Does Ethiopia Need an Electronic Medical Record?

Last week I visited a hospital in Addis Ababa. It was set-up much like all hospitals across the world, with an Outpatient and Inpatient departments, a laboratory, pharmacy and drugstore. However, the buildings were old and dirty and the corridors were filled to overflowing with patients many who looked in desperate need of care. Doctors and nurses say they understaffed and overworked.

I am here to evaluate an electronic medical pilot, which the government intend to rollout across 3,000 hospitals and health centres by 2015. This is in a country in which many areas do not have electricity and those that do are prone to power cuts (even here in Addis I have been without power for more than 24 hours), few people have computer skills and the existing paper based medical record keeping system is poor.

Whilst there are many potential benefits from electronic medical records, few developed countries have realised many of them and the effort required to do this is immense. This raises the question for me of whether Ethiopia really needs electronic medical records at this time. Maybe the money could be spent better? But then who is driving the implementation of electronic medical records? There are many donor organisations who have an interest and involvement in this.

Out and About in Addis Ababa

 

Kidus Raguel Rock Hewn-Chuch

There are hardly any tourists in Addis. Occasionally one might spot an air-conditioned bus with a few Fenegis in it but generally I am the only one around. But then there is not a lot of sight seeing to be done in Addis and a day would probably suffice to see the main attractions. 

Meskel Square is a good starting point for a tour. Next to it, the Red Terror Museum provides a graphic account of the reign of the Derg. During my visit, I was given a personal account of someone's incarceration and torture which makes my visit hauntingly memorable.

Entoto Maryam Church

A few kilometres uphill from Meskel Square, there is the National Museum of Ethiopia. It hosts a replica of the skull of Lucy, estimated to be around 3.5 million years old. The discovery of Lucy proved our ancestors were walking 2.5 million years earlier than was previously thought.

Traditional Dancing

A couple of hours hike out of the city there is a 13th-century hock-hewn church called Kidus Raguel. The church was partially destoyed during the Italian occupation but is still an amazing sight. Visitors are few but the guard is friendly and gives a knowledgeable tour. Also in the Entoto hills is the Entoto Maryam Church where Menelik was crowned in 1882. 

To round off a day of sightseeing, one can go to eat traditional food and watch some energetic and colourful dancers. 

The Cost of Living

The development challenge facing Ethiopia is immense. Its people are among the poorest in the world, the economy is growing too slowly and population growth is rapid.

The median wage in Ethiopia is estimated to be around 300 Ethiopian Birr a month (about £8). A healthcare assistant earns around 500 Birr a month, a GP or consultant around 5,000 Birr and a government official many times more. An IT student told me he hopes to earn several thousand Birr a month when he graduates. But only half of the population participate in work. Most working people in cities are self-employed (around 40%). Government employees make up about 18% and private employees around 16%. In urban areas agriculture is the main work activity.

Whilst the price of food in the market sounds cheap in UK terms (onions, potatoes, bananas and oranges are 10-15 Birr per kilo), a wage of 300 Birr will not go far, given the average number of children women in Ethiopia have is over five (the number is lower in Addis). 

 

The gap between those who earn the lowest or nothing at all and those at the top of the wage hierarchy is growing. Walking around Addis this gap is strikingly apparent. In amongst the shiny new tower blocks and upmarket shops and cafés are makeshift huts, street sellers and beggars. Everywhere you turn there is someone asking for food or money. Like many of my volunteer colleagues, my coping strategy is to simply give away all the coins I accumulate each day to the first beggar I see.

As VSO volunteers, we receive a small monthly allowance commensurate with local wages. This is intended to cover our food, electricity, water bills and transport to and from work. Our accommodation is provided by VSO. By shopping at the local market it is possible to live happily on this allowance. For those volunteers who are placed in rural areas there is nothing much for them to spend their money on anyway. In Addis there are several Ferengi supermarkets where we can spurge 400 Birr on a bottle of imported wine or a tiny bit of rubbery cheese. There are also several luxury hotels where we can eat Ferengi food at Western prices. One of my favourite affordable treats is a mixed fruit drink called Sprice which includes mango, banana and advacado (about 12 Birr).

A Walk in the Entoto Hills

A Walk in the Entoto Hills

Addis Ababa is at an altitude of 2,400m which makes it the third highest capital city. The city has more than three million residents and is crowded and noisy. The air is dusty and polluted from the heavy traffic. But just a few hours walk from the city are the Entoto Hills, where the air is fresh and cool and the views spectacular.

