Mulu Hiluf's Trip
Integrated Family Health Program and other related programs
Minutes of Technical Advisory Committee
Field trip and visit report Eastern Zone, TIGRAY March 30 – April 01, 2011
MULU HILUF’S TRIP
SHIRKA TRIP
Integrated Family Health Program and other related program Technical Advisory Committee Quarterly field trip and visit report - Eastern Zone, TIGRAY
March 30 – April 1, 2011
MULU HILUF’S TRIP
Participants 1. Wz. Genet Mengistu, Population Coordination Core, Ministry of Finance and Economic Development 2. Ato Gemechu Kufa, Ministry of Health 3. Ato Damena Lema, Ministry of Education 4. Ato Tesfa Teferi, Ministry of Women, Children and Youth 5. Ato Alemu Shiferaw, HIV/AIDS Prevention and Control Office 6. Ato Mulugeta G/Hiwot Habte, Charities and Societies Agency 7. Wz. Gezu Berhanu, Consortium of Reproductive Health Associations 8. Ato Birkneh Tewachew Wolde, Board Member- Consortium of Reproductive Health Associations 9. Dr. Samuel Tilahun, Centre for Disease Control 10. Wz. Yalem Tsgeay, Regional Health Bureau 11. Ato Haddish Zewde, Regional Educational Bureau 12. Ato Mulugeta Mesfin, Bureau of Finance and Economic Development 13. Wz. Zenebech Fisseha, Women’s Affairs
Staff of IFHP 1. Ato Tilahun Giday, Addis Ababa IFHP Office 2. Ato Girma Kassie, Addis Ababa IFHP Office 3. Wz. Makida Gebre, Addis Ababa IFHP Office 4. Ato Abdusemed Mussa, Addis Ababa IFHP Office 5. Ato Awala Equar, Tigray Regional IFHP Office 6. Ato Girmay Adane, Tigray Regional IFHP Office 7. Ato Kidanmariam Alemseged, Tigray Regional IFHP Office 8. Ato Solomon Kebede, Tigray Regional IFHP Office 9. Ato Samuel Gebre/Egziabher, Tigray Regional IFHP Office 10. Ato Desta Gebre-Egziabher, Tigray Regional IFHP Office 11. Wz. Adey Abebe, Addis Ababa IFHP Office
Destination Eastern Tigray Zone
Duration of the visit March 30 – April 1, 2011
Sites visited
1. Kilte-Awlaelo Woreda Health Office 2. Negash Health Center 3. Gemad Health Post 4. Adi-Messanu Health Post 5. Adigrat Woreda Health Office 6. Adigrat Health Center 7. Freweyni Health Center 8. Mekelle Hospital 9. REST Office
Wednesday, March 30, 2011 Kilte-Awlaelo Woreda Health Office
The Technical Advisory Committee (TAC) made its regular visit to Tigray region, Eastern Zone. Its first visit was to Kilte Awlaelo Woreda Health Office. Meeting with the Head of the office Ato Tsegaye and other staff members, Ato Tilahun Giday, Country Representative, Pathfinder International/Ethiopia, briefly informed the Office of the intention of visit. He said composed of government, donor and NGO partners, the TAC makes quarterly field visits to the four program regions of the country (Amhara, Tigray, SNNP, and Oromia). The Committee visits projects of IFHP and provides advice and encouragement on what it has seen. He also explained that a parallel structure - Woreda Advisory Committee (WAC) - was laid at Woreda level and composed of religious leaders, women’s association and representatives of relevant government sectoral offices. Accordingly, this quarter, the TAC arrived in Eastern Tigray Zone to visit and discuss with partners.
Head of the Woreda Health Office briefed the TAC on the work they undertook and following his briefing members of the TAC raised certain questions for discussion. In response to various questions, it was explained that IFHP supports the Government’s Health Extension Program by jointly planning its work with Regional and Woreda health structures. During implementation, providing technical, financial and logistic support, IFHP assists in filling gaps within the health plan of the government.
Discussing on particular issues, it was explained that community structures such as Women’s Associations, Women’s League and Developmental Army of Women are
1 used in promoting issues of women and children. Prevention of Mother-To-Child- Transmission (PMTCT) service which is 8% was explained to be low because of low awareness of mothers. IFHP however, is helping the Woreda Health Office in improving the situation.
