Decentralising NCD Care in Ethiopia

Our work on non-communicable disease care in Ethiopia began in response to concerns raised by Dr Shitaye at the University of Gondar Medical School about the significant number of emaciated diabetic patients she encountered from rural Gondar who, after a dramatic initial response to insulin, were not receiving follow up care. In the early stages of the project, patients faced many challenges in receiving long term treatment, including the cost of care and the long distances they had to travel to the hospital. Patients were also forced to say at home when roads were blocked during the rainy season.

Recognising these challenges, Dr Shitaye decided to take the desperately needed insulin to rural clinics near the patients homes. This, of course, came with its own challenges – staff were not trained in how to support patients to make the necessary life style changes associated with diabeties, nor were they experienced in monitoring patients or teaching them how to store and inject their insulin.

To overcome these challenges, a holistic approach was developed which focused on supporting both the patients and the frontline nurses who were providing care. Mentoring was at the centre of this approach, with nurses receiving training in communication and clinical skills. Nurses also received supportive supervision from local hospital staff to make sure that they were continually improving their skills. This approach was soon duplicated around Gondar and, in the late 1990s, also spread to Jimma.

As the number of patients and demand for the services increased, so did our ability to advocate for the local health bureau to allocate funding for previously unavailable essential medicines and simple diagnostic equipment. This helped to ensure sustainability.

For the last thirty years, we have been building on and refining this model, bringing in health extension workers and working with the government to strengthen and develop the policies and guidelines needed to frame NCD care. This has now culminated in an expansion of the approach, in partnership with the Federal Ministry of Health and Health Poverty Action, to seven regions of the country.

The holitisic approach of the project focuses on three major phases: capacity building, consolidation and demand creation. Combined, these phases strengthen the system for patients. The project started with thirty physcians who have gone on to cascade training to nearly four hundred health centre staff members. The health centre staff will be responsible for cascading training to the health extension workers who, in turn, will educate and mobilise the community to increase demand for the improved servies. At all levels, we are ensuring that ongoing mentorship and supportive supervision will embed new knowldege and skills.

The challenges we’ve faced in this new phase of the project are similar to those we found in Jimma and Gondar. In a country where the number of healthcare workers is insufficient to meet the needs of the population, adding to the workload of those on the frontline can be difficult. Collecting data that is vital for patient follow up can also be difficult, as can infrastructure challenges and inadequate supplies of medication and disgnostic equipment. On top of this, staff frequently change jobs meaning that trainees can be spread across the country, far away from where the project is being implemented. Despite these challenges, we are confident that things are improving and that the quality and availability of care is moving in the right direction. Over time, we believe that more and more patients’ lives will be transformed.