Ethiopia's success story / Gebre Selassie Okubagzhi

Ethiopia's success story Gebre Selassie Okubagzhi 0 ne of the most serious obstacles to develop-ment of primary health care (PHC) in Ethiopia has been the absence of a decision-making mechanism at Awraja (District) level. This gap in the organizational structure is unique to the health sector. The existence of a strong district health system not only helps to forge a partnership between government and communities, but also serves to harmonise the policies of central at.jthority with local initiatives and resources. Although there is universal agreement on the need to set up Awraja health management, opinions vary on who should be trained and who should train them. Disenchanted by the existing situation of the training institutions, the Ministry of Health started a new training programme for district health managers at its own Training and Demonstration Centre. This action was supported by WHO, UNICEF and other bodies, and a curri- culum was prepared by an expert committee under the chairmanship of the Minister himself. One two-year training programme would take Awraja health managers to master's level in public health, a second lasting 10 weeks would be an accelerated course for such managers, and a third would train members of the Awraja health team. This training scheme is essentially based on the "learning-by-doing" approach, with extensive practical experience in rural and urban settings. The trainees are assigned to one of their future districts during their residency programme. They are thus encouraged to develop problem-solving approaches through community participation and intersectoral collaboration. They also design and carry out a research project on a primary health care (PHC) topic, which helps them to learn scientific methods of investigation in community diagnosis. They see something of the .organization of health services, the strategies used and the type of interac- tion involved with government and community organizations in delivering health services. Trainees conduct a small survey designed not only to familiarise them with the nature of district health W ORLD HEALTH, May 1989 services and the problems encountered, but also to help them develop the right methods and skills for analysing the prevailing health situation and drawing up an action plan. Serious attempts are made by the trainees to develop a dialogue with government and community leaders in the process of identifying problems and recommending solutions. Objective reaHties The second phase is devoted exclusively to covering the basic theor- etical courses provided by any gradu- ate programme in community health, but its contents reflect the objective realities of the country. The residency phase is the last part of the training programme. During this period the trainee is assigned to an Awraja where he or she works after graduation as an Awraja health man- ager. During this period the trainees are supervised once a month by at least one senior faculty member, who provides guidance and support in the field. The candidates present their health profile and action plan to the health committee of the district for approval, and finally report their findings to their colleagues and faculty members. The discussion that ensues enriches the health profile and action Panos/M. Edwards © plan and clarifies problem areas. The Awraja health team is com- posed of programme coordinators, heads of hospitals and health centres, and prominent non-governmental leaders. The team decides on all technical and managerial aspects of the Awraja health services. The health manager has a secretarial role and in this role ensures that local initiatives are consistent with national health policies. Invoking Ministry of Health experts in teaching has not only alleviated the shortage of instructors but also helped the trainees to receive up-to-date information on various policies, direc- tives and activities of the Ministry. Once the objectives and methods of the training process were clearly stated, a number of institutions were approached to support the pro- gramme. The McGill-Ethiopia Com- munity Health Project agreement was signed between the Ministry of Health and McGill University in Canada. Through CIDA (Canadian aid agency) funds , the project provides the A vital supply of firewood for a remote district community in Ethiopia. Health managers are now specially trained for work in such districts. 21 22 Ensuring safe water supplies is an incessant problem. Mountain streams are at risk from pollution and run dry during a drought. A training poster for Ethiopia 's Awraja health managers spells out the "pyramid" of available hospitals and health stations. essential permanent academic staff and other resources. WHO and UNICEF provided funds for the training pro- gramme and for the Avraja by provid- ing transport and seed money, and CIDA again collaborated in funding ten of the first batch of research projects. Accelerated course Because of the government plan to establish an increasing number of Awrajas, the need for trained Awraja health managers (AHM) became urgent. So the accelerated 1 0-week course was started to assist district health managers to improve the plan- ning, organization and carrying out of PHC programmes, and to develop the skills, leadership and attitudes necess- ary for working with the community, other sectors and the health team. After the course, managers return to their districts for a period of two to six months during which they draw up a health profile and plan of action for health activities. Back in the training institution, they present these and discuss them during a one-week workshop. So far two batches of the accelerated group - 45 trainees - have completed their course and are working as acting AHMs in different districts of the country. Their perform- ance is rated above average by the faculty members who visited them in their Awrajas and by those who work with them . The programme is expected to continue by providing two sessions per year. The Ethiopian training experience has entailed .an unprecedented involvement of the Ministry of Health in the operation of teaching insti- tutions. This may appear strange but has been very instrumental in creating the right kind of orientation towards the actual job of being a health manager. In the absence of well- trained staff for teaching institutions, the use of various experts from the Ministry of Health has proved a very useful and effective way of using the available local resources. The assignment of residents to Awrajas before graduation has many advantages. The residents are exposed to the realities of the district and are able to seek solutions through interac- tion with their colleagues, instructors and Ministry of Health officials. All this helps to prepare them to provide effective leadership in managing health services. International agencies, NGOs and other bodies are more likely to support a programme if they are convinced it will genuinely improve the health status of communities. The support channelled to this programme from the different sources is a prime indication of its usefulness. • W ORLD HEALTH , M ay 1989