In the spring of 2024, Children’s Hospital of Philadelphia neonatal intensive care (NICU) nurse Alexandra Sawick traveled to Gaborone, the capital of Botswana, to work. She wasn’t the first Philadelphia-based nurse to make the journey, but she was one of the first participants in the children’s hospital’s Global Health Nursing Fellowship, which launched the prior year.

Sawick spent 13 weeks as a fellow at Princess Marina Hospital, whose newborn unit serves more than 1,000 children annually. These few months abroad would change the way the African healthcare professionals worked — and the course of Sawick’s career.

Both outcomes were — and are — the point.

During her fellowship, Sawick developed neonatal resuscitation training using low-fidelity simulation (wherein practitioners focus on the very basics, without distractions or complications). Not long after her fellowship ended, she returned to Botswana to further her education. Today, she’s a Global Health Nurse Fellowship educator, part of the program’s leadership team.

Sawick says through the work she’s done abroad, “my framework for showing up has transformed significantly.” The essential lesson: “The most powerful tool that we have is how we interact with each other, how we educate each other, and how much credit we give to the resilience of the mothers who are partnering with us to ultimately get their infant to discharge.”

In other words, for all the good Sawick and her colleagues — she’s one of 16 CHOP nurse-fellows in the program so far and dozens more Penn-based healthcare professionals who’ve worked in Botswana over the last 25 years — have done abroad, they understand they, too, have been beneficiaries, which, in turn, impacts how they care for their patients back in Philadelphia.

Improving neonatal care

In 2001, physicians and nurses from University of Pennsylvania Health System began collaborating with leaders in the medical community in Botswana, a sub-Saharan African country approximately the geographic size of Texas with one-eighth of Texas’s population. The partnership’s original mission was to help address the ongoing HIV/AIDS crisis in that part of the world.

Today, Botswana has become a global leader in suppressing transmissions of HIV from mother-to-infant — despite setbacks that have included a national health emergency in August 2025 caused by shortages of medicine and medical equipment, and despite defunding cuts to healthcare aid by the U.S. government and the Global Fund to Fight AIDS, Tuberculosis and Malaria. (The country still has the world’s third highest rate of HIV/AIDS, however — a status that, experts such as The Lancet predict, is unlikely to improve, considering the declining funding.)

Over 25 years, the Philly-Gabarone medical partnership has expanded to include pediatrics, education, research, and tackling the country’s stubborn neonatal mortality rate. That’s where the CHOP fellowship comes in.

Botswana has made significant progress in child health over the past two decades. Today, more than 98 percent of women deliver their babies in healthcare facilities, and 99 percent of births are attended by a skilled healthcare worker. (These numbers mirror those of the U.S., according to a 2020 report from the National Institutes of Health.)

Yet Botswana’s neonatal mortality has declined much more slowly than other measures of child health, falling from about 29 deaths per 1,000 live births in 1990 to a still-high 18 per 1,000 in recent years. (By comparison, that same rate in the U.S. was 5.6 deaths per 1,000 live births in 2022.) At this pace, Botswana is unlikely to reach the United Nations’ target of 12 neonatal deaths per 1,000 globally by 2030. (The neonatal period comprises the first 28 days after birth.)

Prematurity, birth asphyxia, and neonatal infections are the leading causes of those deaths, situations compounded by delays referring high-risk newborns to specialized care and gaps in newborn resuscitation capacity. What’s more, says Dr. Andrew Steenhoff, medical director of CHOP’s Global Health Center, most of the pediatric nurses in Botswana are generalists. “Our colleagues in Botswana said, This is a problem. We need nurse training in our neonatal intensive care unit,” he says.

This statement alone — and the Philadelphia team’s response to it — demonstrates a shift in how high-income countries like the U.S. have historically worked in places with underdeveloped medical capacity. For decades, American (and European) medical experts were telling African clinicians what they needed. For a quarter of a century, Penn and CHOP have worked to take the inverse approach: Observe first; act second.

To this end, the initial year of the CHOP-Botswana neonatal partnership focused on developing professional relationships between colleagues — NICU nurses and doctors getting to know hospital staff at Princess Marina. Although CHOP fellows also identified and filled needs that no amount of training could replace — for example, sourcing refrigeration to store breastmilk for premature infants in the NICU — their larger goal was working together to foster success within the existing environment.

While other U.S. hospitals — Harvard’s, for example — run similar long-term global health partnerships, CHOP’s model is deliberately specific: one hospital, one ward, one subspecialty, nurses who care for premature and low-birth-weight infants at the highest risk of poor outcomes.

Creating solutions, together

The CHOP fellowship begins stateside. Nurses from the hospital’s neonatal, pediatric or cardiac critical care units first complete an evidence-based practice course to develop a capstone project in collaboration with Botswana-based leaders. Once in Botswana, they spend time observing before implementing.

Sawick describes a fellow’s first few weeks abroad as “beautiful,” because “we learn so much from the local nursing staff, arguably more than we could teach them,” she says. Princess Marina Hospital lacks many of the ample supplies and supports of most American hospitals. The Botswana nurses are experts in teaching their American counterparts to adapt. Steenhoff calls this “two-way learning.”

The fellowship is entirely hands-on, not in classrooms, but working alongside, including at bedside, with 30 Botswana nurses. So far, fellows have responded to the hospital’s requests to assist in improving human milk utilization, resuscitation training, IV/cannula safety bundle, and infection prevention.

Sustained presence, measurable progress

While most international nursing programs last one to four weeks, CHOP’s nearly year-round presence (11 months annually) ensures work begun by one cohort continues with the next. Leaders track progress closely — monitoring lactation metrics through enrollment of eligible mothers, and measuring and recording volume goals, for example — alongside separate safety audits of IV cannula use and staff education records.

Steenhoff says the rate of IV infiltration — when an intravenous line leaks or fails, which can lead to infection — has dropped significantly over the past few months compared with three years ago.

Critically, the fellowship also provides the time and space to ensure improvements last. In a recent case, a baby needed a tracheostomy for breathing difficulties — a rare procedure in this setting. After the procedure, Botswana nurses, with help from their CHOP fellows, spent upwards of 10 weeks working to make the family comfortable managing the care.

“The CHOP nurses learn a lot from these incredibly innovative colleagues, who are hardworking and bright,” says Steenhoff. “One thing is how to do more with less, less resources, but also fewer nurses,” meaning the nurses themselves must train mothers in their children’s care. This higher level of engagement with families, says Steenhoff, is something he’s seen fellows bring back to Philadelphia.

Sawick says CHOP nurses come to appreciate their African colleagues’ “resilience and dedication to helping mothers and babies succeed. The amount of creativity and hoops they have to jump through just to achieve close to the same outcomes that we do is incredible,” she says.

Botswana’s own goals include developing subspecialty training — for doctors in areas like neonatology, pediatric infectious disease and oncology, and for nurses to specialize in neonatal care for their entire careers, rather than rotating through general assignments, as is currently typical. Both institutions share one main goal, however.

This November, 350 healthcare workers from both countries will convene in Gaborone to celebrate the program’s 25th anniversary. During the event, the conversation will certainly turn from what the partnership has built to what Botswana still hopes to build for itself — a nursing workforce, in the words of fellowship director Sally Poliwoda, that no longer needs a CHOP nurse in the room at all.

“Our job is to build capacity,” she says. “We want Botswana nurses to become trainers.”

Correction: After Alexandra Sawick completed her fellowship, she returned to Botswana to pursue additional educational opportunities through her employer, Children’s Hospital of Philadelphia.

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