Hanna Ingber Win, the Huffington Post's World Editor, was recently invited by the U.N. Population Fund to visit its maternal health programs in Ethiopia, which has one of the world's worst health care systems. In the U.S., a woman has a 1 in 3,418 chance of dying from complications due to pregnancy, childbirth or unsafe abortion. In Ethiopia, a woman has a 1 in 7 chance of dying. Here is a piece about what she learned on her trip.
MEKELLE, Ethiopia — The white tile floors in the Ayder Referral Hospital in Mekelle, a large city in northern Ethiopia, look so clean they practically sparkle. Unlike the maternity ward in Jimma that reeks of human waste and sickness, this hospital smells sterile and clean.
Nurses gather at their station writing down their patients' information in orderly files, and a small handful of visitors wait patiently in the corridors. The multistory hospital with a manicured garden and televisions in the hallways looks so modern and fancy it could easily belong in New York.
There's just one problem: many of its new beds go empty.
The hospital, which opened in September 2008, does not have enough doctors or medical equipment for the facility to be fully used. Of the 450 beds in the hospital, only about 65 percent can be filled.
"We aren't serving the numbers we are supposed to serve because of the lack of staff," says Dr. Amanuel Gessessew, an associate professor of gynecology/operations and the hospital's sole gynecologist.
Ethiopia has one physician for every 38,000 people. The lack of medical professionals — a result of not enough trained medical students and an inability to retain Ethiopian doctors — has resulted in a health care system that ranks among the worst in the world.
"This government has failed at the very important task of training the professionals," says Dr. Beyene Petros, chairman of the opposition United Ethiopian Democratic Forces party and a member of the Ethiopian House of People's Representatives. "You can put up huge buildings, but if you don't have a program to properly train and maintain the manpower, what's the value?"
The Ayder Hospital, which serves as the one referral hospital for 4 million people in northern Ethiopia, has only 14 doctors including two internists, one surgeon, one pediatrician, one gynecologist and nine general practitioners. To be fully operational, Dr. Amanuel says the hospital should have at the very least five specialists and six general practitioners in each department.
"We need more doctors, more educated doctors with specialties and more equipment," he says as we stand near the nurse's station.
I ask what types of procedures the hospital cannot perform due to lack of equipment, and Dr. Amanuel rattles off so many that I get lost. I hand him my notebook, and he jots down some examples: endoscopy, laparoscopy, hysteroscopy, colposcopy, colonoscopy, radiotherapy.
The poor health care system has a huge impact on Ethiopia's women and girls and causes hundreds of thousands of preventable deaths every year.
In an effort to beef up the nation's health care system, the Ethiopian government has installed 30,000 health extension workers in rural health posts around the country to provide basic services like family planning and immunizations, and has started a pilot program to formalize a health strategy called task shifting.
The task-shifting program, which has also been implemented in other African nations like Mozambique and Malawi, trains health practitioners who do not have medical degrees to perform emergency and obstetric surgery.
"Expansion of health center services to provide basic emergency obstetrics care services in these facilities is also undergoing that will ensure universal health center services by end of 2010," Dr. Kebede Worku, state minister of health in the Ethiopian federal ministry of health, writes in an email. "Training of health officers in collaboration with Ministry of Education and The Carter Centre/USAID is mainly to improve maternal health. The emergency surgical officers will be placed in primary hospitals [which] serve about 100,000 people."
The task-shifting program receives financial assistance and support from the UN Population Fund (UNFPA), which sponsored my trip to Ethiopia, and is being implemented in Mekelle, Jimma and Hawassa universities. The budget for the first five years of the program is $6.7 million, as of July 2008, according to UNFPA.
"The program aims at increasing the number of trained medical practitioners especially in rural areas where the availability of health workers is inadequate," according to a statement from the UNFPA. The lack of medical practitioners and health facilities are the main factors contributing to Ethiopia's high maternal mortality rate, it states. In Ethiopia, approximately 673 women die for every 100,000 live births, according to the country's Demographic and Health Survey conducted in 2005.
Health officers receive training for three years in basic emergency surgeries and are given a specialization. They then receive a Masters of Science in Surgery (MSc).
The purpose of the program is so the country does not see "any more women dying in childbirth," says Dr. Chuchu, the clinical director of the Jimma Specialist Hospital and program director for the MSc program there.
Goitom Berhane, 31, is one of the 55 health officers being trained in this program. He has finished his first three months of training and is now in a phase similar to that of being a resident. He says he always wanted to become a medical doctor, but when he graduated from high school he did not have the opportunity to attend medical school, he says as he stands in the maternity ward at Mekelle's Ayder Referral Hospital. The ministry of education at that time randomly assigned students to colleges, regardless of their grades or interests, and it assigned him to a college that did not provide medical training.
Goitom studied public health and got a job as a health officer in northern Ethiopia. Even though he had no formal training, he performed surgeries at his hospital because they had no one else to do them. He worked long hours, was on call every night and earned only 1,600 birr a month (about US$125).
"I couldn't leave the hospital; I couldn't leave the town. [There was] only one in charge of handling difficult births," he says, recalling the difficult conditions under which he worked. He said the staff was trained so poorly and had such little equipment with which to work that mothers needlessly died in the hospital.
"I had no [ability to provide a] blood transfusion, and in some instances I become very successful, and in some ... deaths on the table."
Goitom says that the MSc program provides the first opportunity for him to get clinical training. He wants to follow it with training to become an MD, but he does not know if the government will create such a track for health officers like him.
He says he does not know how much he will be paid by the government once he gets the MSc degree, and he therefore does not know if he will be able to stay in Ethiopia. He says he feels frustrated by the lack of respect he is given as a medical professional by the government and the inability to continue his studies and become a doctor.
Asked if he wants to stay in Ethiopia rather than emigrate to the West or wealthier African nations like so many Ethiopian doctors, he says "definitely."
"You see mothers dying, young ladies with their first baby dying — you can't leave this," he says. What would be most meaningful to me would be "to stay here and serve the poor."
While the Ethiopian government has shown some commitment to improving the health care system, critics argue that its efforts pale in comparison with the extent of the problem.
"Some of these are good programs," Dr. Beyene says, "but they address only a tiny, small portion of the 80 million people."
To read more of Win's series on Ethiopian maternal health and to see her photographs, click here.