Memorandum submitted by Tadeyose Belay
HOW EFFECTIVELY
DFID IS WORKING
WITH RECIPIENT
COUNTRIES TO
MAKE EMERGENCY
OBSTETRIC CARE
AVAILABLE AND
TO ENSURE
THAT ADEQUATE
NUMBERS OF
SKILLED BIRTH
ATTENDANTS AND
OTHER STAFF
ARE BEING
TRAINED TO
MEET MDG 5, AND
ARE INTEGRATED
WITHIN A
ROBUST HEALTH
SYSTEM
1. This is a contribution with a good intention
to galvanise on going effort in reduction of maternal and newborn
mortality in Ethiopia. I may not be the right expert or academician
to provide scientifically sound prescription or a person with
reputable recognition in this specific area. I wish you understand
my contribution as an ordinary professional who had a decade of
solid experience in serving for the good cause of mothers and
children health as a medical doctor and program manger across
spectrum of health delivery level—rural health centre, district
and referral hospitals and at the Federal Ministry of health.
While I was working in the public sector and after I resigned
I had the opportunity to be involved and lead country wide maternal
and newborn health situation in this country. Thus, from this
perspective I would like to bring to your attention potential
constraints/challenges and commendable action in order to speed
up access to essential and emergency obstetrics intervention to
reach those helplessly dying pregnant mothers and newborns in
this country.
2. I think lack of co-ordination of donors'
assistance and partner's role is a critical constraint that
requires an immediate action to maximise resource and to ensure
concerted effort to accelerate progress in maternal and newborn
mortality reduction. Sadly to note here the fact that the prevailing
situation in Ethiopia vividly tells us that the working relation
in the implementation of Emergency obstetrics and newborn projects
among partners and agencies (including UN SISTERs) is undesirable
and sometimes unhealthy. Rather than working to complement effort,
they work hard to compete through maneuvering individuals at different
level to gain unfair attention through undermining the effort
of the other. Because of this undesirable environment, we can
cite a number of constraints—confuse the government with
different agenda and priorities; lack of collective voice for
advocacy (eg skilled birth attendants strategy, waive service
fee for delivery); undermine effort in scaling up effective intervention;
cast question on credibility of recognised institution etc.
3. In the other side, the lack of co-ordination
among donors further is fueling this unwanted situation through
allowing partners to compete for funding. Let me readdress my
point with a practical example so that you can understand how
the competition is further complicated with donor's decision.
As you are aware since 2001 WHO has brought the concept of MPS
strategy in Africa at large and as a pilot implantation in five
selected countries including Ethiopia. The government of Ethiopia
has adopted the MPS intervention package as a national strategy
to reduce the unacceptable maternal and newborn mortality in the
country. Accordingly, WHO has provided a led-technical and financial
support for pilot implementation of the MPS strategy in four government
selected sites (zones) across the country. To document evidence
and changes gain due to MPS intervention, WHO has supported an
evaluation mission of the pilot implementation in the four pilot
sites in collaboration with the lead role of FMoH. The finding
indicated an encouraging implementation gains and calls for resource
mobilisation for consolidation of efforts and expansion to new
sites.
4. Simultaneously, the European Union has
been approached by WHO to support the initiative, and the UNION
has committed a sizable amount of fund to support MPS implantation
in six African countries including Ethiopia. The six countries
which have received the EU fund via Afro WHO office already engaged
in the scaling up of the MPS implementation. To the surprise of
many, the fund allocated to MPS/Ethiopia has been relocated from
WHO/Ethiopia country office to UNFPA country office. Having secured
the "relocated fund" the country office spent much time
to hire technical officers for MPS implementation and partly they
succeed in taking technical officer working in the very WHO country
office who had been hired for MPS program.
5. As I have been informed the fund is designed
in such a way to be spent in the SAME INITIAL FOUR MPS sites.
Since the inception of the MPS program in 2001 WHO is a lead agency
and have built solid capacity at different level—HQ, Afro
and country level. While resources are critically needed to scale
up the MPS intervention through WHO at global and regional level
to accelerate the unacceptable maternal and newborn mortality
in African countries, such is a typical example which can be sited
as an obstructive competition between two SISTER agencies at many
fronts: critical MPS intervention priorities are being diluted
to address annexed/additional institutional agenda; the situation
created unequal voice/sometime sluggish response to implement
Afro priority MPS intervention as indicated in the Biennial POA;
and because of partners divergence/competing agenda difficult
to reach consensus for priority advocacy themes. Furthermore,
the project has posed a far reaching complication: regards the
WHO Afro MPS implementation momentum at the country level to accelerate
through duplication effort in the same pilot sites, which has
been supported by WHO; undermine UN sister agency's complementarity
through duplication of role; and eroding the partnership effort
for at the country level ... etc. Unfortunately, this event
has taught us an important lesson—despite your designated
role, money at hand (grant/fund) becomes a critical instrument
to get adequate attention of the government counterpart to pursue
an important intervention.
