Gathering information at 9000 feet above sea level

Julia Entwistle - School for Environment and Sustainability

The rainy season is in full force here in North Showa, Ethiopia. The area, which had not seen a drop of rain in several weeks, now experiences daily storms. The dry arid landscape has been transformed into lush green meadows in a matter of days. With the rain comes colder temperatures, overcast skies, and mud, lots and lots of mud. In a place where the closest paved road is 25 km away and walking is the primary form of transportation, this makes getting around more challenging. 

Our household surveys of local farmers are well underway, but with the sudden onset of rainy season, I decided it would be wise to try to complete data collection in the most distant area that we needed to access by road, a region called Metkoriya. Metkoriya is a very remote area only accessible by a single lane dirt road that winds alongside cliffs, up and down steep mountain passes, and sharp switchbacks. Here in the highlands of Ethiopia, most plateaus are over 9000 feet above sea level and getting to Metkoriya involved descending from the plateau I live on and then climbing back up to the neighboring plateau. 

A survey in progress at 9000 feet above sea level

So as soon as I could secure a vehicle to rent, three translators and I set out on the road to Metkoriya one morning. After a few minutes of travel I realized we may already be too late to access this area. After only a week or so of rain, the road had been transformed into sloppy mud with deep puddles. The van we were in was not equipped to handle the steep inclines and declines and the spinning tires so close to the edge of a cliff were making me nervous. Several times we all got out to push the van out of a deep puddle. The driver was not too happy with the situation and after 2-3 slow miles of travel down the mountain side and into the valley, he said he wouldn't be able to take us any further. With about 2-3 uphill miles left until we reached Metkoriya, I asked my translator what we should do now. "We walk" he said, "into the cloud." He pointed up the steep muddy slope that after 20 feet was obscured by thick fog. 

So we set off on foot on the uphill hike into the clouds. The mud clumped around our shoes and added a few pounds of weight to each step. The inside of a cloud is unsurprisingly very wet and we were all soaked by the time we reached Metkoriya. As we summited the top of the plateau where Metkoriya sits we were rewarded by the spectacular view of looking down at the cloud covered valley below. 

View from Metkoriya

We have since found a large truck to rent that is better equipped to handle the terrain and are making progress towards our goal of 80 household surveys in Metkoriya. This remote region may be the most beautiful I have seen in Ethiopia and its people are extremely welcoming, but I have to confess that I will be relieved once we are finished skidding along the sharp turns on the edge of the mountain. 

A Metkoriya farmer showing off one of his barley plants

Brief Summary of the RDH Retreat



Sorting out pre-retreat logistics with Alice, my co-planner 

Nana Asare - Ford School of Public Policy

Due to an unplanned ministry of health evaluation at the Ruli District Hospital, the 2017 RDH retreat was almost pushed back. This would have been the second time the retreat was delayed, putting my summer of hard work in jeopardy. However, with the stellar help of my co-planner (Alice) and the TIP country director (Delphine), we were able to negotiate and keep the retreat going as planned. The planning process largely focused on building on and tailoring the work of the University of Michigan's Ross School BA 685 team's work to the expectations of the RDH hospital. Since the majority of the hospital staff aren’t fluent in English, Alice and I put in a lot of effort to developing a teamwork approach in delivering our retreat exercises. Specifically, I’ll start and explain each section in English and she’ll follow up with the French or Kinyarwanda translation when necessary.

The retreat was structured in three phases and scheduled for 3-days with each day dedicated to a different aspect of the strategic plan. Below is a summary of the three phases;

•       Phase one of the retreat was dedicated to a recap of the 2016 Ruli District Hospital retreat, reports of 5 pilot projects developed during that retreat and a visioning exercise for the 2017 retreat.
•       Phase two was a SWOT Analysis segment conducted with the WHO’s health systems framework guidelines (Building Blocks). The six building blocks were connected to the main departments of the RDH in efforts to turn the negatives affecting quality health service delivery into positives to promote health.
•       Phase three was a Stakeholder Analysis and S.M.A.R.T Goal Setting workshop structured to develop goals to be achieved through the RDH’s 5-year Strategic Plan.

RDH staff and Admins brainstorming S.M.A.R.T Goals

The retreat was attended by the Administration members and department heads of the hospital. The key purpose of the retreat was to focus on a 5-year strategic plan regarding the processes, skills, and the hospital’s future goals. Furthermore, the retreat served as a platform for a successful dialogue between the administrators and department heads.

During the retreat, we didn’t encounter many issues besides occasional participant lateness and delays. The retreat as whole was a huge success for the hospital as everyone finally felt that they were on the same page in the next steps for the hospital. The hospital employees felt at ease and were able to specifically voice out their opinions which was great because “critiques” of leadership isn’t really part of the work culture at the RDH. Additionally, the outcomes of the retreat set the tone for the next steps of the strategic plan, which involves action planning and implementation.

