Amidst the discussion and debate about U.S. health care, it’s easy to wish we could just start over. To some degree and with the help of Tulane School of Public Health and Tropical Medicine, Ethiopia is doing just that.
“Our country is one of the poorest countries in the world,” explains physician Kifle Woldemichael, dean and associate professor of epidemiology at Jimma University in Jimma, Ethiopia. “Health indicators like maternal mortality rate, infant mortality rate and under-five mortality are the highest. Moreover about 80 percent of our population is suffering from communicable diseases and malnutrition.”
The need is undeniably great but the University Technical Assistance Program (UTAP) is addressing it. Jimma University has partnered with faculty at Tulane to develop training curricula to expand the country’s growing health workforce, from community health workers to health officers in the Ethiopian Ministry of Health, which brokered the relationship between Tulane and Jimma.
“The government is working hard to build numerous health infrastructures, and staffing these facilities with appropriately trained health work force is the top priority agenda, said Woldemichael. “These all speak for building and strengthening schools of public health in our country.” Tulane’s experience is making it happen.
In many ways, Jimma could be a sister school to TUSPHTM, says Carl Kendall, professor of international health and development and principal investigator for UTAP. “The university is progressive and has a strong focus on community-based education and community service.”
Seven other countries are receiving assistance through UTAP: Haiti, Brazil, South Africa, Zambia, Angola, Zanzibar and Rwanda. Kendall is working with Tulane’s Department of International Health and Development, the Center for Global Health Equity and the Payson Center on those projects, but the bulk of his time and effort is devoted to Ethiopia.
The Birth of a National Health Infrastructure
The expansive international project began five years ago with a seemingly simple goal: developing systems to find out whether health services, particularly those directed towards preventing and managing HIV/AIDS, were effective.
UTAP was launched to find ways to answer that question. The program is funded by the Centers for Disease Control and Prevention, originally as part of the Global AIDS Prevention (GAP) effort. UTAP is now part of U.S. Emergency Plan for AIDS Relief (PEPFAR). At least $60 million has been directed towards the partnership between Tulane and the University of California San Francisco and to develop monitoring and evaluation capacity in Ethiopia.
"If you are thinking about what people are doing when they deliver health services on a daily basis, monitoring and evaluation is one way to professionalize those day-to-day activities," explains Kendall, professor of international health and development at Tulane. "It is a way to look at things health staff do every day and help them find ways to improve their work, or to remove obstacles from achieving their goals. It's systematic research that gives workers more control over their job and the impact of their work."
Ethiopia faces devastating epidemics of HIV/AIDS, tuberculosis and malaria as well as high rates of maternal and infant mortality. The country ranks 170th out of 177 countries in the Human Development Index, with a GNP per capita of $97. Between 4 percent and 6 percent of the country's adults are HIV-positive. Approximately 1.35 million are living with HIV/AIDS, including 120,000 children under the age of 14, according to government figures. The epidemic is estimated to have produced 750,000 orphans.
At the same time, international funding has poured into Ethiopia and other countries in the developing world to try to address these health concerns. Standardized monitoring and evaluation practices would help funders know whether their investments were paying off, points out Kendall.
Tulane faculty have specific expertise in monitoring and evaluation that enables them to direct just this kind of program, says Kendall, From a funding perspective, Tulane’s ability to keep overhead costs low was also attractive.  | Wuleta Lemma, research assistant professor and
country director of Tulane Ethiopia Project, in red, with Jimma University faculty. |
“One of the reasons CDC kept coming back to us is we had a strategy of not having big headquarter costs,” says Kendall.
With low costs, funding went directly to curriculum development, networking technologies throughout the country, and capacity building among health care professionals in country.
One of the keys to success has been working closely with health professionals and health leadership, such as the Federal Ministry of Health, to support their goals for infrastructure development and workforce training.
“Everything we do is national, supporting the minister of health,” explains Wuletta Lemma research assistant professor and country director of the Tulane Ethiopia Project. For example, creating new graduate level training programs at Jimma University has enabled the ministry to keep and invest in their workforce while expanding it.
Lemma is looking forward to initiating two new masters programs in biostatistics and health management in the next year. “We also are working on internet technologies, such as telemedicine, teleducation, and connecting institutions to share medical records. We have the goal of networking 300 facilities in five years.”
The need for telemedical technologies is obvious. Ethiopia has 11 regions and a population of 77 million people with many communities at a considerable distance from the cities. Lemma stresses that the program plans are scalable; where needed, bare bones infrastructures are put into place and expanded over time. As new technologies and methods are applied, program support and education have become increasingly necessary. The scope of education that the program provides is broad, however, and is extending to include a new medical training curriculum.
“One of the biggest things we are going to embark on is medical education. We have 2,500 doctors [in Ethiopia] and most of them are in the cities,” says Lemma. Originally, the Ministry of Health had the goal of training 5,000 health officers and 30,000 community health workers to meet the country’s needs. The Ethiopia Project itself has expanded, from a handful of employees at the outset to approximately 200 today.
As a result, “we have been asked to bring a four-year medical training curriculum to Ethiopia and we are looking at [Tulane’s School of Medicine] for a model. The goal now is to train 9,000 physicians before 2050.”