The Entoto Hills were site of Menelik's capital before Addis Ababa – New Flower - was founded in 1887. They are covered in a thick forest of eucalyptus trees. These trees grow at an extremely fast pace and saved the city from being reallocated to a site 50KM to the west called Addis Alem - New World.

Our trek starts at the British Embassy and takes us on a 24K round trip, walking a circular path high above the city. We pass small villages, farms and schools. Small children rush out of their houses to greet us with the usual call of “Ferengi ferengi!” and shake our hands, as well as ask for money in some cases.

The word Ferengi is generally taken to be a generic Amharic for foreigner, but some say it was derived from the word “Ferenchi” which is itself a corruption of the English "French" or "Frenchie" and stems from the time when the English and French were in nearby in the Yemen and Sudan. This certainly fits with my experiences, as I have been spoken to in French numerous times whilst walking down the street.

 

We picnic on a lovely spot overlooking the valley below and the continue our walk passing a new college which is still being built and ending at the hilltop palace where Emperor Menelik II lived with his wife before moving down to establish Addis Ababa. It has taken seven hours, so we take a line taxi back to the city centre.

My Work at the Federal Ministry of Health

VSO has been working in Ethiopia since 1997, first in the area of education and more recently in health.

In 2005 the government put in place the first Health Sector Development Plan (HSDP). This plan in now in it’s fourth phase and a key focus of the plan is to use Information and Communication Technology (ICT) to improve health care delivery and outcomes. Work has been undertaken to pilot electronic systems to collect management information (e.g. for planning, finance and human resource management) and develop an electronic medical record.

My role here in Ethiopia is as a ‘Health IT Expert’ working for the Federal Ministry of Health (FMOH). I will be undertaking an evaluation of the electronic medical record pilot and helping to devise a strategy for national roll-out. The government has defined a very challenging timescale for roll-out, with a target of full implementation across health centres and hospitals by 2015. 

On a day to day basis, I expect to be meeting with various stakeholders and visiting pilot sites across the country to understand what has been implemented and how it works, the barriers and challenges encountered and lessons learnt. Having conducted similar evaluation projects in the UK and Saudi Arabia, it will be interesting to compare and contrast the different contexts and implementation strategies.

These photos show a line taxi which is how I get to work and various sights along the way. My office and desk space don’t make particularly interesting viewing.

More about my house and the surrounding area

As requested by my friend Gail, here are a few more photos of the inside of my house and the surrounding area. 

This is the kitchen and an important item of equipment, the water filter. Every day we need to boil several large pans of water and then filter the boiled water through limestone elements. Boiling kills bugs and filtering removes the muck and debris. 

 

 Here is my bedroom. It is small but I have made it cosy. VSO supply a very hard pillow and a couple of blankets but we had to buy curtains and bedding from the local market which involved a great deal of haggling.

 

My house is surrounded by more gated compounds and a few schools and colleges. In front of this area is a piece of waste ground where goats are tended. Further on there is the main road called Haile Gebre Selassie Road. This road is the main thoroughfare which runs from west to east and leads out of the city to Debre Birhan, Mekele and Asmara. 

My address is Haile Gebre Selassie Road, opposite N.O.C Filling Station in front of the Megenagna Clinic. The house is about half a kilometre from the main road but most roads do not have a name and houses are not numbered. If you want to get mail you need to set-up a PO Box. The general confusion is compounded by the fact the government recently decided to rename 52 of the city's roads after each of the non Ethiopian member states of the Organisation of African Unity.

My House in Addis Abbab

 

This is where I will live for the next six months. It is a two bedroomed bungalow situated inside a walled compound. 

 

We (my flatmate Milat and I) live at the front of the compound and our landlord, Kebele, lives in a house at the back with his family and various assorted helpers. 

 

 

There is a high crime rate here and so most people live in a compound or have a night and day guard to protect their property and possessions. 

 

The house is 10 minutes walk from the VSO Programme Office and Pride Bar which is where the Addis based volunteers congregate. There is a local market, Shola, and a few westernised supermarkets within 20 minutes walk, as well as a few nice cafes. 

 

Inside the house things are quite basic. There is only cold water in the taps. The shower heats water slightly but it is only tepid. There is no cooker or fridge. VSO have given us each a one ring electric hob and a kerosene cooker (for when there is a power cut). Everything is a bit shoddy. Plugs are hanging off the wall, basins leak and door don't close. 

 

 

The streets of Addis are dusty, crowded and noisy but inside our compound it is peaceful and relaxing. The garden is lovely and we have a small terrace with a bench so we can sit outside and enjoy the late afternoon sunshine which is what I am doing at this very moment.