The Central American Healthcare Initiative (CAHI) fellowship
Investment in leadership programs for physicians and other health professionals in low- and middle-income countries is limited. However, some organizations have developed training and networking programs to strengthen these capabilities among health professionals. Some examples include: a) the Young Physician Leaders (YPL) launched by InterAcademy Partnership for Health for health professionals worldwide [
22], b) the international network for Human Resources for Health (HRH) managers in nine Francophone African countries developed by Vision Tokyo 2010 [
23] and c) the Flagship Program, a partnership between the World Bank and the Harvard TH Chan School of Public Health [
24]. These programs focused on capacity building, knowledge transfer, networking and peer learning, among other things, but did not carry a specific Central American focus.
The CAHI Fellowship is an executive education diploma program for multidisciplinary health professionals in Central America. The program seeks to equip participants with the technical skills needed to manage innovative projects successfully as well as provide fellows with the necessary practice experiences in leading teams and change processes so that they become active social change agents in their communities. In 2012, the faculty of the Center for Latin American Competitiveness and Sustainable Development (CLACDS, by its Spanish acronym) at INCAE Business School began working with the staff and executive board of CAHI to design a fellowship program for Central American health leaders from the public, private, and non-profit sectors with a broad range of professional expertise. CAHI, a non-profit organization based in the United States, was formed to support health professionals in Central America, as they strengthen their skills in leadership, innovation, and project management.
CAHI and CLACDS launched the CAHI Fellows program in 2013. The program provides health professionals with different levels of education and experience the opportunity to improve their leadership and innovation skills while they apply project management theory directly to a specific project in solving a health-related challenge in the region. The fellowship consists of four one-week in-person modules over nine months, where participants receive 175 h of coursework. Additionally, participants engage in virtual sessions to refine the work plan of their projects, receive one-on-one coaching from faculty, and learn about emerging issues in health innovation. Coursework includes team-building activities, simulations, workshops, case studies, and theory-focused lectures.
Five cohorts of CAHI Fellows graduated between 2013 and 2019. They all became part of the CAHI Fellows’ Network—a multidisciplinary network of professionals who share the common goal of reducing health inequities in Central America. Tables
1 and
2 provide descriptive statistics of CAHI’s network, including information on the different projects carried out by fellows organized in four categories. By February 2019, the network had 100 fellows distributed in Central America, with representatives from the government, private sector and civil society. CAHI promotes knowledge exchange among alumni from different generations as well as countries and helps strengthen their ties.
Table 1Descriptive statistics of fellows
Total | 16 | 21 | 20 | 24 | 19 | 100 |
Country |
Guatemala | 1 | 3 | 5 | 6 | 5 | 20 |
Honduras | 1 | 2 | 3 | 3 | 3 | 12 |
El Salvador | 2 | 3 | 2 | 3 | 1 | 11 |
Nicaragua | 5 | 3 | 2 | 4 | 2 | 16 |
Costa Rica | 6 | 7 | 7 | 5 | 4 | 29 |
Panama | 1 | 3 | 1 | 1 | 4 | 10 |
Mexico | 0 | 0 | 0 | 2 | 0 | 2 |
Gender |
Male | 11 | 11 | 10 | 11 | 8 | 51 |
Female | 5 | 10 | 10 | 13 | 11 | 49 |
Age group |
21-30 years | 6 | 1 | 3 | 4 | 7 | 21 |
31-40 years | 4 | 10 | 6 | 11 | 3 | 34 |
41-50 years | 6 | 5 | 7 | 5 | 7 | 30 |
51-60 years | 0 | 3 | 4 | 2 | 1 | 10 |
More than 60 years | 0 | 2 | 0 | 0 | 0 | 2 |
Non specified | 0 | 0 | 0 | 2 | 1 | 3 |
Health Professional background |
No | 4 | 10 | 6 | 6 | 6 | 32 |
Yes | 12 | 11 | 14 | 18 | 13 | 68 |
Table 2CAHI Fellows’ project type
Hospital management executive training | 4 | 8 | 9 | 12 | 4 | 37 | Text messages for the prevention of hypertension Intersectional plan for the prevention of violence, unwanted pregnancies, and chronic diseases in the adolescent population |
Strategies for health promotion and prevention | 3 | 6 | 6 | 5 | 4 | 24 | Delivery of high-quality, low-cost generic drugs in rural areas Mobile platform technology to provide remote consultations and medical care |
