Why It Matters
IHI's Don Goldmann explains what he learned on a recent trip to learn about IHI's work to improve maternal and infant health in Ethiopia.
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There's No Substitute for Proximity in Improvement Work

By Don Goldmann | Wednesday, June 6, 2018

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Dawit Hailu, Senior Project Officer supporting IHI’s work in Ethiopia, Don Goldmann, IHI Senior Fellow, and Hema Magge, IHI's Ethiopia Country Director, visited a primary care hospital in rural Ethiopia. Goldmann, center, is helping with an evaluation of IHI's improvement work in Ethiopia. 

IHI’s programs in Africa are inspiring, perhaps none more than a country-wide project to help Ethiopia meet its Sustainable Development Goals for maternal and neonatal mortality. Funded by the Bill & Melinda Gates Foundation and Margaret A. Cargill Philanthropies, and conducted by an in-country IHI team in full partnership with the Ethiopia Federal Ministry of Health, IHI seeks to accelerate Ethiopia’s already exemplary progress in reducing needless deaths of mothers and babies. Evidence-based practices for reducing mortality are well known, but implementing these intervention at scale — or even locally — requires a deliberate, phased approach.

Sounds like amazing work, doesn’t it? It sounds so logical, sensibly planned, and well executed. Sitting in Boston, I could nod my head in appreciation of the Addis Ababa team’s work and focus on what I do best — help with a tricky evaluation that will need to demonstrate that the investment by donors, the Ethiopian government, and IHI is indeed accelerating the pace of improvement that Ethiopia already has achieved.

But candidly, what could I really know without being there to see the work up close? Context matters. Ethiopia is a very large, geographically diverse country of more than 100 million people. Most live in poverty, many in remote rural areas where access to medical care is extremely challenging due to long distances and poor roads. Quality of care is highly variable due to gaps in infrastructure, training, and resources. So to get a first-hand look, I flew to Ethiopia, and the trip turned out to be a revelation and a blessing.

The most inspiring and informative visit of the five-day trip was in southern Ethiopia — a short plane ride from Addis Ababa — that I took with Dr. Hema Magge, IHI’s Ethiopia Country Director. It’s a beautiful area known for its lakes and wildlife — some of it up close and personal, like the baboons and warthogs on the grounds of the hotel. As an infectious diseases physician, I noticed that Addis is at nearly 8,000 feet, and there is no malaria. Where we were going in Chencha is even higher — about 9,000 feet. There is definitely no malaria there, and, in fact, it was downright chilly. Everyone was wearing jackets and layered clothing. It gets into the 40s at night. People use small coal fires to heat their houses, which are often traditional round dwellings with thatched roofs.

The dirt road to Chencha Primary Hospital seemed to go up endlessly through forest that changed as we climbed, with occasional sweeping views over the valley and its lakes. The road is rutted and rocky, in part because in the rainy season the runoff gouges the road very deeply. The road can be virtually impassable in the rainy season, and the dirt tracks leading to the road almost certainly would be. The hospital’s one 4-wheel-drive ambulance would be of very limited use when it rains hard. There were very few people to be seen on this road, except near a rather rough and ready resort built, I assume, for eco tourists. The local textiles in the very bright colors favored by the Dorza people who live in the area were being displayed by women on the side of the road near the resort.

After many miles, we suddenly came upon the town, which was surprisingly large and active in contrast to the sparsely populated areas through which we had driven. There was a mix of traditional thatched dwellings and newer “modern” buildings, most with tin roofs. The majority of people who live there are farmers. The Chencha Primary Hospital prides itself on being the oldest primary hospital in Ethiopia, although this level of care is relatively new in Ethiopia. The first level of care is provided by health extension workers, a form of paid community health worker. The next level is the health center. We visited the Dorza clinic, which delivers babies and triages high risk mothers to the Chencha Hospital.

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Chencha Primary Hospital, above, cares for people with a variety of conditions, including infectious diseases.

