II HOSPITAL ASSESSMENT REPORT FOR CLINICAL OUT REACH PROJECT

ASSESSING TEAM. Drs.1. Abraham G/Egeziabeher, Plastic surgeon 2. Hagos Biluts, consultant surgeon 3. Tessema GASHAW, Medical officer 4. Yegeremu Kebede, Plastic surgeon Sr. Abeba Mekonen, out reach nurse

December 10/2006 Addis Ababa Ethiopi

Table of contents

EXECUTIVE SUMMARY. 3

1. INTRODUCTION 4

2. METHODS AND INSTRUMENTS 5

3. RESULTS 9

4. DISCUSSION. 20

5. RECOMMENDATION. 22

Executive summary.

The majority of Africa’s population lives in rural or remote areas while only a small percentage of healthcare facilities capable of specialized treatment are accessible to them there. Ethiopia shares the same in the way that a concentration of trained healthcare workers in the urban centers in overcrowded hospitals that not only have to treat their own patients but support the surrounding facilities. Even while the federal system in Ethiopia has provided referral hospitals in remote areas they are under-funded and constantly experiencing a shortage of trained staff. The objective of this project is to strengthen the capacities of ten university and regional hospitals, selected from a group of twenty referral hospitals in Ethiopia. The current specialized clinical out reach project in Ethiopia is just starting up as national programme. Therefore it has limited experience and resource in the Ethiopian context. Therefore it is assumed to be an area of lesson accumulation, start up for advocacy on the need of the population and indigenous system establishment. The specific criteria for assessment of hospitals were drafted based on the above the generalized scheme of strategies and they are listed as follows i.e. Hospitals should render public services, they have cadres of staff who are trainable to carry out some specialist care tasks both at the medical, nursing and paramedical levels, they receive an adequate number of patients requiring specialist treatment i.e. Catchment’s population of 200,000 and above and they have the required infrastructure to take advantage of specialist services or willingness to put in place such infrastructure Generally Hospitals lack most of the general specialty areas. Some of the relatively better available general specialty fields are Internal Medicine, Pediatrics, Gynae-Obs, and Surgery. Services like dentistry, ENT, Ophthalmology, Psychiatry and Orthopedics are seriously lacking in almost all Hospitals. The sub specialty areas such as plastic and reconstructive surgery, Maxillofacial surgery, orthopedics surgery and hand surgery are seriously needed by general surgeons. The maintenance and installation of medical equipments is a serious problem across all Hospitals. Based on the assessment results, consultation workshop discussion and the project concepts the following recommendations are made i.e. The hospitals such as Mekele, Gondar, ,Dessie, Adama ,Bahir dar, Awassa, Hossana, Karamara and Metu are worth selecting ,capacity buildings and out reach specialist services are better if they focus on general surgery, plastic and reconstructive surgery, orthopedics surgery, hand surgery and equipment installation and maintenance; Comprehensive team training is advisable approach and s subsequent project appraisal on un met needs of hospitals is valuable

1. Introduction

Almost 80% of Africa’s population lives in rural or remote areas while only a small percentage of healthcare facilities capable of specialized treatment are accessible to them there. Ethiopia is no different with a concentration of trained healthcare workers in the urban centers in overcrowded hospitals that not only have to treat their own patients but support the surrounding facilities. Even while the federal system in Ethiopia has provided referral hospitals in remote areas they are under-funded and constantly experiencing a shortage of trained staff. The objective of this project is to strengthen the capacities of ten university and regional hospitals, selected from a group of twenty referral hospitals in Ethiopia. The decision will be made using predetermined criteria and will mean intervention with the aim to provide secondary health care services and efficient and effective tertiary care for those persons that require specialized medical services. Volunteer doctors, nurses and paramedics from more populated areas will visit the chosen hospitals and provide many desperately needed services in the areas of general and specialized surgery, obstetric and gynecological care, pediatrics, internal medical and surgical care, orthopedics and radiological and diagnostic services which are inaccessible to approximately 80% of the population. Sensitization and awareness programs in the urban centers, where there is already an expressed interest among doctors, nurses and specialists will encourage participation in the program. Visits by these healthcare professionals and the development of training material and specifically designed training workshops will work to strengthen the delivery of health services in the areas lacking both human and financial resources. The most obvious benefit of these actions will be the at least 10,000 patients treated by the doctors who without these visits would have to wait indefinitely for treatment, if they had access to it at all. The second and equally important outcome to these volunteer services is the educational value allowing the treatment of patients to continue after the expiration of the project. 500 health care professionals will benefit from direct training from the visiting specialists and another thousand will gain knowledge and insight from indirect on-the-job training in the hospitals. The beneficiaries of the workshops and the medical service visits will obviously be the children that receive reconstructive surgery, the women who receive obstetric and gynecological care (especially to repair obstetric fistula) and the people with preventable or correctable disorders receiving help that without this project they had no hope of receiving. On top of these, the healthcare professionals receiving the refresher and training courses and first hand observation experience will benefit from this project and be able to greatly help their own communities. The improved health of the population and increase capabilities of healthcare personnel will in turn benefit the regional healthcare centers and referral hospitals and further the aims of the Federal Ministry of Health. At the same time the project will create avenue for professionals to help their needy citizens.

