerequisite classes so they are prepared to enter the four-year “Bachelor of Science in Nursing” program.

**We anticipate a partnership with an University to offer a 4-year, Bachelor of Nursing Science option for students having completed a 3-year diploma.

During the 4th year of nursing school:

• New students will enroll replacing the students recently graduated.
• The remainder of the four-year students will graduate nursing school

• “Bachelor of Nursing Science” in Cameroon
  • (Similar to US Bachelor of Science in Nursing RN).
• Once graduated, some of these some of these four-year degree nurses will choose to:
  • begin providing care in their local home communities.
  • Perhaps, a few of these graduates may continue onward towards a Master of Nursing Science provided at other universities.

Phase II:  Neyang Rural Primary Health Partners (NRPHP) – Community-based Primary Care

Many of the elements necessary to successfully support embedded nurses in rural communities are being determined, since this aspect of our proposal will slowly begin ~18 months after we start rolling out the infrastructure for the school.

Some of the anticipated support needs for remote professional nurses involve:

• Electronic Medical Record (EMR) web-based platform with Integrated Transdisciplinary Networ, secured and connected to St. Leonard's
  • Note:  Obtaining and utilizing an EMR before students graduate would be very beneficial so students can develop capacity in using this system prior to becoming field nurses.
• Continued need for cell phones, computers, IT supports, and transportation
• Supporting nurses with adequate material resources such as medications, vaccines, and supplies will also be necessary. 
• Beyond telecommunications across transdisciplinary care teams, there will be of course, a continued needs to coordinate, direct and mentor nurses once they are in the field.  The nuances of how that will manifest are currently in development.  Professional and emotional supports will play an important role in transitioning novice nurses into the full scope of their practice and avoiding a sense of isolation. 

Phase III:  Expansion of Neyang Health Initiative (NHI) – NHA and RPHP

In the spirit of moving from success to success, we plan to expand across the 10 geographic regions of Cameroon.  Leveraging the knowledge acquired during the initial pilot - rolling out nursing and primary care programs - we plan to begin carefully and systematically adding additional locations distributed across these regions.  The dispersed locations will be “Centers for Education” providing physical infrastructure necessary to support the administrative and in-person clinical elements of the blended e-learning and rural primary care programs in each the 10 areas. 

There are a host of measurables that would indicate the success of Neyang Health Initiative.  The following are a few:

From the Neyang Health Academy perspective:

• Prospective nursing students applying to the school
• Students entering the nursing program
  • Numbers completing each phase of the offered educational options
  • Numbers graduating and passing nursing requirements
• The geographic, tribal, and gender spread of nursing students
• Expanding from one nursing center for excellence to other sites

From the Neyang Rural Primary Health Partners perspective:

• The number of nurses residing in rural communities
• The geographic, tribal and gender spread of nurses
• The number of patients served per each locality, and throughout the entire NRPHP system
• Patient diagnosis and treatments provided
• Immunization
• Infectious disease spread and amelioration
• Morbidity and mortality
• Maternal and infant health statistics
• Opening of currently vacant rural health clinics with nurse staffing

The core technologies within the Neyang Health Initiative stem from across a spectrum.   

• From the perspective of science, St. Leonard is committed to adhering to Evidence Based Best Practices in health care, and the advancement of knowledge through scientific research.
• Information Communication Technology is a critical tool in both the Neyang Health Academy and Neyang Rural Primary Health Partners.  The distance learning platform for rural students, the remote Electronic Medical Record, and the transdisciplinary care team communication platform provide the 21st Century ability to communicate, gather and organize data irrespective of geographic limitations. 
• Social Networks -  Existing social networks are leveraged through the development of new nurses within local communities.  Expanding social networks will evolve as students, nurses, communities, and teams collaborate across distance and culture

Saint Leonard Health and Research Foundation holds firmly to the belief that all of our undertakings are enhanced when the diverse perspectives and lived of experiences of people from different groups - social, geographic, ethnic, tribal, nationalities, racial, economic status, genders, identities, and abilities  - shape our actions.  We are committed to fostering a welcoming and inclusive environments in the workplace, at school, and in service to patients and communities. We are dedicated to addressing disparities and  eliminating barriers that prevent full participation to all people in having equitable access to opportunities and advancement.

