By Rosalind Steege
The European Commission funding of the REACHOUT project may have officially come to an end, but the impact of the work and its legacy will surely live on. This became apparent to me when I was fortunate enough to visit the REACH team in Ethiopia for the project’s final dissemination meeting. REACHOUT has been working for the past five years in Shebedino district just outside of Hawassa.
It had been a year since my last visit and the road from Hawassa to Shebedino (where the project was implemented) is still being worked on, it makes for a strenuous journey as stretches of new tarmac are interspersed with patches of rubble that would challenge even the best suspension mechanisms. Over time of course, piece by piece, the rubble will be filled in until inevitably one 25km swathe of smooth tarmac will connect the two and greatly improve the efficiency (not to mention comfort) of the journey. Travelling this bumpy road on the way to visit the health centres in Shebedino, I couldn’t help but reflect on how the incremental step by step approach they have taken to building the road, is not dissimilar to the approach REACHOUT has taken with its Quality Improvement (QI) cycles, where QI teams use a PDSA (plan, do study, act) approach resulting in continuous incremental improvements that expands the overall quality of health service provision.
The final dissemination meeting was held in a hotel in Hawassa and was well attended by delegates from the Zonal Health Department, Regional Health Bureau, health centre staff, Health Extension Workers and of course, REACHOUT project staff.
Aschenaki Kea opened the day by outlining the findings from the context analysis completed at the start of the project which revealed some of the strong cultural beliefs upheld by communities with regards to maternal health. For example, the practice of burying the placenta beneath the house believed to ‘root’ the child, which can be a barrier to delivery within facilities. He also highlighted that there had been a level of mistrust of health workers and misconceptions around payment for ambulance services. This was compounded by poor supervision structures and a lack of referral systems. REACHOUT’s approach was therefore across three core areas: community engagement, referral linkage and supportive supervision. Initially, 45 health centre staff were trained in Shebedino, which was then expanded to a total of 81. He then handed over to the nine health centres who had done the hard work to present their achievements.
I was struck by the dedication the health centre QI teams had, they spoke of how integral the PDSA approach has become to their work - and they have the health benefits to show for this dedication. The comprehensive problem-solving approach that they adopted has gone beyond maternal health, impacting across health services from HIV to TB. The teams now also have a dedicated budget for QI activities which they plan and implement on a regular basis.
The presentation from Abela health centre not only spoke to the decrease in drop-out rates for ANC attendance – which are now up to 81% - but have other aspirations: not content with just ‘model households’ the team have set their sights on creating a ‘model village’. Woinadega health centre spoke of their pro-equity approach; identifying patients with special requirements implementing three-step programme to better serve them. This includes waiving payment for services, establishing an outreach programme and implementing a microfinance initiative to improve their socio-economic position. The head of Dulecha health centre also spoke of the importance of teamwork “Many threads together are strong enough to tie a lion”. Whereas another health centre staff member reported on the capacity building side of the project, “This REACHOUT project was like a school to me, I learned about presentation skills on top of QI and everything.”
Prior to the meeting I also had a chance to visit some of the health centres to see the impacts first hand and get a more comprehensive overview their individual achievements. Telamo health centre is a well performing and impressive health centre. It has a laboratory as well as delivery room that surround a well-manicured garden with bright pink flowers. I spoke with the head of the centre, Solomon Daniel, about their experiences with the REACHOUT project. In his opinion, the biggest changes they have seen relate to the establishment of a referral system for pregnant mothers (there was none before), and guidelines for the pregnant women forum (PWF).
“REACHOUT is a kind of spice to add flavour to the dish, but we are the cooks, it’s our own work, so we will continue to do it,” Solomon Daniel
He highlighted that the impact for the community of the QI teams is that the health development army is functioning well, which leads to improved information dissemination within the community. As a result of this well-established link between health centre and community, health seeking behaviour has improved.
One of the wonderful initiatives that has been up and running for six months at Telamo health centre is the mothers’ waiting room. The waiting room was built in the traditional Sidama cultural style of a round hut with a thatched roof, in accordance with community wishes. It serves as a place for up to four mothers (and their family members) to stay whilst they wait to deliver for up to a week before their due date. This is especially useful for women who live far from the health centre but want to give birth in the facility. The room is kitted out with electricity and even a TV. The expectant, and new, mothers are also well looked after; the health centre staff contribute ten Birr from their salary every month (about 0.37 USD) to provide tea, coffee, flour, butter, sugar etc. They celebrate each newborn arrival with a porridge ceremony. On my visit I met a young mother who had given birth the day before. She lay comfortably on the bed breastfeeding her new son Chance. She lived 28k away and had stayed for two days before her birth accompanied by her mother and sister and without this waiting room, may not have had the chance to deliver in a facility.
I also visited Abela health centre and spoke with their head, Gebre Tunga. Gebre highlighted the main impacts of REACHOUT at Abela to be the improvement in coverage, and the improvement in the quality of services. Before REACHOUT they did not provide a syphilis and HIV tests for pregnant mothers, but now this is part of their routine care. This is important for the health outcomes of the community as testing is provided alongside information and counselling services. Information to expectant mothers on the syphilis testing is provided during the Pregnant Women's Forum and they are counselled on the importance of knowing their status. If they test positive for HIV they will be counselled and linked to antiretroviral treatment. If they test positive for syphilis they will be treated, protecting the baby. The test is given at the first antenatal care visit and with a negative HIV result, the test is given repeatedly at three month intervals in case the viral load is undetectable at first.
But in answer to the all-important question…Will it be sustained?
“Without a doubt, no question. It is our routine task. Our knowledge and practice is due to REACHOUT training. Quality is one component of health centre reform, which is also part of the government initiative, so REACHOUT’s focus on quality is aligned with the government initiatives of health centre reform,” Gebre Tunga
This project is funded by the European Union.