2. Methods and instruments

2.1. GENERAL STRATEGIES OF SELECTION

The current specialized clinical out reach project in Ethiopia is just starting up as a pure national programme. Therefore it has limited experience and resource in the Ethiopian context. This current project is assumed to be an area of lesson accumulation, start up for advocacy on the need of the population and indigenous system establishment. The selection of the hospitals and their need assessment takes the following general strategy into consideration.

2.1.1 Areas of lesson accumulation

The projects Ethiopian experience as mentioned above is limited and the resource dedicated to it is limited. As we all know and anticipate will be the need of the population is high. The rationale behind this mismatch based on AMREF accumulated experience elsewhere is to use this limited resource as an area of lesson accumulation for overall health system improvement. Institutions which can exploit this limited resource and assumed to be productive in an area of direct enhancement of capacity and can make some kind of management, technology, and knowledge synergy and thereby produce their alike with minimum leverage are likely to be the first to get priority.

2.1.2. Start up for advocacy

As mentioned else where it is just starting in Ethiopia .The experience of this project will play a key role in the future for improvement of the referral services. This is not a simple area of trial and error. Care should be taken at the beginning; otherwise we will fail in becoming responsible health professionals in general and citizens in particular. The concern we have, the result we produce with this minimum resource, the system we establish which shows our capacity and sincerity to answer the genuine needs of our society given the means to act are the image building acts which we shouldn’t miss at the beginning. There fore institutions which are responsible to carryout relatively good out comes with the available resources and can establish accountable systems speak loud to the project. The result of the project shouldn’t be diluted by over stretching these minimal resources and speak against the project. Targeted and fruitful results which will have a vibrant image should be the means for forward movement.

2.1.3 Indigenous system establishment. We should use this chance to establish an indigenous system. We have specialized health professionals who can share their experiences with minimal resource and at the same time we have junior health can be trained on the job to make the system really locally driven than solely dependent on the out side world. Therefore the project should work hand in hand with the ongoing indigenous capacity building activities so that it can share the available resources which are dedicated to the hospitals and thereby form synergy than establishing its own venue. At the same time it should be an instrumental means to bring substantial change in making specialized services accessible to the under served segment of the population and be an example of improving quality in the heath system. Hence institutions at this time of the project are supposed to be those which are relatively targeted for capacity building activities which do have potential to be enhanced with minimal input at the same time do have the adequate cadres of heath and the basic infrastructure. This in practical term means those institutions which can fill the budget gap through their own system and can participate with the ownership feeling of the project should be the target institutions.

2. Specific criteria of assessment and selection

The specific criteria are drafted based on the above the generalized scheme of strategies and they are listed as follows. A. Hospitals should render public services B. They have cadres of staff who are trainable to carry out some specialist care tasks both at the medical, nursing and paramedical levels C. They receive an adequate number of patients requiring specialist treatment i.e. catchment’s population of 200,000 and above D. They have the required infrastructure to take advantage of specialist services are willing to put in place such infrastructure.

2.2.1 Hospitals should render public services The hospitals should render public services means they shouldn’t be private, military and other special groups of hospitals .They should be hospitals run by the government or missionary or NGO.

2.2.2 They have cadres of staff who are trainable to carry out some specialist care tasks both at the medical, nursing and paramedical levels.

The hospitals which do have general specialists with adequate number plus relatively better retention potential are the first target hospitals for priority of selection. This goes in line with our philosophy of establishing indigenous system and at the same time production of professionals who are later assets for the project during expansion. However this priority is not rigid it can be flexible based on the local context. The indicators in this regard can be the number of population per physician and the number of population per nurse.