IFHP’s support in undertaking Integrated Supportive Supervision (ISS) by providing skills training, helping in developing and jointly implementing follow up tools, was greatly appreciated. It strengthened joint efforts where Zonal and Woreda people visit health facilities to identifying gaps and provide on the spot technical support. Regular review meetings held between IFHP and the various government administrative bodies was also explained to be very effective in ensuring proper implementation of health services. As a result, Kilte-Awlaelo Woreda Health Office has been recognized as one of the best performing Offices in the Zone.
The Woreda Health Office stated that IFHP is more than a partner whom they consult on any problem they have. The organization has great commitment not only in assisting but also in following up on assistance provided, e.g. follow-up of capacity building trainings it regularly provides. The Office is now requesting IFHP to provide capacity building training for the newly established Developmental Army of Women.
Negash Health Center
The TAC moving on further visited Negash Health Center where it was met by the Center’s head Ato Fitsum Aregawi who gave briefing on this newly established health center. He explained that the Health Center used to be located elsewhere before it moved to this new location six months ago. It serves a population of 26,833, has 4 Health Posts under it and closely works with 4 Kebele peasant associations and 161 Developmental Army of Women.
Ato Fitsum took the group around explaining the functions of the different blocks by starting from a small garden where vegetables were planted. This is a demonstration site where they would teach mothers about nutrition and at the same time it generates income for the Health Center. However, water is not sufficiently available and the Center is trying to approach various partners to help resolve this problem.
Explaining on the various services provided by the Health Center, institutional delivery was said to be still low because of low awareness by mothers on the benefits of delivery at these facilities. In addition, timely Ambulance service to bring in mothers for delivery is another problem. It was stressed by the Woreda Health Office that the Health Center should work more on improving services of the facility and making the environment more pleasant so that mothers can find it more attractive and beneficial to delivery at Health Centers.
2 Provision of PMTCT was said to be 100% with all women coming for ANC receiving the service. However, problems of partner testing (husbands refusing to test for HIV) and resistance to be linked to follow up services by those tested as positive, are some of the difficulties.
It was further explained that Negash Health Center does not provide ART service instead refers to Wukro Hosptial. Because of low case load (low demand for service) it has not been necessary to provide the service at this Health Center. However, several people from Mekelle city and Afar region test for HIV/AIDS at this Center.
Capacity building assistance in insertion of Long Acting Family Planning service, provision of PMTCT and FP/HIV integration services, Essential Nutrition Action (ENA), Expanded Program on Immunization (EPI), Integrated Supportive Supervision (ISS), etc. complimented by financial support provided by IFHP was appreciated and said to have helped in improving quality of service provided by the Health Center.
As a result of health services provided by Negash Health Center Ato Fitsum says that changes that have been happening are:
1. Decreasing rates of maternal and child mortality, 2. Increasing demand for Long Acting Family Planning methods such as Implanon, and 3. Improving awareness on health issues which is evident from increasing demand for HIV/AIDS testing.
Nonetheless, the TAC voiced its concern regarding lack of proper service provision especially in services of delivery. Insignificant problems such as lack of bed sheets and mattress for already available beds (which IFHP said that it could easily have provided had it been notified) was hindering provision of services. Furthermore, unavailability of children’s ward in which case the Center had to convert a men’s ward into a children’s ward was also a concern.
Gemad Health Post
The visiting group continued its visit to Negash’s primary health care unit – Gemad Health Post and met with Kidan GebreMedhin. She briefed the TAC on the work she carries out with her colleague Tsehay (the other Health Extension Worker (HEW) working here).
It was explained that there are 3 Developmental Army of Women which assist the HEWs. They assist in mobilizing communities and raising awareness. They also work hard in ensuring that households practice the 16 health package (of the Health Extension Program) and integrating it with other sector programs (other than health) as well.
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Moving on, the group visited the home of Gebrehiwot who is a Kebele Chairperson. It is one of the model households within the Kebele. The TAC found the house very impressive in terms of cleanliness and innovative use of materials to build a toilet and kitchen. The group took time to talk to Gebrehiwot.