Jotting down notes during our S.W.O.T Analysis exercise

On a personal note, I was very satisfied with the retreat. There were several times when I didn’t feel confident that it was going to go as planned because the hospital wasn’t as forthcoming and involved as I hoped. However, during the retreat, everyone was thoroughly engaged in the exercises and offered feedback to make the event fruitful. Moreover, my co-planner was excellent to work with and although her time at TIP has ended, she helped me transition in the new B.A Liaison in following up with the retreat and setting up the necessary steps for TIP’s health systems management program.

A Visit to a Diabetes Clinic

Danielle Wilkins - School for Environment and Sustainability

June 30^th marked the culmination of my first month in Sri Lanka and what a first month it was. By the end I had done what I previously thought to be impossible, survived a Sri Lankan summer without the help of an air-conditioning unit. But we had also started to make strides in putting together a training program for a new form of Medical Assistant specializing in diabetes care and big players like projects funded by the United States Agency for International Development (USAID) were voicing interest in our work.

Admittedly when I first arrived at Grace Home I was a little apprehensive. As I mentioned in my last post, I have a background working on development projects in Sri Lanka, but this was the first time I had undertaken a project focused on medical care, and without the formal backing of one of the big development agencies that generally lead these initiatives. I started out visiting the Diabetes Clinic with the Assistants from Grace who had previously received medical training. These young women (to date no young men have been trained) are to be our front line in the quest to show our new way of caring for diabetic patients actually works. I wanted to see what their working environment was like. It was, in a word, chaotic.

The Diabetes Clinic in Trincomalee General Hospital is held in a room approximately 20ft x 15ft. There are four standard desks with four desktops, four blue chairs, a screen separating a small private area. As I was directly informed when I took a seat in a blue chair, only physicians are permitted to sit in the blue chairs. Each desk has a stool for the patient and three stools are set up in the middle of the room for patients to wait for an available doctor. A nurse guards the clinic door checking to make sure only those with the permitted numbers have access to the room. All other patients wait in a sea of blue plastic bench seats outside.

To date the Assistants are not actually permitted to work with the doctors of the Clinic (we still need to obtain a number of permissions for the Trincomalee Ethics Committee and the Ministry of Health), so they arrived at 6:30am on Monday morning to see patients who arrived early to collect their number. Numbers are very important to the clinic model in Sri Lanka’s public hospitals. Patients arrive to the clinic and line up to receive numbers from the Orderly. The first people in line receive the first numbers and are thus able to see the doctors first. This has significant advantages. These people will also be able to get to the pharmacy first and will have little wait time in filling their prescription. The result is that they are able to get out of the hospital and on with their day quicker than their fellow patients. The early numbers are highly coveted. Or, at least they used to be. More on the change in number policy in a bit.

As the patient’s crowd into the Clinic room to find the Orderly who distributes the small laminated number card, the Grace Diabetes Assistants (DAs) set up shop at one of the doctor desks. The blue chair pushed aside, the Assistants and their patients sit on stools around the desk. They have been coming early on Monday mornings for about a year now. Some of the Orderlies know them and they have a small group of patients, generally older women, who slowly make their way into the clinic to sit and wait their turn. The Grace DAs take their time with each patient. They review their medical book. Each diabetes patient carries with them their medical records. Most of these records are kept in a small notebook. Only doctors are permitted to write in these books and they contain all the notes test results for each person. The DAs perform a quick exam. They check each patient’s blood pressure, their blood glucose, their weight and their feet. The feet of a diabetic patient are very important. Many patients they see do not have great control over their diabetes. As a result, they are at a high risk for neuropathy, characterized by a loss of feeling generally in the feet. Without feeling in their feet these patients are at risk to develop foot ulcers and other lesions that can prove deadly. Monitoring the feet of these patients are just one of the activities in the care model that help the DA collect important baseline information on each patient.

In the midst of their exam the DAs are constantly interrupted. The most frequent interruptions come from newcomers wanting to know where they can collect their number. Other patients want to know what is going on, “are the doctors here?”. The orderlies and nurses are often bustling around preparing the room for the doctors. Through it all the DAs are gracious. They answer questions and return to their patient. They spend on average 15 minutes with each patient, asking about their daily habits and advising them on the need for exercise and an improved diet. Not every patient comes back each month, but a surprising number do.

Around 9:00 the doctors have finished their rounds and are starting to trickle into the Clinic. It is the cue for the DAs that it is time to leave. They have managed to see seven patients today and more of the nurses and orderlies have started to recognize them and offer assistance. Slowly the DAs are gaining acceptance from the patients and the hospital staff.