2.2.3. They receive an adequate number of patients requiring specialist treatment i.e. Catchment’s population of 200,000 and above.

The hospital should have adequate number of patients who can benefit from specialized services which are going to be rendered to it. Therefore the limited resource which is going to be invested should have better return. This part of assessment can be measured using catchment’s population, OPD new consultations per 100 persons per year, Admissions per 100 persons per year and number and types of referrals done.

2.2.4 They have the required infrastructure to take advantage of specialist services are willing to put in place such infrastructure.

Hospitals should have the basic infrastructure for the specialized health services to be done. These include the diagnostic set up, the pharmacy, number of beds, the operative theater room and the power supply. The diagnostic set up should render the minimal services like x- rays, hemoglobin, blood group

3. The process and instrument of hospital assessment and selection.

The assessment check list was developed with the above general frame work in consultation with the ministry of health, volunteer specialists and related literature. Then 20 hospitals were selected taking their geographic distribution, potential staff kind and number and their work load into consideration. The selected 20 hospitals were assessed using the structured format(annex 1) developed for this purpose by the assessing team who are volunteer specialists, medical officer and out reach nurse of the project. The assessing team assessed a hospital half a day and travel day of about a day between hospitals. The collected assessment was compiled and written by the project medical officer and out reach nurse. The draft write up was presented for consultative meeting which is a body composed of people from all assessed hospitals, Federal Ministry of Health, AMREF Ethiopia and Volunteer Specialists. Then the final Assessment report document produced which is going to be filed, communicated to the relevant bodies and based on it, action plan for the out reach clinical service and lesson plan for on job training produced.

3. Results

Generally Hospitals lack most of the general specialty areas. Some of the relatively better available general specialty fields are Internal Medicine, Pediatrics, Gynae-Obs, and Surgery. Services like dentistry, ENT, Ophthalmology, Psychiatry and Orthopedics are seriously lacked in almost all Hospitals. The sub specialty areas such as plastic and reconstructive surgery, maxillofacial surgery, orthopedics surgery and hand surgery are seriously needed by general surgeons. The maintenance and installation of medical equipments is a serious problem across all Hospitals.

Hospitals expressed need for the training of personnel, if possible with long term training in general specialty fields i.e. Internal Medicine, Pediatrics, Gynae-Obs, and Surgery Dentistry, ENT, Ophthalmology, Psychiatry and Orthopedics. Surgeons need training in the areas of reconstructive and plastic surgery, hand surgery, orthopedics, and maxillofacial surgery. The trainings have been suggested to be a kind of team training which involves all the professionals who are related i.e. surgeons, scrub nurses, anesthetists etc…

The work load of Hospitals is presented in Tables 3.1 and 3.2. The Variables included are population of the catchment’s area, Administrative Zones and Districts and referring hospitals and health centers in Table one and Annual OPD visits, Admissions and operations in Table 3.2. Table 3.2 shows Jimma, Dessie, Bahir Dar and Awassa do have population size of greater than 5 million in their catchments area. Fig.1. shows that Awassa has population size of 14 million and that of Jimma 10 million in their respective catchments area.

The ten top causes of OPD visits and Admissions are generally infectious and acute diseases but there are chronic disease conditions mentioned i.e. Diabetes Mellitis, Hyper tension, valvular heart diseases. The referral system of hospitals is not well documented but discussion with related bodies mentioned that patients with chronic disabilities are referred to hospitals like ALERT but very few can make it possible because of economic problems.

Fig 1 Catchement population of Hospitals

Butajira 2 Hossana 2 A.Minch 1.5 S/Shmene 1.5 Adamma 5 Awassa 14 Bahir dar 7 Gonder 5 Axum 1.4 Mekel 3.4 Disse 7 NegleBorena 1.18 Metu 1.8 Karamara 2.5 Dil Chora 5 Hiwot Fana 3 YAH 1 Jimma 10 AMbo 2.1 Nekemet 2 Values in millions

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Table 3.1. Work load of Hospitals by Number of Population, Zones, Districts, Referring Hospitals and H/centers