Adi-Mesanu Health Post Atsbi
Azmera Gebre who is the HEW at this Health Post welcomed the group upon its arrival. She is one of the first HEWs who received training on Implanon insertion. The Health Post was also said to be one of the exemplary health facilities especially in the provision of PMTCT and nutrition services. It provides health services to a population of 7,583 and 1,723 households. From out of these, 1,628 household have graduated as model households.
Thursday, March 31, 2011 Adigrat Woreda Health Office
The following day the TAC drove to Adigrat town and started the day’s visit by dropping into IFHP’s Cluster Office which is located in the compound of the Woreda Health Office. Basic information on the work carried out by this Office was given where it was stated that it covers 7 woredas and two administrative towns in Eastern Tigray Zone. Various financial, technical and logistic supports are provided especially in improving the government’s health system through Integrated Supportive Supervision (ISS) and through joint review meetings.
It was further explained that both IFHP Cluster Office and Woreda Health Office closely follow up on trainees after each training program. Both offices have detail information on each trainee and this is especially one of the reasons why ISS is carried out. The Cluster office undertakes the task of closely following up all the way from Health Centers down to household levels.
Next the group met with Ato Berhane, Mayor of Adigrat town and Ato GebreMeskel, Head of the Woreda Health Office, who explained their close working relation with IFHP in realizing the Health Extension Program. They briefed the visiting group on the capacity building training, technical and financial support they receive from IFHP.
It was then explained that a Woreda Advisory Committee works closely with the Woreda Health Office in mobilizing communities and raising awareness on issues. It is an effective body in promoting issues of HIV testing, family planning, PMTCT, ANC
4 services and fighting against harmful traditional practices. This is a great help to the HEWs. Nonetheless, it was said that there is some resistance to institutional delivery of mothers.
The WAC meets quarterly to review performance and it expressed its appreciation of the support provided by IFHP in terms of implementing ISS. This helps not only strengthen government programs but also sustains it. This Committee is a composition of representatives of Muslim and Orthodox Christian religious leader, Women’s Affairs, youth representative and representatives of the different government sector offices, it was said.
Giving a general overview of health improvements Ato GebreMeskel, stated that they work closely with HEWs, VCHWs, and Developmental Army of Women in improving maternal health to reach the Millennium Development Goals. Whatever concerns and grievances are voiced by communities these are addressed in the shortest time possible. A case in point was a mother who delivered in her home though she had decided to deliver her child at a health center. The Woreda Health Office made it a point of going out and asking this woman why she changed her mind. She explained that she went to the Health Center thinking that she was ready to deliver but was told that she was not due until sometime later. But upon returning home she gave birth and this had in fact upset her. Thus, the Woreda Health Office, through the health staff who had been following the mother, apologized for the mistake. In a similar case, a mother was forced to delivery at home because the ambulance service she asked for did not come for her on time.
In response to a query on the availability of contraceptive supply Ato GebreMeskel, informed the meeting that there is sufficient supply and if there is any shortage IFHP is always ready to supply immediately. However, sufficiently equipping some health centers with necessary furniture and equipment is posing challenges in providing health services, especially considering the fact that Adigrat is one of the highly populated areas of the Region.
Adigrat Health Center
The TAC then drove to Adigrat Health Center and visited a Youth Friendly Service (YFS) site where health services are provided to youth between the ages of 10-24. IFHP’s Tigray Regional Office through its Adolescent Reproductive Health program started by setting up 3 YFS facilities with the Woreda Health Office. This number has now grown to 24 in Tigray.
The YFS serves both married and unmarried young people within the stated age range. It was explained that more young girls visit the YFS than boys since they seem to have more health issues.
5 Post Abortion Care is one service that is provided by the YFS site and awareness raising on the issue is made by working jointly with schools. However, a religious leader (member of the Adigrat WAC) voiced concern stating that though it is appreciative that this service is available to minimize the rate of young girls dying from abortion complications, it could also mean that there are more and more unwanted pregnancies happening. This in turn is indication that young people today are losing their moral values and freely practicing sex. Furthermore, he questioned, whether or not continuous use of contraceptive could negatively affect the health of these young people?
In response it was explained that contraceptives do not have any negative effects on long time users. It was however suggested that peer educators of the YFS and service providers while linking their work with schools work towards bringing about behavioral change in the sexual practice of young people. They should advise abstinences and delay of sexual activity or practice of safe sex if they cannot delay such activities.