The Importance of Expanding the Health System
In the 90s and 80s the international trend in health provision was to focus on primary care. Countries with limited resources prioritized building a cadre of doctors over public health infrastructure, which meant that while cities might have adequate medical resources, rural areas completely lacked access to medical care. The lack of investment in public health infrastructure meant that most people had no medical records, and government ministries of health were ill-equipped to monitor the prevalence of diseases such as HIV/AIDS and malaria or the effectiveness of programs to counter them.
“One of the things I like to talk about is that during the primary health movement in the 80s and 90s, the government sectors were kind of hollowed out and that meant that for people who lived in capital cities there was a private health system but for others there wasn’t much in terms of health services,” explains Kendall. “So when TB and HIV needed longer clinical management, the infrastructure wasn’t there . . . so we are recreating it.”
The change is occurring just in time, says Kendall. Chronic diseases such as diabetes are increasingly prevalent in the developing world and require intensive clinical management almost to the same degree as infectious diseases.
“We first began by helping CDC design the monitoring and evaluation systems that [they] used and implemented in all the countries of GAP,” says Kendall. Tulane faculty were integral in identifying indicators to be tracked, developing courses, and designing training programs for monitoring and evaluation inside developing countries. “That original activity morphed into two pieces – health management information systems and training in general. CDC asked us to get started in Brazil to work on a course at a university there that became a test for health monitoring and evaluation in Latin America. We then extended that to Ethiopia where students can get a masters of science in health monitoring and evaluation.”
The curriculum development lead to involvement with the Federal Ministry of Health, says Kendall. Training was seen as a way to retain staff by building a career ladder. The government of Ethiopia established a new group of health monitoring officers. But as the training progressed, Kendall and colleagues realized there was no system to gather information in support of monitoring and evaluation, so they created an associate’s degree program at Jimma University for health clerks who would input data and track records.
“Initially it was all pencil and paper,” says Kendall. “Then we began to work on electronic medical records and the other things people have been hearing about here in the U.S. Then finally, because we were so involved in training staff and setting up information systems, we got involved in human resources for health. So gradually we became this sort of back room for ministries of health.”
The training available through Jimma University not only retains health professionals in government service but expands the cadre of health professionals in Ethiopia and neighboring countries. This year, for the first time, students have arrived from outside Ethiopia’s borders to complete their degrees.
UTAP is part of an international effort to rebalance the distribution of services and resources, says Carl Kendall. The success in Ethiopia provides a shining example of how academic expertise, combined with resources and a country’s energetic commitment at all levels, can help to reorganize the public health infrastructure.
In 2007, the UTAP team received what they thought was the last installment of a five-year, $30 million university technical assistance project funded through the GAP, the implementation arm of the $18 billion PEPFAR. The success of the program, however, has led to an extension of two years funding for additional work.
Tulane Faculty Teach in Ethiopia
When epidemiologist Felicia Rabito arrived at Jimma University in Ethiopia to teach a course on experimental methods, she arrived the night before the graduation of the second class of graduate students. Rabito donned cap and gown to celebrate the event with Kendall and others in the program staff and faculty. She was impressed by what she saw and continued to be impressed by the students as she began her instruction.  | Felicia Rabito, associate professor of epidemiology,
fourth from the left, is shown with students from
Tanzania. The courses at Jimma are attracting
African students from outside of Ethiopia. |
“They’re all professionals. Every one of them already is a health officer or a medical doctor. They are basically working in the field from all around Ethiopia,” says Rabito. Giving research tools to experienced professionals was a treat, says Rabito. “They really wanted to apply what they are doing to their work in the field. That’s what distinguishes a group like them from students who don’t know what they want to do yet.”
Rabito also had the opportunity to observe planning meetings between Tulane and Jimma faculty.
“There’s a lot of respect among the people who run the program,” says Rabito. “It’s very delicate to do something like that. I’m impressed by how committed people are at the local level and the caliber of the students blew me away.”
She also observed that this is happening in a context of increased openness within Ethiopia. The energy of her students is mirrored by the growth of small businesses throughout the country and the return of ex-patriots from overseas.
UTAP’s International Reach
Ethiopia is a central focus for Kendall’s work but UTAP is geared towards other countries as well, including Brazil and Haiti. While the program in Ethiopia focuses on building information systems and training, in Brazil the focus is shifting to working with groups of people who are at-risk for HIV infection, such as men who have sex with men and IV drug users, says Kendall.
“We need new surveillance methodology to reach these populations and get more reliable information about program outreach,” says Kendall, who is constantly challenged by the creative act of developing appropriate measurement tools.
Further north, Kendall and company are engaged in similar UTAP activities in Haiti, where they have been asked to help build the first public school of public health in Haiti in collaboration with Partners in Health.
Overall, UTAP has expanded so rapidly that Kendall admits he has not had a chance to publish as much as he and his colleagues could or should.
“We have enormous need for documentation of all the stuff that we’ve been doing,” says Kendall, who intends to make this one of his many priorities in the months to come.
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Editor: Dee Boling
Assistant Editor: Laura Horne
Contributing Writers: Keith Brannon, Laura Horne,
Donna Kulawiak, Arthur Nead, Fran Simon, Madeline Vann
Photographers:Paula Burch-Celentano, Dominica Fotino, Alicia Duplessis Jasmin,
Jeffery Johnson, Carl Kendall, Rick Olivier, Ryan Rivet, Margarita Silo, Brady Skaggs We continually seek content for publication. Please submit alumni notes, stories, and photographs to Editor, Global Health, 1440 Canal Street, Suite 2430, TW-13, New Orleans, LA 70112 or to globalhealth@tulane.edu. |