6. In this very example, I attempted to
address a lesson that all of us (implementing partners and donors)
should be learnt to rectify mistakes ensure a functional partnership
to maximise resources for implementation of a health program towards
MDG goals. Strengthening Partnership is also critical to ensure
role complementarity and to stay focused on priority high impact
health intervention to rescue those needlessly dying mothers and
children those needlessly dying.
7. Taking into consideration this constraining
situation, I would like to suggest that putting in place a co-ordination
mechanism is a priority to ensure cohesion and complementarity
of efforts among partners and donors at different level.
8. Please find below proposed action and
effective interventions to accelerate access to basic and emergency
obstetrics and newborn care in the Ethiopia context:
— Strengthen co-ordination framework
at MoH and RHB level: The initiative can start by revitalising
and restructuring the existing weak Reproductive Health Task
force at the Federal Ministry of Health. The Task force is
comprises of more than 30 partners working in the area of reproductive
health including UN agencies, international and indigenous NGO,
professional associations, academic institutions. The Task force
also has four technical committees—Family Planning, Safe
motherhood, logistic and supplies and IEC.
9. Apart from enhancing the leadership role
of the MoH, I would like to suggest the following action to strengthen
the role and function of the Reproductive Health Taskforce:
— Include key donors as core group
to advice and share information.
— Define a binding ToR (definition
of role, function, mandate) for RH task force and four sub technical
committees.
— Develop a national INTEGRATED ROAD
MAP owned primarily by Government and each partners to clarify
roles, determine funding mechanism, agreed on priority interventions,
implementation milestones and needed resources.
— Replicate the National RH task force
at least in the biggest four regions.
— Encourage professional association
(especially Ethiopian Gyn/bost society, Ethiopian Midwives Association,
Nurse Association) as an advocate for ethics, professional competency
and quality standards, rather than the current trend of implementing
"projects".
— Initiate out reach residency program
at AAU for final year postgraduate Gyn/Obs student. This is intended
to fill a critical shortage of specialist doctors/GPs at district
hospital for the provision of emergency obstetrics care (operative
intervention). Arrangement can be made with the AAU gyn/obs department
to deployed final year postgraduate student along with a group
of four to five interns to provide emergency obstetrics and surgical
intervention for two to three months as part of practical attachment.
Supervisors would be jointly identified with university faculty
and other concerned partners. A modest financial reward for supervisors
and per diem for students is required. This intervention is a
new innovative proposal, which would partly address the current
human resource crisis in the health sector and contributes to
strengthening the pre-service education—offering more practical
exposure for new graduate GP.
— Initiate maternal death audit/review
mechanism and Health extension workers-led verbal autopsy at health
facilities and community level health facility.
— Strengthen linkage and working relation
between health extension workers and health center providers.
— Update midwifery curriculum at mid-level
health training institution.
— Support delegation of life saving
obstetrics procedures to midlevel health workers (HO, MW and nurses).
— Arrange performance rated financial
incentives for health care providers in the provision of basic
and comprehensive emergency obstetrics care. This will dramatically
improve delivery at health centres.
— Forge a regular forum with professional
association, partners and government counter part.
— In collaboration with professional
association, organise regional level pool of experts (gynecologists/obstetrician,
pediatrician) to initiate on-job training for health facilities;
to assist/advice the RHBs; ensure supervisory support to the regional
health bureaus, and facilitate local in-service training. It has
a significant impact in retention of scarce experts at regional
level and reduce the cost of in-service training.
— District focused MPS program planning
and implementation: fine-tune with ongoing district centered decentralisation;
strengthen linkage/complementarity of facility based EOC with
community based Health extension program: support competency
of health extension workers to manage normal/complicated delivery
and essential newborn care; community mobilisation/behavior change
communication; referral linkage with health facilities; introduction
and application of best practices and tools for obstetrics and
newborn care of (focused ANC, the 3 6's).
— Intensify advocacy effort at different
level to enhance political national commitment and mobilise
resource to accelerate maternal and newborn mortality reduction.
— Strengthening pre-service midwifery
education—curriculum review, introduction of essential
obstetrics/newborn care competencies and best practices/tools;
training of tutors.
— Building implementation capacity,
both at programme and facility level: technical assistance;
program management training; adaptation/development of in-service
training curriculum/guidelines for bEOC and cEOC; scale-up task
shifting for midlevel health workers (HO and MW/Nurses); enhance
capacity of front line health workers; strengthening pre-service
education; pursue cost-effective best practices/lessons (eg create/organise
local professionals/expert pool for on-job training ... etc.
