Training for the future: Building sustainable health systems, one doctor at a time

By Oscar Abello
Dr. Kassahun Desalegn Bilcha, a dermatologist at Ethiopia’s University of Gondar hospital, is working to improve medical care and continuing education in the country by ensuring the aid resources allotted for both are spent smartly and promote sustainability in the process. Photo: Petterik Wiggers / Oxfam America

An Ethiopian doctor charts a new course to end foreign aid dependency by equipping his peers and the health system with the skills and resources they need.

In the yellow hills of northern Ethiopia near Lake Tana, the source of the Blue Nile, is the country’s first and most prestigious medical training institution. Founded in 1954, it is known today as the University of Gondar College of Medicine and Health Sciences. The University of Gondar Hospital provides essential healthcare to a catchment area containing about 6 million people, some as far as 200 miles away.

One of the university’s proud alumni is Dr. Kassahun Desalegn Bilcha, a dermatologist who grew up in Gondar. Dr. Bilcha sees 20 to 30 patients per day in the outpatient dermatology ward at the University of Gondar Hospital, as well as consulting on patients in other wards such as general medical, malnutrition, and leishmaniasis.

But the hardest part of Dr. Bilcha’s job these days is not his patient load. It’s often revising the expectations of his peers.

Co-author of the African Dermatology Handbook and former clinical director at the University of Gondar Hospital, Dr. Bilcha is the founder and director of the King Holmes Continuous Professional Development Center, which is currently responsible for the continuing education of health professionals in ten hospitals in the Amhar Region of Ethiopia.

“When we took over the in-service training for medical professionals, we reduced the per diem to just 150 birr ($8),” says Dr. Bilcha. “Many people were angry."

As is common throughout Ethiopia and across Africa, health professionals are traditionally paid a daily rate, or per diem, for their time spent in continuing professional education, which is mandatory.

Dr. Bilcha treats one of his patients at the University of Gondar hospital. Photo: Petterik Wiggers / Oxfam America

Continuing education can get expensive. Beyond the per diem are also the stays in luxurious hotels, with fancy conference rooms and expensive meals. And don’t forget the fee to the conference management contractor company—usually 20 percent of the hotel bill. Continuing education, while vital to quality healthcare throughout the world, is also big business.

The King Holmes Continuous Professional Development Center has sparked a massive shift away from that model in Ethiopia.

“It’s been endorsed by our Ministry of Health as a benchmark of transition, a benchmark of capacity building,” Kassahun says. “We had a plan to be the leading in-service training center in the country."

The Center took its name from Dr. King Holmes, a professor at the University of Washington’s School of Public Health. Dr. Holmes, once dubbed “The King of Global Health," was the lead on the US President’s Emergency Plan for AIDS Relief (PEPFAR) grant that got the Center started. PEPFAR 2.0’s aim was to move from pure emergency care to more sustainable healthcare systems.

“Under PEPFAR it was important in an emergency setting to make as many health professionals as possible aware of how to treat HIV and AIDS, as quickly as possible, but the way we were doing it was not sustainable,” explains Dr. Bilcha, who was also a New Voices Fellow of the Aspen Institute.

Eventually, these trainings had to be conducted by the Ethiopian government-supported healthcare systems, whose resources are already stretched thin.

The Center started as a partnership of the University of Washington’s International Training & Education Center for Health (I-TECH), the Amhar Regional Health Bureau, and the University of Gondar. Per the agreement, I-TECH’s involvement and the PEPFAR financing that came with it was phased out over the course of four years, as the Bureau’s support phased in.

The Center is now entering its second year without I-TECH and PEPFAR funding. They've just renewed their contract with the Amhar Regional Health Bureau, agreeing to train 1,000 health professionals in the next year.

But that’s hardly the only money coming into the Center.

After the first two trainings in 2010 took place at hotels as usual, they were able to move the third training to a university guest house, and later secured the use of lecture halls for training sessions. Using the cash that would have went to hotel lodging, conference room rental, and the event management contractor, Dr. Bilcha’s team began renovating a few buildings on the hospital campus, adding a kitchen, training halls, and a tea break terrace overlooking the hillside.

Dr. Bilcha speaking to his health professional peers during a continuing education session at the King Holmes Continuous Professional Development Center. Photo: Petterik Wiggers / Oxfam America

The investment is already paying off. Besides securing the contract from the Amhar Regional Health Bureau, the Center is a popular training site for international NGOs working in the region. On the training schedule the day we visited included: four Save the Children training sessions on maternal and neonatal health; two Jhpiego training sessions; and more. A 21-day maternal and neonatal health training grosses 21,000 birr (about $1,000) for the Center. The tea break area does very well on its own too, serving hospital staff, medical and nursing students, and other visitors.

All in all, Dr. Bilcha estimates, training hall rentals and the tea break shop gross the Center about one million birr ($43,000) per year. And there are even bigger plans for that money.

“We want to build our own lodging at the Center,” says Dr. Bilcha. “What we’ve earned is not quite enough so we plan to make a proposal to the university to invest in a new enterprise, for-profit, that would run by itself as a regulated and staffed hotel."

“Gradually we want to expand it, and make this a training center for the country and for Africa, for anybody who wants to pursue some training on tropical medicine,” says Dr. Bilcha. “They can come here, pay us a fee, and get the same training we are already delivering."

After four years, Ethiopia’s Ministry of Health said now they are going to establish 30 more in-service training centers at universities throughout the country. In the meantime, the Ministry is planning an even bigger overhaul, hopefully an upgrade—by shifting the payment burden to the professionals themselves, and eliminating the per diem practice entirely at locations that can provide their own lodging and meals. Given the growing network of in-service training centers like King Holmes at the University of Gondar Hospital, they will also introduce a licensure system to have medical staff certified through these training centers in addition to their academic training.

“At least that’s what they've said,” says Dr. Bilcha, adding that for one thing they will need to add a continuing medical education cred to medical staff salaries. “We’ll see what happens in September."

This story is part of an Oxfam series that highlights local leaders who are standing up for accountability, making demands of their government, and getting results in the fight against injustice. Though Oxfam may not fund every project or organization featured in the series, Oxfam stands in solidarity with all those around the world working to right the wrong of poverty.

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