Continuing their visit the TAC visited a group of HEWs following a training program on Integrated Community Case Management (ICCM). This is a six day training provided to HEWs by IFHP and organized in collaboration with the Woreda Health Office. Trainees will visit health facilities as part of the practical training and learn how to identify and provide basic treatment for killer diseases of children such as pneumonia, malaria, etc.
At the time of visit trainees were on their last day of training and felt it has been a useful training. Their capacity and focus of work as HEWs has always been preventive health practices as opposed to curative and communities have frequently questioned why it should be limited to preventive care only. Now, says one of the trainee HEW, this training has given us the chance to build skills in practicing curative health practices as well, complimenting their skills in promoting preventive health practices . Furthermore, it is a very effective approach in preventing child mortality.
Feedback to Zonal Health Department At this stage of the visit feedback was given to the Zonal Department on what has been visited so far.
• Response of Woreda Health Office to concerns and grievances of communities is admirable and should continue.
• Working through Developmental Army of Women is appreciable especially considering their role in mobilizing and involving communities. Similarly the role of WAC was appreciated but suggestions to include Ministry of Women, Children and Youth instead of including only Women’s Association was given.
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• Integrated work among government, NGOs and communities is exemplary. The important role played by NGOs in filling government gaps has been an eye-opener especially the system of running one common health program. It would in fact be useful if this practice of collaborative working be implemented by the other sector offices. The Charities and Societies Agency in fact offered to provide profile on NGOs working in the region to sector offices who were interested to initiate such collaboration.
• YFS are very useful services but it is important to make careful selection of Peer Educators since they themselves first need to be exemplary.
Freweyni Health Center
Driving to Freweyni Health Center the TAC visited around the Health Center. It visited the delivery room and rooms where PMTCT, family planning and ANC services were provided. During the visit it was explained that PMTCT service has reached 84%. In the under five room Integrated Management of Neonatal and Childhood Illness (IMNCI) services and related issues such as growth monitoring, ORT, etc. were given was also visited by the TAC.
The issue of waiting time for mothers coming in for the service was raised as a concern since most of these mothers are usually pressed for time. While thorough service provision was appreciated, the suggestion was that service providers just be conscious of this as an issue.
Next the visiting group dropped into the YFS located within the compound of the Health Center. This is one of the newly established YFS. Sr. Mulu is the service provider at this YFS and has shown great commitment in running the service. She has taken her own initiative in improving the health services provided.
Twenty five peer educators serve at the YFS and out of this number 15 are girls. TAC members encouraged these girls to work as actively as possible especially in advising other girls to take better care of themselves especially in avoiding repeated post abortion care services.
Friday, April 1, 2011 Mekelle Hosptial, Mekelle
The following day driving into Mekelle, the TAC visited Mekelle Hospital specifically Pathfinder’s project of Cervical Cancer Prevention supported by the Center for Disease Control (CDC/PEPFAR). The Medical Director of the Hospital met the group and informed them briefly about the work they carry out. Mekelle hospital which is
7 now almost 50 years since it was first established has 300-350 staff out of which 126 are technical and again out of which 7-8 are specialists. The hospital has an ART room which provides services to people coming from Gonder and Afar as well. It is here that Pathfinder’s CDC/PEPFAR supported program of Cervical Cancer Prevention is carried out and currently the program targets HIV positive women who are more likely to be affected by incidents of cervical cancer. This program started on September 2011 and Mekelle Hospital is one of five hospitals around the country selected for this pilot project.
The TAC was then able to visit around and gained information on how the procedure works. It was impressed by the simplicity and high effectiveness of the treatment especially considering that it is a life saving procedure, which in Mekelle has so far served a thousand women. It does not necessarily require doctors to carry out the procedure – nurses are being trained to do it.
The visiting group commented by stating that the Ministry of Health should scale up this project so it could have wide coverage and more women could benefit from the service.
In response Dr. Fitahnegest Mamo, Mekelle Hospital, shared the views of members of the TAC that the project needs to be scaled up. However, he underlined the fact that training the staff is not sufficient on its own; the commitment of these staff to carry out the task in addition to their already crowded schedule and hospitals willingness to give rooms for the service is the determining factor to sustain the project.