Business Plan Development for Online Learning

Saint Leonard Health and Research Foundation

Neyang Health Initiative: Neyang Health Academy

Audience Profile:

The primary intended initial audience will begin years 1-3.  This audience will be English speaking O-Level qualified students accepted into the Neyang Health Academy nursing program in Cameroon. 

The secondary audience will begin after ~ year 3.  This audience will include French speaking Baccalaureate qualified students located further from Limbe, Cameroon and accepted into the Neyang Health Academy nursing program in Cameroon.

We anticipate intended growth in the number of learners per year taking courses:

Initially 50 students/yr during years 1-3,

Each planned expansion (beginning year 4) will increase the number of students taking courses to by 50 students/yr.

Year 4:  100 students/yr

Year 5:  150 students/yr, etc.

Initially, courses will be synchronous and offered sequentially to a maximum of 50 students per semester.  As we expand, we anticipate a need for self-study (module) format as more students progress through the program.  This self-study format is especially important to those students taking prerequisites during a “gap-work-study” year in order to prepare to enter the next level of nursing education. Currently, identifying the number of students utilizing the module format is not relevant to the design, delivery, approval and implementation of this project to planning.

During the first few years of the program the target students will be living remotely in rural Cameroon within travel distance to Limbe, Cameroon. Thereafter, students will be from much further away in rural areas.

Student level of access to web-based learning will be dependent on the speed and reliability to network access.  The available networks are:

The technology tools that will be necessary to support rural students include:

• Smart phones
• Laptops or tablets
• Mobile Wi-Fi hotspots
• Solar chargers and batteries for inconsistent electricity access

Currently, our students are graduated from secondary school and not attending any other nursing program because no remote education options are available to them.

Our potential students are highly motivated to engage in an online nursing education program offered to learners in remote areas of Cameroon for several beneficial reasons:

• It costs less for remote student to remain at home than moving to an urban center and attending classes
• Students maintain local family and social support system
• Students will obtain nursing credentials
• Nurses from poor communities will have a path towards high demand job that provides a source of income.

Deliverable & Technologies:

The Neyang Health Academy curriculum and courses will follow the national standards of nursing education established by the Cameroonian government for the certification and licensure of nursing students:

• One year “Nurse Aid” in Cameroon
  • (similar to US Licensed Practical Nurse - LPN)
• Two year “Nursing Assistant” (NA) or “National Diplomat” (ND) in Cameroon
  • (similar to US Associate Degree Registered Nurse - RN)
• Three year “State Registered Nurse” (SRN) or “Higher National Diplomat” (HND) in Cameroon
  • (similar to US Diploma RN)
• Four year “Bachelor of Nursing Science” in Cameroon
  • (similar to US Bachelor of Science in Nursing RN).
  • **We anticipate a partnership with an University to offer a 4-year, Bachelor of Nursing Science option

The overall course/curriculum objectives are to provide develop nursing knowledge, capacity and competency for student currently living in remote areas and planning to practices as community-based primary care providers in their own communities.

The targeted length of each course will be one semester.  The series of courses necessary for completion for each of the certification sequences (1-year, 2-year, 3-year or 4-year) will vary according to the license nursing path each student pursues. 

Neyang Health Academy courses and learning objectives will echo the curriculum already in place at the nursing school at Saint Leonard Health and Research Foundation in Limbe, Cameroon.   Due to the unique nature confronting students and community-based primary health nurses in rural low resourced communities, classes and clinicals will likely need to be modified in the future to optimize learning and capacity.

There are multiple educational and work options available to students at every step throughout their education/professional pathway.  This approach provides students a higher degree of flexibility, agency and autonomy according to their own unique circumstances.  The “gap-work-year” may be especially suited to lower income students who initially may be unable to afford the upfront tuition commitment of a three-year program.  There is also another benefit from students selecting this option: we can place more nurses quicker within local communities while fostering a culture of continuous learning and professional development.

Students may choose to obtain a lower-level nursing certification, and then take a “gap-work-year” in their local communities.  During this year, they may be taking part-time asynchronous prerequisite courses so they are prepared to enter the next level of nursing training the following academic year. 