Populationx Zones Districts Hospitals H/Centers 1-2 Million Axum, YHA S/Shemene A/Minch, Metu Negle Borena 2.1-5 Million Gonder, Nekemt Adama Ambo Hossana H/Fana Karamara ,Butajira Dil Chora,Mekele >5 Million Baher dar Jimma Awassa ,Dessie 2-4 Axum, Butajira Axum Ambo Negle Borena/Fana Hossana, A/Minch Gonder H/Fana S/Shemene,Metu A/Minch D/Chora Nekemt, Ambo Butajira Karamara Negle borena Nekemet,Metu 5-7 Jimma, H/Fana Jimma Awassa Mekele Gonder,B/Dar YHA Adamma Adama,Mekele Bahir dar,Dessie 8-10 Karamara Awassa, Butajira Awassa S/Shemene YHA, Dil-Chora Hiwot fana Butajira Dessie Jimma,YHA Dil-Chora, 11-14 Awassa Negle borena Mekele Nekemet,Metu Ambo,S/Shemene Butajira. >15 Nekemt,Ambo Axum,Gonder, Jimma,Karamara Bahir-Dar,Adama Metu,Axum,Adama A/Minch S/mene,A/Minch Hossana Hossana, Mekele Dessie

Populationx .Hospitals are graded into 3 based on their catchments population. These are graded 1 with 1 to 2 million, graded 2 with 2 to 5 million and graded 3 are those with greater than 5 million. Table 3.2 shows that Axum,Dessie,Gondar,Mekele,Bahir Dar,Adamma,Shashemene,Arbaminch,Hossana,Nekemet, Metu,Dill chora and Yergalem Hospitals do have Annual OPD visits greater than 45 000. The annual Admissions in Bahir Dar, Arbaminch, Nekemt, Yergalem, Dill chora and Dessie is from 7000 to 10,000.

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Table 3.2. Work load of Hospitals by Annual OPD visits, Admissions and Operations;

Number Annual OPD Annual Admissions Annual Visits Operations Majorxx 100-300 Ambo Karamara,NegleBorena S/Shemene 301-500 Axum Butajira A/Minch 501-1000 Karamara Nekemet H/fana,D/Chora Metu,Axum B/Dar,Awassa/6 moths Hossana 1001-1500 Negle borena YHA,Jimma Awassa/6mths !501-3000 Hossana Dessie,Mekele,Gonder Butajira Adama 3000-7000 Ambo,Gonder Adama,S/Shemene Mekele 7000-10,000 B/Dar,A/Minch Nekemet,YHA Dil-Chora Dessie,Nekemet 10,001-25000 H/Fana,KaraMara NegleBorena Awassa/6mths,Butajira 26,000-45,000 Ambo >45,000 Axum, Dessie Gonder, Mekele Baherdar Adamma,S/shmene A/Minch,Hossana Nekemet,Metu Dill /ChoraYAH

Annual OPD Visitsx .Hospitals are graded into 3 based on their annual OPD visits. G rade1 are those with 10,000 to 25,000, grade2 are those with 26,000 to 45,000 and grade3 are those with greater than 45,000.

Annual Operations Majorxx . Hospitals are graded into 5 based on their annual operations done. Grade1 are those with 100 to 300, grade2 are with 301 to 500, grade3 are those 501 to 1000, grade4 are those with 1001 to 1500 and grade5 are those with 1501 to 3000.

The capacities of Hospitals are summarized in Tables 3.3 and 3.4. The variables which are used to describe are Number and types of medical staffs, Surgical beds, operation Tables and anesthesia machine. Gondar, Mekele and Dessie do have surgeons greater than 3. There are 2to 3 surgeons in Dill chora, Karamara, Jimma, Adama and Awassa Hospitals. Axum, Negeleborena, Shashemene, Arbamich and Bahir Dar do not have surgeons.

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Table 3.3 Capacity of Hospitals by Number of Medical staffs Numbers Surgeonx Gyn.Obs GP Anes.Nurse Staff nurse Lab tech. X-Ray Tech. No Axum, Negle Axum S/shemene Negle borena Mekele A\MinchBaher dar