Representative of the Federal Ministry of Health explained that the Ministry has great interest in scaling up this project. In fact, it has already established a Technical Working Group which oversees the work (i.e. developing standard and training material; monitors and evaluates progress; and raises awareness). However, results of the pilot project have to be documented and continuity of the project will then be determined.
REST Office
TAC members then made a visit to REST’s Office (which is an Implementing Partner Organization of IFHP) where they were briefed on the expansive work that REST carries out.
This was then followed by discussion where various questions were raised. In response to a concern raised about the sexual and reproductive health situation of young people in universities it was explained that REST is making efforts. It has introduced a program – ‘Water Drop’ - which helps young people in becoming a part of the development effort of the country by involving them in various community
8 work. A task force has been established to scale this up to other universities in the country. TAC members were invited to support the task force.
REST regularly reviews it performance with stakeholders (Regional, Zonal, Woreda and Keblele offices) and donors. This is one way of understanding the impact of its work. Reviewing it against baseline surveys also gives a better picture of program impact. Responding to a query on the availability of family planning supplies, it was explained that REST does not have any problem since IFHP provides it sufficiently.
In response to a query as to how far youth centers and Youth Friendly Services are integrated, it was stated that peer educators work between the two institutions and provision of health information is made available at both locations. Thus, youth centers are linked to YFS through the peer promoters.
The TAC quarterly meeting Ato Tilahun Giday, Country Representative of Pathfinder International, briefly explained the work of Pathfinder as per the pie chart seen.
Presentation of quarterly report Following this a presentation on IFHP’s achievements during the last quarter (October – December 2010) was made. During the discussion that followed, explanation was given on why these regular reports are presented to the TAC members. It is important that TAC members have a clear understanding of the plan of IFHP, especially its achievement as reported against its plan since each TAC member is expected to provide comment and advice that will help improve the program. Furthermore, for problems reported Government offices could offer solutions or assistance.
In response to a question on sustainability of donor support it was explained that Pathfinder is working on broadening its donor base (beyond USAID) by preparing and submitting proposals in response to various requests for proposal. This issue is worrisome not only at the Ethiopia program level but also at headquarters level. Thus, constant effort is being made in diversifying funding source.
Explaining 70% operational (program) vs. 30% administrative cost, which was raised as an issue, it was stated that IFHP works in supporting government program and this is mostly technical which thus falls under operational cost. Nonetheless, it seems debatable on what activities are defined as operational and what are administrative.
9 Thus, recommendations that Charities and Societies Agency examine this issue further, was forwarded.
Responding to a question on why results areas of IFHP - System Strengthening and Program Learning are separate activities, it was stated that the funding donor had its own specific objectives for having them as such. Thus, IFHP was implementing its program accordingly.
Referring to particular activities, concern was voiced on whether or not Pathfinder will achieve its annual plan of distributing HMIS manuals since quarter performance was reported as being very low. Explanation given was that these activities are carried out based on the availability of government staff to attend training but who could be caught up in urgent tasks. This causes plans to lag behind. Nonetheless, Pathfinder is confident that the annual plan can be achieve within the remaining time period.
On a question regarding Memorandum of Understanding (MoU) signed between IFHP and Ministry of Women, Children and Youth, explanation was given that this is a continuation of what was started between Pathfinder’s Adolescent and Youth Sexual Reproductive Health Program and the former Ministry of Youth and Sports (that used to manage affairs of the youth). The purpose of the MoU is, to support youth centers built with government funds with basic furniture, equipment and in-door games that would be provided by IFHP.
Impressions on the field visit Participants were then invited to state their impressions on the two and a half day field visit they made, which they gave as follows:
• It was very impressive to see that family planning services are given without interruption because there are no problems of supply, which was not the case a few years back.
• It is encouraging to see that significant efforts are being made in decreasing maternal death by intensively working to bring women to health facilities especially to deliver.
• Integrated work between government and IFHP seems to have become stronger than ever in supporting the Health Extension Program (HEP). Joint work ensures sustainability and transparency. Furthermore, resources are used effectively and this experience needs to be shared with others.
• Initiatives taken on improving the situation for youths in Universities is encouraging and should be strengthened to take it further.
10 • Documentation in all health facilities visited was very good and this partially helps in resolving certain problems.
• An area of gap observed is absence of legal bodies in the WACs formed, which would have helped in programs of harmful traditional practices and gender based violence. Since they have important contributions to make, Pathfinder needs to consider their involvement in these programs.