Intellectual Property:

All content and courses developed and delivered for Neyang Health Academy will be owned by Saint Leonard Health and Research Foundation, including intellectual property rights. 

Should the final project be licensed to other institutions/program areas in the future, Saint Leonard Health and Research Foundation will determine the distribution to individuals, academic units, and offices.

If in the future other institutions use the content, courses, or delivery created for Neyang Health Academy, contracts will need to be developed.

Funding and Operational Support:

Design and Develop costs/budget:

The internal source of funding for development of Neyang Health Academy will be from student tuition.   The operational and staffing needs include:  Director/CEO, Finance/CFO, Administrative support, Nursing Educators and Nursing Clinical Educators.

Currently there are no external grants, foundations, government agencies, or other sources of funding available. 

Start-up funding will be necessary to build the infrastructure necessary to begin the project.   Additional sources of revenue will be needed to enhance capacity and expand Centers for Nursing Education. 

Ongoing, maintenance costs/budget:

Based on the financial capacity of poor rural students, tuition is limited to $1,500 per student per year.  During the first 3 years, each class will have ~50 students.  Afterwards, the number of sites for Centers for Nursing Education will increase following Fibanacci Sequence of growth.  With each new Center for Nursing Education, 50 additional students will enroll.

The annual revenue that needs to be generated to offset costs of a fee-based set-up (course registration fees, curriculum cost, train the trainer fees) ~$222,000.

The director/CEO, finance/CFO, advisors, administrative support staff, academic nurse educators and clinical nurse educators will support the needed infrastructure and maintenance for this course/mode.

The online education offerings will only be available to those either currently enrolled in  Neyang Health Academy or taking a “gap-work-year.”  Registration will be required for each course.

Currently we are using the “Teachable” educational IT platform.  We will either need to upgrade to a more robust version of “Teachable” (costs ~ $400 /month and additional tech supports ~200/month) or will we need to purchase a more robust system. 

Once the project is developed and available to participants, funding from tuition and capital investment will be used to sustain the project.  We will be pursuing other sources of funding such as governmental sponsorship, grant application, and partnerships to enhance and expand Neyang Health Academy capacity, expansion and scope.

Staffing & Instructional Support:

In planning ahead for course implementation and staffing needs is a priority.  Once the project has been developed, we anticipate the required staffing will continue to include director/CEO, finance/CFO, administrative assistance, nurse educators, and clinical nurse educators.

Marketing, development, and dissemination will continue to be a collaborative endeavor, headed by the Director/CEO and implemented by the administrative assistant.

Registration system, set-up, troubleshooting will continue to be part of continuous improvement process to optimize capacity and address issues as they arise.

Maintenance of the course site Learning Management System needs to be part of the web-based education platform.

Trouble-shooting tech challenges for participants utilizing the web-based education platform and hardware will arise during the courses.   Robust remote tech support adept at dealing with challenges will need to be immediately available both telephonically, via the internet, and potentially in person during orientations.

Instructor(s)/Facilitators(s):

Nurse educators and clinical nurse educators will continue to instruct or facilitate, or answer content questions in self-studies.

The web-based educational platform tutorials and support staff, nurse education advisors, educational/clinical faculty will collaborate in the development and training of instructors/facilitators.

Evaluation:

The transdisciplinary team will develop the evaluation to meet academic requirements, as well determine the functioning of the blended courses within a e-learning platform.  The team will develop and collect evaluation data and identify the best method(s) of analysis to support continuous quality improvement.  The plan is to maintain, fix and edit content as needed annually, with lead course review process 3-5 years.

Marketing and Publicity:

Neyang Health Academia nursing education will utilize a spectrum of approaches to promote and publicize to target audience of potential nursing students; from radio advertisements, to distributed fliers in rural communities, enhancing website and social media, and leveraging email list serves from rural community leaders.

