Governance structures in Dodoma and London

The partnership between Central and North West London NHS Foundation Trust and Mirembe Hospital Tanzania has carefully planned its governance structure to include committees with broad membership,

accountability to senior personnel in their institutions, and champions responsible for the different strands of their work.

Mirembe Hospital and Nursing School in Dodoma, Tanzania and the Central and North West London (CNWL) NHS Foundation Trust have been working in partnership since 2010, encouraging two-way learning, supporting capacity building and enhancing professional development on both sides. Mirembe is the national referral mental health hospital in Tanzania. The current programme involves four strands of work relating to substance misuse:

training staff, an income generation project for patients, a peer support programme, and community engagement.

Innocent Mwombeki is a psychiatrist at the hospital, and Haidary Makungwe an Occupational Therapist. They are both “Champions” for the link programme. Chris Bumstead is the Link Manager in the UK.

As the four strands of the programme comprise distinct activities, the governance structure in Mirembe needed to be carefully planned. This was driven initially by the UK partners, and subsequently jointly discussed and agreed at a summit meeting in Tanzania.

This built on previously developed governance structures which are mirrored in the UK and Mirembe, whereby the committee oversees the project as a whole and subgroups are accountable to the main committee.

Each strand of work has a co-ordinator at Mirembe. All four co-ordinators meet together on a monthly basis at the main link project meeting,

along with the Mirembe’s project co-ordinator, the programme accountant, and the hospital superintendent. Each co-ordinator also has a regular strand meeting with their teams, also attended by the project co-ordinator.

The formal structures are welcomed by the UK partners. According to Chris, there is a “sense of fidelity about our relationship. The trust element is really important around governance.”

The committee responsible for the project in the UK (the Tanzania Link Committee) has evolved since the beginning of the partnership. It meets monthly, typically with between six and eight attendees, and has set up a number of subgroups to deal with link activities and priorities. Consistent with the link project meeting at Mirembe, meetings in the UK are minuted for decisions and actions. The governance of the programme was reviewed at an away day.

The Committee grew as the benefits of having more people involved were understood. It is a multi-disciplinary group with managerial and clinical expertise. Attendees now include two consultant psychiatrists, two social workers, two community psychiatric nurses, an assistant director of nursing, a psychiatric registrar doctor, a service user coordinator (who is a former patient), an employment specialist, a political lobbyist (Tanzanian), an NHS education specialist, and the link manager (an occupational therapist and senior manager by background). The two consultant psychiatrists are the joint chairs, a mechanism which ensures that one of them is available for almost every meeting. The wide engagement in the Committee was mainly through word of mouth and inviting colleagues and contacts from both within and outside the Trust.

Within the formal structure a level of flexibility has been adopted. Some members attend on a less regular basis, including volunteers who are not employed by the trust, including some from the Tanzanian diaspora in London.

Chris is clear about one of the benefits of this, over and above the broad representation and varied skills and knowledge it allows:

If we had less people to do the various bits of work it would become rather more onerous. Having a larger committee, with a stable core membership and people who float in and out, is more sustainable in the long run than having just a few people who get burnt out because there’s too much to do.

The project committee in the UK is directly accountable to a Director on the CNWL Board, particularly for financial management and governance. The committee is required to present a progress report to the Board on a quarterly basis and has a Trust Board non-Executive Director sponsor in the UK. Both non-Exec and Executive Directors are invited to attend the committee, and occasionally do. This senior level involvement is reflected in Tanzania by the involvement of the hospital superintendent.

One of the ways the Mirembe Hospital superintendent stays involved is through attendance of the monthly champions meeting. The champions play an important cross-strand role in the programme which, in addition to delivering the work, contributes to its stability by reducing reliance on just a handful of people.

Innocent values the transparency that this approach ensures:

Everyone knows what they’re doing. I know what’s going on in several parts of the work. It also gives us a sense of ownership.

The champions also attend strand meetings relevant to their individual involvement. For example, Haidary attends the two income generation meetings per month, and also the peer support strand meetings.

The champions are crucial in promoting the work. In both Dodoma and London the team are aware of the need to keep involving more people, both to ensure the programme is a success in the immediate term, and so that there will be people to lead and govern it in the future. The summit meeting in Mirembe helped to generate further interest in the programme, and internal communications is an important part of the role of champions such as Innocent and Haidary’s role, championing the work in clinical meetings, at events, and through social media and internal channels. Although there is no specific role of champion in the UK, there are individuals who take on more of a leadership role regarding various issues, such as training, which underpin the project.

Despite having clear governance structures, reliance on individuals remains a risk, as key members of the team can and will leave their posts. The link manager post in the UK is particularly vital to oversight of the programme. The sustainability plan if this post holder leaves is fairly simple: recruit another one. However, since this post is no longer core-funded and the project now has to raise its own funds, this poses a considerable risk. The number of people involved in the governance of the programme would help to ensure continuity in the event of any gap, although the reality is that it is likely the project would need to be scaled down in this instance.

At Mirembe, although the project co-ordinator has the most knowledge of the programme as a whole, the governance structure ensures that more detailed knowledge of each programme strand is held with the individual co-ordinators. This reduces the impact of key personnel leaving and reduces reliance on one person. For example, despite the former Superintendent of Mirembe Hospital, who was central to setting up the Tanzania Link partnership, moving on a year or two after it started, the programme has since continued to grow and flourish.