Naming of the trip Upon conclusion of the meeting participants discussed naming the trip after an exemplary or impressive project or individual they observed, as is usually done with each TAC trip. Certain suggestions were proposed and these were Mekelle Hospital’s Cervical Cancer Prevention Program, Sr. Mulu Hiluf from Freweyni Youth Friendly Service, and Adigrat Woreda Health Office (for the initiative it took in apologizing to the women who were not able to deliver at the health center). However, it was finally decided that Sr. Mulu Hiluf of Freweyni Youth Friendly Service be honored with the naming of the trip. Sr. Mulu through her own initiative has improved health services provision of Freweyni YFS. She has also taken initiatives of assisting several young people by involving them in youth programs. She is a young woman who is an exemplary figure for the youth she assists and works with. Thus, the trip was named ‘Mulu Hiluf’s Trip’.
The TAC members then agreed that as per their already developed annual calendar, the next meeting should be held in three months time in Oromia region and details as to specific areas to be visited and specific dates will be communicated to members of the TAC well in advance by IFHP.
Any other business On behalf of the representative of CORHA Wz. Genet Mengistu made a brief presentation on family planning and population growth in Ethiopia emphasizing the important role family planning plays in helping to address issues of high population growth.
This was followed by another presentation by Ato Negash Tekelu, PHE, on the integration of population, health and environment to bring about sustainable development. He emphasized the importance of raising awareness and lobbying that needs to be done in improving grave environmental situations around the country.
The way forward • Pathfinder’s work on family planning/HIV integration work does not come out strongly from observations made during the field visits and as per the performance report. Thus, more effort is expected to be exerted.
11 • Number of sites/projects visited need to be minimized during the TAC visits in order to allow effective feedback from members of the Committee at each site.
• This is the first TAC visit and meeting held since the Committee was revitalized in February 2011. Thus, Committee members who attended the meeting and trip need to work closely together, be committed, and not drop out in future so as to ensure continuity. It is important to open communication channels among Committee members so as to provide feedback to Pathfinder.
12 ANNEX I
Hope for the young
Sr. Mulu Hiluf is a 22 years old woman. She has worked as a nurse for the last three years out of which over the past one year she has been working as coordinator of the Freeyni Youth Friendly Service site in Saesi Tsaedaemba woreda of Eastern Zone of Tigray region.
Being a young woman herself she was responsive to the needs of the young people in this area. She wished to help them by turning the Youth Friendly Service located in Freweyni into a site that would respond to each need of young people from ages 10-24. Thus, through her own initiative she took a bus ride into Wukro town located 40 kms away from Freweyni and dropped into Wukro Health Center. There she met Sr. Amakel Argaw, Coordinator of the youth friendly service in Wukro Health Center. Sr. Amakel being an exemplary coordinator herself shared her experience with Sr. Mulu on how she and her colleagues were able to help the youth friendly service grow to provide comprehensive health services.
Retuning to Freweyni, Sr. Mulu worked hard to change Freweyni Youth Friendly Service into a health facility that provided a range of health services fully responding to the needs of Freweyni’s youth.
Sr. Mulu has also been able to assist young people who completed high school but were neither able to join college or have a job. In addition to 25 peer educators she had (who assisted her in her job by linking the Youth Friendly Service to schools and communities) she trained these youths as additional help to influence and advocate on any health matters of concern.
Always ready to help out, she closely follows up on the youth in her area. She has helped 15 teenagers who had unwanted pregnancies, gave birth and were chased out of their homes. Though some of them had even turned into bar ladies to earn a living to raise their babies, after intensive persuasion she was able to turn them back to working with her and teaching others.
She is a sign of hope for most of these young people as she works with great commitment to pave the way for a better future.
Sr. Mulu counseling one of her young clients
13 ANNEX II
THE VISIT (in pictures)
Visiting a Kebele Chairperson’s house which is one of the model households in Negash.
Developmental Army of Women working with Gemad Health Post, Negash
Woreda Administrator who promtly responds to grievances and concerns of communities, Adigrat
Religious leader who serves as a WAC member and is highly concerned about moral values of youth Woreda Health Office explaining performance of the Health Post, Atsbi
TAC members, IFHP staff, REST and regional media staff
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