The Neyang Health Initiative meets the challenge of financial sustainability because it has been developed and tested in Cameroon.  There is a profound need for healthcare services in rural communities and an extensive population willing to pay for services.  Currently there is virtually no competition to providing remote nursing education and/or rural primary care services.  These distributed nurses create an efficient network delivering healthcare services, medications, vaccines, and products.  During the next COVID 19 or Ebola outbreak, this network can be utilized to monitor disease progression and rapidly deploy critical treatment such as vaccines far more efficiently than current rural models.  We do expect our innovation to eventually become economically self-sufficient from this revenue source. 

St. Leonard's is spearheading this multi-faceted program.  Both aspects of the Neyang Health Initiative - the remote nursing education and the rural primary care programs - are considered initiatives of St. Leonard's.  Although St. Leonard's has been fiscally responsible and has continued to be modestly profitable, profits are continuously cycled back into this nonprofit to further grow and develop service delivery.  Because St. Leonard's lacks the start-up capital necessary to acquire the physical infrastructure to roll-out the remote nursing education department, we are seeking that capital now.  We will continue to need additional financial resources for the first few years from the initial launch.  For both the remote nursing education and rural primary care programs we anticipate that the differences between revenue and overhead will be funded through partnerships, individual donations, cooperative sponsorship, fundraising, grants and awards.  Both programs should become self-sufficient within a few years because, as the number of Centers for Education increases, there will be corresponding increase in students and nurses, while many costs will remain the same.

Neyang Health Academy (NHA) - Remote Nursing Program:

• Students will be charged $1,500/year of training.  Annual revenue from tuition will be $75,000 per class of 50 students.  The overhead cost of running the blended e-learning nursing school will be ~$200,000/year.  As the blended e-Learning nursing school expands into different regions, we expect tuition revenue to increase since many of the costs will remain fixed.
• Individual nurses will be charged by the Neyang Health Initiative to cover program support costs - $400/mo = $4,800/year.  For 50 nurses = $240,000/year.  The overhead costs of running the primary nursing program will be ~$220,000/year.  We anticipate a profit of ~$20,000/year per 50 embedded nurses.  As this program expands, we expect the overhead costs to increase too, but at a much lower rate than the initial startup.

Neyang Rural Primary Health Partners (NRPHP) – Remote Nursing Program:

• Individual nurses will be charged by the Neyang Health Initiative to cover program support costs - $400/mo = $4,800/year.  For 50 nurses = $240,000/year.  The overhead costs of running the primary nursing program will be ~$220,000/year.  We anticipate a profit of ~$20,000/year per 50 embedded nurses.  As this program expands, we expect the overhead costs to increase too, but at a much lower rate than the initial startup.

It is important to view both the remote education and rural primary care initiatives as elements of a whole - because they are mutually dependent and reinforcing.  Essentially, neither program can develop or operate without the other.  Funds we receive through grants and aid to further the remote nursing school and rural primary program will go directly to St. Leonard's.  This money will be ear marked for these Neyang Health Initiative programs.  St. Leonard's will invest profits and use capital investment income to help support these programs.

For the past 12 years, Dr. Sinda’s group has been providing healthcare education, primary care, and research services in Limbe, Cameroon, and conducting medical outreach in rural communities several times each year.  We are poised to scale service to a larger part of the population, who cannot be reached due to lack of healthcare human resources and geographic isolation.  Our nursing education content is ready to implement a  global platform can educate nurses anywhere in the world with Wi-Fi access.

The plan for development for blended nursing education is in place.  The physical infrastructure startup costs and acquisition of items continue to be the greatest hurdle.  Some of these costs include a water bore hole, smart phones, hardened laptops, emergency generator, etc.  In addition, IT supports will be essential in providing remote students with the supports necessary to be connected and successful

Once we have the infrastructure in place, the first class of NHA students will begin (estimated 50 new students per year) beginning the following semester.  Remote nursing students can afford tuition but not the additional cost of living in an urban center.  The e-learning platform will provide a cost-effective option for distant students.  As Dr. Sinda has already noted, the demand by qualified O-Level nursing candidates to enter a remote nursing education program is roughly twice that of the class size.  New students will orient at St. Leonard's in Limbe, and then return home with their equipment to take classes on-line.  There will continue to be clinical education in-person outreach to students, as well as students returning (approximately once per term) for intensive development of clinical competencies and evaluation.