Access to medical services | 5 | 4 | 3 | 3 | 8 | 23 | Plan to improve processes to reduce surgery waiting list in a public hospital Information systems medical imaging to improve response time to diagnose patients |
Training for health professionals | 4 | 3 | 2 | 4 | 3 | 16 | Specialization program focused on patient safety for nurses Guidelines for training health professionals in the care of indigenous populations |
CAHI Fellows have developed relationships among themselves, both on their own initiative, as well as intentionally promoted by CAHI. The Central American region provides certain conditions that can support the development of networks. For instance, given that the region encompasses six countries in a small territory, public and private organizations have often felt the need to reach out to others to increase the volume of its operation. Sharing the same main language (Spanish), similar historical background (indigenous cultures and colonial period) and a precedent of efforts seeking geographic, economic and political integration (Central American Integration System), also support these regional efforts. In the health sector, countries have articulated initiatives such as the Central American Council of Health Ministers that coordinate efforts at the regional level (e.g., jointly bargaining and purchasing health supplies to access a more favorable price due to higher volume). Likewise, multilateral and cooperation agencies (e.g. Pan-American Health Organization, Spanish Cooperation Agency), have often had a regional approach to support interventions in multiple countries. The development of regional working groups—particularly when there was a high flow of aid into the region—precedes the CAHI fellowship. Unfortunately, once the integration efforts vanished and international aid left, so did many of these regional initiatives. Once more, a non-profit organization like CAHI brings a regional vision into its intervention: the fellowship program.
The ties developed among CAHI fellows go beyond belonging to the same cohort and being classmates. Sharing information outside of the class, supporting other CAHI fellows through mentorships, and developing projects together are some of the most common ways the fellows interact. As such, we mapped these networks to understand better how CAHI management can support and strengthen the development of its alumni network. CAHI believes that fellows connected through strong ties will be more effective than individual fellows when it comes to making significant improvements in the health of the region, expand health care access and delivery.
Despite the similarities that the CAHI fellowship shares with other programs for human resources in health, some features make it different. First, its interdisciplinarity as it selects representatives from different sectors and backgrounds (e.g., public, private and civil society), as well as from different professional backgrounds (e.g., information systems and industrial engineers, lawyers, pharmacists, business administrators). Second, CAHI fellows are recruited with a project proposal that they have to advance during the program. Thus, they can apply/practice in their own project the acquired capabilities. Finally, the program is done in partnership with a business school. Business schools can contribute to the training of health leaders on innovation management and entrepreneurship, among other skills that would help them focus on implementation rather than on research [
25].
We used social network analysis [
26,
27] to conduct our study. Dershem, Dagargulia, Saganelidze, & Roels [
28] propose a set of steps to develop a network analysis. First, a study design phase that includes determining and compiling a complete list of the population, defining the critical types of relationships among them, and a timeframe for the analysis. Second, a data collection phase in which the research team develops the questionnaire and initiates the data collection process. Then, the data collected must be structured in a way that can be analyzed using social network analysis and data visualization software.
We identified the relationships between the total population of CAHI Fellows (
n = 100). For this population, we mapped three types of relationships: information-sharing between fellows, mentorship, and the development of joint projects among fellows. The difference between mentorship and joint projects is that the former is assigned by CAHI management, while the latter is an initiative that two or more fellows start voluntarily because they see a potential benefit from collaborating. Table
3 shows the definition of the different types of ties and examples within each category.