10. STRENGTHEN
LEADERSHIP SKILL
OF HEALTH
MANAGERS AT
THE DECENTRALISED
LEVEL IN
THE HEALTH
SECTOR
10.1 The problem
The ongoing country wide woreda (district)
centered decentralisation process shakes up many linkages existing
within a health system while it turns the system upside down.
Health managers at different decentralised level addressee the
following challenges, depending on the management level at which
they work:
10.2 Challenge at the decentralised level—Region,
Zone and district
Achieve a balance between local and national
priorities: Develop locally responsive health services while
respecting national health policies; balance conflicting demands
between providing routine local health services and participating
in national health initiatives (eg, immunisation days); and meet
the demands of unfunded central mandates.
Establish new working relationships:
Develop supportive working relationships with the local administration,
politicians, and organisations whose agendas may not be linked
to priorities of local health professionals; and build partnerships
with local communities to achieve better health.
Mobilise resources: Cope with unpredictable
and delayed resource flows from the central government; and compete
with other sectors for locally controlled resources.
Achieve a cohesive health system: Ensure
appropriate referrals and technical support between hospitals
and primary care facilities that belong to different jurisdictions.
Develop motivated and competent staff:
Motivate a workforce whose job security, compensation, and professional
development are threatened by changes resulting from decentralisation;
and develop competencies for the new management responsibilities
among local staff.
10.3 Challenge at the central level—Federal
Ministry of Health
Achieve a cohesive health system: Develop
a cohesive set of national health policies and strategies that
protect vulnerable populations, guarantee nationally important
services (eg reproductive health), and respond to local needs,
despite competing interests of government ministries and politicians;
ensure an integrated health system even when primary care facilities
and hospitals fall under different jurisdictions; maintain competent
management, technical expertise, and integrity of Family health
program (maternal and newborn health, Family planning, PMTCT of
HIV) and key disease prevention programs (malaria, tuberculosis,
leprosy, HIV/AIDS, and immunisations); and develop national information
systems with the essential public health and management information
needed to support management responsibilities.
Maintain quality of care: Achieve compliance
with minimum standards and practices across the nation without
line control over decentralised service delivery. Maintain adequate
preventive and behavior change services when local priorities
focus on curative care.
Mobilise resources across the health system:
Promote equitable access to services between rich and poor populations
and geographic areas. Ensure the availability, affordability,
and quality of pharmaceuticals when procurement has been decentralised
to the local level.
Develop motivated and competent staff:
Ensure equitable salaries and benefits, adequate opportunities
for professional development, and flexible job transfers across
jurisdictions. Develop new sets of skills and management systems
to assist central-level managers; and share best practices and
learning among decentralised areas.
10.4 Rational
To ensure a functional and a speedy transition
of the ongoing district centered decentralisation, managers at
different levee (including Regional, zonal and District) need
to adopt new leadership roles to shape the process and bring smooth
transition to the ongoing decentralisation. Their prior experience
in a centralised system did not prepare them to take on new roles
and deal with the added complexity of their health system.
10.4.1 Thus, a tailored training package
on leadership and management is needed to deliver improved health
management function at various decentralised level, especially
at the district level. Managers at the regional, zonal and district
levels come together to define new management responsibilities
and to create supportive management structures, systems, resource
flows, and activity plans. To ensure such changes, health managers
at all levels need to become leaders who can mobilise people inside
and outside their organisations to create new paths toward improved
health.
10.4.2 Health managers at different levels
need to be equipped with state-of-the-art leadership and management
skills in order to redefine their roles and responsibilities to
better support both the people they serve and the staff at management
levels closest to the population. Moreover, health managers can
adopt leadership practices to carry out their new roles and ultimately
make decentralisation work. It offers ways for these managers
to adapt specific leadership skills and practices so that they
can not only adjust to the changes of decentralisation, but actively
shape the process. By shaping the process, there will be a greater
opportunity to actively involve staff and external stakeholders
to achieve results that benefit their clients.
11. GENERAL OBJECTIVE
To provide support to the ongoing government-led
district centered decentralisation process in Ethiopia to ensure
stable and cohesive health system through implementation of tailored
management and leadership training for health managers at different
level.
12. SPECIFIC
OBJECTIVE
— To define functional and effective
complementary leadership and management roles that managers at
different level have to play to bring decision-making closer to
the population and to infuse government programs with a sense
of local ownership.
— To introduce a user friendly management
tools to achieve and sustain client responsive and high quality
of health service without sacrificing efficiency and effectiveness.
— To equip managers at different level
with a package of tools to ensure progress toward justice, fairness,
and equity in health services?
— Familiarise managers with a contemporary
leadership skill on how to maintain sense of stability amid personal
confusion and organisational turbulence.
— To help manager to acquire and practice
new skills required to perform new management responsibilities.
| 
