With grant funding awarded by the Bill & Melinda Gates Foundation in 2015, IHI and its partners are supporting the Ethiopian Federal Ministry of Health's efforts to reduce maternal and newborn mortality in Ethiopia. IHI Africa Region Executive Director Dr. Sodzi Sodzi-Tettey describes what he learned and observed during a recent visit.
By 2012, only 14 percent of pregnant Ethiopian women delivered their babies in health care facilities under the care of skilled health professionals. In 2016, I am pleasantly surprised to see a sharp increase in this figure to 68 percent. So, what has changed?
A lot, actually! A recent field visit to Butajera put it all in perspective.
To truly appreciate what has changed, one must understand the organization of the Ethiopian health system, the volunteerism of its people, the tenacity of its health professionals, and the discipline of its political leaders.
Ethiopia’s health system is known for the deep partnerships established between the community and health facilities in an integrated development agenda. The smallest level of the Ethiopian health system is the health post, which serves a population of 3,000 - 5,000 each and is staffed by one health extension worker, a young woman trained for one year to deliver a package of preventive and basic curative health services. The health extension worker at the health post not only provides antenatal services, but demonstrates what model housing should look like, what provisions should be made for a latrine, best practices for feeding infants, and how the household may address its energy needs. This she does through deep engagement with the community leaders, who head well-demarcated households of groups of five, in a system that accounts for each individual community member. These leaders of households constitute what is called the health development army, a key resource in rolling out a package of interventions. In addition, the health extension worker manages basic cases like malaria and diarrhea, while facilitating prompt referrals of women in labor, including calling for an ambulance.
At Dalocha, we visited Germama health post where the health extension worker sees an average of 15 to 16 patients each day, from morning until about 1pm, after which time she does her community rounds, visiting 8 to 10 households per day.
On one wall of the health post was this statement: “The sun should not set twice on a woman while she is in labor.” No doubt, this is an attempt to prompt her against prolonged labor. Fortunately, our colleagues at the Last Ten Kilometres project (L10K) — whose aim is to improve high impact maternal, neonatal and child health (MNCH) care practices among rural households — have been hard at work supporting best referral practices, including pre-referral management, identification of complications, and prompt referral.
Overall, however, it is the surge in health facility deliveries that is most astounding. During a visit with Cairo Radi, a 40-year-old leader of 13 households, selected by her community, I spoke with her about her role in getting women to deliver at the health center. Here’s what she told me:
“I identify pregnant women in my community. I then link these pregnant women to the health extension worker to enable them to access antenatal services. I also make sure that during conversations with the family as part of the birth preparedness planning, we agree on the need for facility delivery. When the woman goes into labor, I am informed and then I call the ambulance to take her to the hospital. If the road is very bad, we organize a traditional stretcher to carry the woman. Sometimes, the ambulance is not available for one reason or another. When that happens, we mobilize other vehicles from the Primary Health Care Unit.”
On a wall in Cairo’s room is a community map showing all the households in her catchment area. Using stickers, she has readily illustrated which households have pregnant women, which households have newly born babies, which households have latrines, etc. She regularly updates this community map to get a better sense of performance on the various issues and also to track the effect of her interventions. This community map and the work around it is what the Ethiopian health system calls community-based data for decision making.
Later at the Dalocha Health Centre, we glean further insights when we learn that deliveries have skyrocketed from 249 in 2012 to 1,141 deliveries in 2015, an increase of almost 400 percent.
Among the reasons are a strengthened relationship with the health development army; the purchase of 800 ambulances nationwide by the government of Ethiopia, and the ready availability of additional alternate “ambulances” from other government administrative agencies like the police; and the construction of a maternity waiting home, where mothers living very far from the health center, or who may not have ready access to a means of transport, can arrange to stay at the home in the week leading to delivery. Last but not the least, we heard of a ban placed by the government of Ethiopia on home deliveries.
With so much demand being stimulated, inevitable questions about the quality of care arose. Among other interventions, the health administrators have taken to staff rotation and duty roster scheduling in an attempt to align the workforce to peak workload seasons.
What level of discipline at the national level will it take to raise leaders of this caliber? How is the Ethiopian government marshalling resources — internally and externally to address health needs, provide equipment, etc. — in what is essentially a free health care service? And what are the levels of political and public sector corruption that have made these kinds of interventions feasible? On each of these issues, it was evident that some thought had gone into it with resultant action. As one doctor said, “Corruption is not a major problem in Ethiopia. You can see the very simple attitude of the workers and administrators for yourself.”
Overall, Ethiopia is very serious and determined to create a strong health system. In addition, Ethiopia gives you the sense of a national political system truly working in the service of its people.
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