1 Hosanna S/Shemene,Adma Axum Butajira Negle borena Butajira,Nekemte A/Minch,Hosana S/shemene,Hosanna Butajira AmbomMetu ButaJira,Nekemt Metu,Karamara YHA,H\Fana Ambo,YHA Negle Borena Metu,Karamara 2-3 Dil-Chora Gonder Hosana Axum Mekele,Axume Karamara B/Bar,Awassa Ambo Awasa,Adama Awassa,Adama Jimma H/Fana A/Minch,YHA,H/Fana S/shemene Adama,Awassa Dil-Chora,Dessie Dessie Hossana, Mekele Dil Chora, Metu >3 Gonder jimma Jimma,Dil-Chora Mekele, Dessie 4-10 Adama Dessie Dessie S/Shemene Mekele,Axum Gonder A/minch,Butagira B/Dar,Awassa B/Dar Jimma S/Shemene A/Minch,Ambo H/Fana,Metu Butajira,Ambo Jimma,YHA K/Mara Metu,Negle Borena H/Fana,Kara Mara Negle borena Hossana Dessie

10-20 Gonder Hosana Gonder B/DarYHA Adama,A?Minch DilChora Jimma,YHA/Fana DilChora,KaraMara >20 Awassa All hospitals Except Hosana Hospitals are graded into 4 based on their surgeon availability as follows. Grade1 when there is no surgeon, grade2 when there is one surgeon, grade3 when there are 2 to 3 surgeons and grade4 when there is greater than 3 surgeons.

Table 3.4 shows that Jimma, Gongar and Bahir Dar do have surgical beds greater than 81 while Negele Borena, Karamara, HiwotFana, Ambo, Nekemet, Shashemene and Hossana do have surgical beds from 20 to 40. Metu, Gondar, Yergalem, Bahir Dar and Awassa have Operation tables greater than 81. Fig2. Shows the operation room set up of Yeregalem Hospitals.

12 Table 3.4 Capacity of hospitals by Number of surgical beds, OR tables and Anesthesia Machines

Number Surgical beds Operation tablex Anesthesia machine >81 Jimma Gonder,Bahirdar 61-80 Axum YHA,Dil-Chora 41-60 Mekele Awassa,Adama A/minch,Butajira,Metu 20-40 NegleBorena(16) Karamara,HiwotFana Ambo,Nekemet S/Shemene,Hossana 3-4 MetuGonder Metu, JimmaYHA,mekele Gonder B/Dar,Awassa Jimma 2 Axum,Adama,A/Minch Bahirdar,Awassa Hosana,Butajira,Ambo Adamma, Hosana H/Fana ButajiraAmbo,D/Chora D/Chora,Karamara H/Fana,Dessie Mekele,

1 Nekemt Axum,S/shemene Negle Borena A\Minch Dessie NegleBorena KaraMara YHA,Nekemet

Operation tablex Hospitals are graded into 3 based on operation table availability. These are grade1 with one operation table, grade2 with 2 operation table and grade3 with 3 to 4 operation table.

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Fig. 2. A photograph from Yergalem Hospital to show the operation room set up

Fig 3 shows the distribution of Surgeons in the 20 assessed Hospitals.

Fig.3.Distribution of Surgeons in Hospitals

Dessi 5 Negle 0 Kara 2 Metu 1 Dil 3 H/ 1 yHA 1 Jimm 3 Ambo 1 Neke 1 Buta 1 Hosan 1 A/ 0 S/She 0 Adam 3 Awas 3 B/Dar 0 Gond 8 Axum 0 Mekel 4 Number of surgeons

14 Op.table Sum of Priority Remark grade grades grade ( Ser.No Hospitals Surgeon. Pop. An.OPD An.Op.grade descending grade grade grade order) 1 Mekele 4 2 3 5 3 17 1 2 Axum 1 1 3 3 2 10 7 3 Gondar 4 2 3 5 3 17 1 4 Dessie 4 3 3 5 1 16 2 5 Bahir Dar 1 3 3 3 3 13 4 6 Butajira 2 2 1 2 2 9 8 7 Hossana 2 2 3 3 2 12 5 8 Arbaminch 1 1 3 2 2 9 8 9 Awassa 3 3 1 3 3 13 4 10 Shashemene 1 1 3 1 1 7 9 11 Metu 2 1 3 3 3 12 5 12 Ambo 2 2 2 1 2 9 8 13 Nekemet 2 2 3 3 1 11 6 14 Borena 1 1 1 1 1 5 10 15 Yeregalem 2 1 3 4 3 13 4 16 Karamara 3 2 1 1 2 9 8 17 Hiwot Fana 2 2 1 3 2 10 7 18 DilChora 3 2 3 3 2 13 4 19 Gima 3 3 3 4 3 16 2 20 Adamma 3 2 3 5 2 15 3

3.5. Hospital grading matrix.

Fig.4.Distribution of sum of grades of Hospitals

Adamma 15 Jimma 16 DilChora 13 Hiwot Fana 10 Karamara 9 Yeregalem 13 Borena 5 Nekemet 11 Ambo 9 Metu 12 Shasheme 7 Awassa 13 Arbaminch 9 Hossana 12 Butajira 9 Bahir Dar 13 Dessie 16 Gondar 17 Axum 10 Mekele 17 values

15 4. Discussion.

