There are change efforts, and there are change efforts. Edna Adan Ismail, referred to in the Western press as the Muslim Mother Teresa, created a small revolution when she founded the Edna Adan Maternity Hospital in Hargeisa, Somaliland. From securing buy-in and permissions from Siad Barre's government, acquiring land and struggling to keep it, and designing and constructing a new building, to educating a health care workforce, attracting physicians, and attending to the health care needs of a poor population, the case sets the stage for an analysis of change management. As Edna Adan Ismail feels the impact of globalization and the demands of global standards of care from the developed world, she faces some complex problems. How would she continue to add and improve hospital operations, educate the local population of health care providers and patients, and meet the objectives and standards of international actors? The material in this case presents complex problems around efforts to innovate and implement change on a grand scale.

They were part of leading a high-profile global consortium aimed at, in the words of Rwandan Minister of Health Agnes Binagwaho, creating "a critical mass of health professionals" and transforming Rwanda's health care system. HRH paired United States faculty from more than 20 institutions-including Dartmouth, University of Virginia, Duke, and Yeshiva-with Rwandan college faculty counterparts. A discipline-specific "twinning model" sought to provide a two-way learning experience that would help support and develop a sustainable health care system in Rwanda. The HRH Program held not only great promise for the country of Rwanda, but it also held personal promise for Dr. Ntakiyiruta's day-to-day life and work. Since joining the University of Rwanda in 2008, where Dr. Ntakiyiruta taught undergraduate as well as post-graduate courses in addition to maintaining a full clinical schedule at the University Teaching Hospital of Kigali (CHUK), there had never been more than four permanent university-employed faculty in the Department of Surgery. If the HRH program achieved its ambitious human resource growth targets, it was reasonable to conclude that the professional lives of devoted physicians like Dr. Ntakiyiruta would witness desired improvements with the opportunity to serve more patients and to educate the next generation of surgeons in Rwanda. It would also provide more time for published research and academic inquiry. When the HRH program was launched a little more than two years earlier, news of the Rwandan effort was accompanied by great fanfare. "This is the boldest effort I've seen to make good on a central promise of global health," said Dr. Paul Farmer, the Kolokotrones University Professor at Harvard University and Chair of the Harvard Medical School Department of Global Health and Social Medicine. "The fruits of science serve everyone, especially those that bear the highest burden of disease," he also noted.

Because improved surgical care leads to better health outcomes, multiple groups of surgeons have developed metrics and tools for monitoring the availability and quality of surgical care. However, a critical barrier to monitoring quality in surgical care is the need to include a risk-stratification model to account for differences in case mix and patient comorbidities between hospitals. Researchers in developed countries use protocols for risk-stratification in surgical care, but staffing and resource issues have prevented researchers from using these protocols in low-income countries. To improve the quality of surgical care in Mozambique, a partnership was developed between the Universidade Eduardo Mondlane Medical School and the University of California, San Diego School of Medicine, with guidance and support from the Mozambican Ministry of Health. The immediate priority of the research team was to define the epidemiology of surgical conditions and evaluate local capacity to meet that need at three pilot hospitals across the country. This case explores the process of implementing a risk-stratification model for low- income countries and challenges students to critique the model and set direction for future work.

In 2011, Dr. Paul Firth, an anesthesiologist from Massachusetts General Hospital, began to explore methods for capturing and utilizing clinical data for quality improvement at Mbarara Regional Referral Hospital (MRRH) in Mbarara, Uganda. Partnering with Dr. Stephen Ttendo, head of the anesthesia department at MRRH, Firth obtained funding from the Harvard Milton Fund and from the General Electric Foundation in 2012 and established an electronic medical record database, now known as the SQUAD (Surgical Quality Assurance Database) initiative. Case A discusses the challenges of implementing an electronic medical record system in a public hospital where patient data had not previously been prioritized, and where resources for providing even basic care are limited. Case A explores the process of determining what to measure and how to measure and validate data.

In 2000, Dr. Benjamin Warf, a pediatric neurosurgeon, became the medical director and chief of surgery at CURE Children's Hospital in eastern Uganda. He quickly noticed a high incidence of hydrocephalus among his patients. Frustrated by the lack of options for these patients and by the limitations of shunts in a low-resource setting, Warf pioneered an alternative low-cost, one-time treatment for hydrocephalus using endoscopic techniques. This new approach, ETV/CPC, combined two procedures: endoscopic third ventriculostomy (ETV) and choroid plexus cauterization (CPC). Through rigorous clinical trials, Warf showed that ETV/CPC was at least as safe and effective as ventricular shunts but required much less medical infrastructure and post-surgical maintenance. In addition to his clinical work, Warf started the International Program to Advance Treatment of Hydrocephalus (IPath). He also designed a training program for neurosurgeons from developing countries around the world to learn this new hydrocephalus treatment. After his return to the United States, Warf began investigating the role ETV/CPC might play as a hydrocephalus treatment in both developed and developing countries.