The Hospital cares for a broad range of patients — basically, whoever shows up. Given my infectious diseases background, the excellent young physician who heads up the medicine program insisted on showing us patients with TB, HIV, and a staphylococcal syndrome called scalded skin syndrome. There were some children with malnutrition, cardiac conditions, and other acute and chronic problems. But we were there to see the mothers, the delivery services, and the babies. We were taken around by the CEO of the hospital, who said he has been a leader at the hospital for 17 years. He’s a well-trained OB-GYN surgeon, and his pride in his training and service shone through, even though it was difficult for him to focus on his own accomplishments rather than the litany of problems and challenges he faced running a full-service hospital with very limited resources.

The infrastructure and quality of care issues in the delivery room and neonatal unit were typical of what I’ve seen in other resource limited settings around the world — problems with equipment and supply, running water, and infection control, for example. But the truly unique, even transformative experience was our visit to the maternity waiting house. This indeed is a house — a traditional Dorza dwelling with a small door, a dark interior, and a dirt floor. This is where mothers deemed to be at high risk wait to deliver. They sleep on cots and sit on benches. They are warmed by a small coal fire in the center of the room. The hospital provides meals, which is unusual as families are often expected to bring in food for patients in hospitals like this one.

As the group of us — mostly men — talked about women’s preferences in maternal health, Hema thought to ask the mothers “in waiting” themselves. Inside the dwelling, two women were sitting side by side on a bench, dressed in layers of clothing to ward off the cold. Hema has had vast experience in maternal and child health in Africa, including amazing work on implementation and scale up in Rwanda with Partners In Health. She also is extraordinarily empathic and person-focused. So I was not surprised to see her engage the moms directly with a simple question — “What can the hospital do to make your stay more comfortable or improve your experience?”

The two women appeared to be having very different experiences. One was accompanied by family, smiling and engaged with us. The other sat still and silent, breathing rapidly and not making eye contact. The CEO translated, and the first mom said that she was comfortable and blessed to have access to a hospital where she could deliver her baby safely.

Then the mother on the right started to answer the question. She immediately began to cry, tears streaming down her cheeks. She said that she had two previous Caesarian deliveries, and in both cases the babies were born dead. After the second stillbirth, her husband became depressed and ultimately abandoned her. She was alone. No one was there for her. She was sad but hopeful that this time, at last, she would have a healthy baby.

The CEO told her that she was at the top of his mind every minute of the day. She was his most important patient, and he would drop everything to help her because it was imperative that she deliver a healthy baby. Hema put her hand on the mom’s shoulder and said a few comforting words, and mom gave a small smile. They cousin’s child had been sitting between the mothers, looking on with the widest eyes I’ve ever seen. So I hunched down, thanked her for her patience, smiled, and waved goodbye.

Later, Hema explained that most stillbirths are caused by complications during labor and childbirth, and are preventable with high-quality, accessible, and timely care. Although I’d just seen how difficult the travel conditions were for women who sought to deliver their babies at health clinics instead of at home, the fact that the woman had C-sections before meant that she had gone to the trouble of accessing care. The issue was the quality of care she received after going through the effort to reach it. It was tragic to consider that she lost these babies despite making this effort — and underscored the importance of quality of care, in addition to access to care.

This insight is what it means to be proximate, to begin to understand, and to carry the importance and impact of our work in our heart. We heard about proximity last year at the IHI National Forum, where human rights lawyer Bryan Stevenson spoke about his work to fight racial inequities in the death penalty. I thought of Stevenson’s exhortation after meeting these women.

The truth is that I could memorize the IHI’s proposal to the donors, obsess over the details of the project plan, tweak the qualitative and ethnographic inquiry process, come up with an oh-so-clever evaluation scheme, and remind the Ethiopia team that a stepped-wedge design and interrupted time series analysis might be helpful. None of this would have given me the insight, knowledge, and passion to truly appreciate what our Ethiopia team is doing, to understand the challenges they face, and to have a clear mental picture of the conditions in the countryside, including the difficult terrain and long bumpy car rides. And certainly not to hold the mothers IHI is trying to help in my heart as well as my mind.

Learn more about IHI's work in Africa.

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