The fact that Hospitals lack most of the general specialty areas is a sign of the chronic deficiency of health care professions in Ethiopia. Some of the relatively better available general specialty fields are Internal Medicine, Pediatrics, Gynae-Obs, and Surgery and this may be the result of the current capacity building activity of the government. Services like dentistry, ENT, Ophthalmology, Psychiatry and Orthopedics are seriously lacked in almost all Hospitals and these must be the areas where intervention must target.

The sub specialty areas such as plastic and reconstructive surgery, maxillofacial surgery, orthopedics surgery and hand surgery are seriously needed by general surgeons and these are the areas where chronic health care deficiency contributes for poverty of disadvantage group of people.

The maintenance and installation of medical equipments is a serious problem across all Hospitals and these further compounds the problem of Hospitals i.e. uses resources but not functional.

Hospitals need to be trained if possible with long term trainings in general specialty fields i.e. are Internal Medicine, Pediatrics, Gynae-Obs, and Surgery Dentistry, ENT, Ophthalmology, Psychiatry and Orthopedics. Surgeons need training in the areas of reconstructive and plastic surgery, hand surgery, orthopedics, and maxillofacial surgery and these are according their services deficiency those fact that they needed long term training above the scope of this project. Therefore some kind of arrangement to answer these needs must be designed. The trainings have been suggested to be a kind of team training which involves all the professionals who are related i.e. surgeons, scrub nurses, anesthetitics etc… and this is worth appraising.

The ten top causes of OPD visits and Admissions are generally infectious and acute diseases but there are chronic disease conditions mentioned i.e. Diabetes Mellitus, Hyper tension, valvular heart diseases. The referral system of hospitals is not well documented but discussion with related bodies mentioned that patients with chronic disabilities are referred to hospitals like ALERT but very few can make it possible because of economic problems. This shows that the chronic disabling disease conditions are really the hidden domain of the disease burden of a community. They are incapacitating for those who are affected but their number is few to speak loud. Therefore a very strong advocacy role is needed to convince all responsible in health care policy, planning, Implementation etc.

The hospital grading matrix was done according to the project concepts and philosophy such as. A. Hospitals should render public services B.They have cadres of staff who are trainable to carry out some specialist care tasks both at the medical, nursing and paramedical levels C.They receive an adequate number of patients requiring specialist treatment i.e. Catchment’s population of 200,000 and above D.They have the required infrastructure to take advantage of specialist services are willing to put in place such infrastructure

16 The consultative work shop discussed thoroughly on the assessment report and modified the hospital selection criteria. The criteria mentioned and agreed by the workshop members were catchment’s population size, remoteness from the nearest referral point and the hospital infrastructures.

Based on the above appraisal, the workshop selected: Mekele, Gondar, Jimma, Dessie, Adamma, Bahir Dar, Awassa, Hossana, Karamara, and Metu. This means one hospitals in Tigray region, 3 hospitals in Amhara region, 3 hospitals in Oromoia region, 2 hospitals in SNNP and one in Somalia Region. This means 4 teaching hospitals and 6 referral hospitals. Therefore the result is in line of the general strategy of the project .i.e. be an area of lesson accumulation, start up for advocacy on the need of the population and indigenous system establishment.

5. Recommendation.

Based on the hospital assessment report, consultative workshop and the project concepts the following recommendations are made.

1. The Hospitals such as Mekele,Gondar,Jimma,Dessie,Adamma,Bahir dar,Awassa,Hossana, Karamara and Metu are worth selecting. 2. Capacity buildings and out reach specialist services are better if they focus on general surgery, plastic and reconstructive surgery, orthopedics surgery, hand surgery and equipment installation and maintenance. 3. Comprehensive team training is advisable approach. 4. Subsequent project appraisal on un met needs of hospitals is valuable.

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