Table 3Definition and examples of network ties
Information sharing | Exchange information by email, telephone, text messages, face-to-face get-togethers, public events, online meetings, webinars, or field visits. Note: CAHI organizes multiple events to support these sharing opportunities. | Director (MD) of one of the principal public hospitals in Panama (Gen_5) visited the Project Coordinator (nurse) of an Ambulatory Care Hospital in a public hospital in Costa Rica (Gen_4). The intention was to learn from her experience to replicate the project in Panama, including information about the implementation challenges; financial, infrastructure and human resources requirements; and lessons learned during launching and first months of the hospital. | An industrial engineer from Honduras (Gen_3), an MD from El Salvador (Gen_1), were the speakers of a panel discussion (online) where they both presented their projects on health interventions for teenagers to the CAHI fellows. As part of the preparation, they shared information about their projects, including strategies on how to approach teenagers at social risk, and the challenges of partnering with organization from different sectors (government, NGO, and for-profit organizations) |
Mentorship | An assignment to support a CAHI fellow by providing guidance and recommendations based on personal knowledge and experience. Note: CAHI invites particular alumni to become mentors based their expertise on a specific topic, potential value-added for a fellow’s project, and mentees’ expressed needs | Costa Rican information systems engineer (Gen_1) mentored technology focus projects in during multiple cohorts. | Costa Rican industrial engineer working in public hospitals (Gen_2) mentored a Panamanian MD working at the social security (Gen_5) leading an initiative to decrease waiting lists in public hospitals |
Joint projects | Coordination of efforts and resources for the implementation of joint projects or initiatives. | A Costa Rican psychologist working as Executive Director of a nonprofit organization promoting healthy behaviors in teenagers via an online platform (Gen_2) and a Costa Rican MD working as a Social Security Director of a health region (Gen_1) are partnering to promote the use of the platform to prevent risky behavior in this geographic area—where violence and poverty are higher than in the rest of the country. | Costa Rican information systems engineer working as the Social Security Medical Record Director (Gen_4) and the Program Coordinator of a public palliative care hospital implemented a project for remote patient care using high technology devices and telemedicine systems. |
We also identified three characteristics of the network members: country of origin, professional background, and type of project developed. We modeled the network as a one-mode directed social network, meaning all nodes are individuals with the same characteristic (i.e., they are all CAHI fellows). We included only direct ties between the nodes. For instance, when one fellow exchanged information with another member directly, we captured it on the map. We did not include cases when one fellow exchanges information with all classmates via email.
We collected data about the direct relationships among CAHI fellows in several ways. First, the CAHI management team met and discussed all the relationships that they knew have happened among fellows. Given that the CAHI management team spent a significant amount of time with the fellows during the program and followed up on their project development during this time, it was not difficult to keep track of these connections, as the cohorts were relatively small. Moreover, many fellows would call and report back to CAHI management on their project progress years after they graduated, which was also captured in our program evaluation. Second, we revised archival data on mentorship assignments through different cohorts. Third, we distributed a survey among the fellows where they had to validate the relationships identified by the CAHI management team and asked them to report on any other relationship with fellows from all generations. The survey was distributed online. A draw of a free trip to attend a CAHI event in Panama was offered among the alumni who responded to the survey within a given amount of time. The response rate was 58%.
We coded the data on three kinds of relationships among fellows—information sharing between fellows, mentorship, and joint projects among fellows.
We took two complementary approaches for analyzing these network ties as identified: visual and statistical. The visual approach provided a comprehensive and explorative perspective on the network. The statistical approach provided intuitive metrics that captured the salient features of the network [
29]. These two methods helped us understand the characteristics of the network and actors (e.g., density, inclusiveness, average degree) [
28].
The visual analysis was conducted using the
Gephi software [
30]. For each map of each type of relationship and the different characteristics of the network members, we used
Force Atlas [
31] to compact the figure, considering that nodes become closer if they are connected [
29]. The size of the node (i.e., size of the circles) captures the number of connections per individual. For the statistical analysis, we used a software called
Ucinet 6 [
32], to estimate several measures (density, inclusiveness, average degree) to better understand the characteristics of the network and each type of relationship between the individuals [
28,
29].