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INTRODUCTION Personal Background I have been involved in teaching and training for over 11years. Firstly at Colleges of Further Education, teaching a range of subjects on various IT, Finance and Business related courses, some franchised by the University of Glamorgan. Over the last 6 years I have been with Gwent Healthcare NHS Trust. Initially as an IT Training Officer, but more recently as project manager for the introduction of the Government’s Basic IT Skills Initiative. Namely, the European Computer Driving Licence, part of the National Programme for IT and funded via the Welsh Assembly Government’s Access-To-Learning project. Just over a year ago I applied for a placement on the International Learning Opportunities Scheme with the Public Service Management Wales. Although I was successful in getting to the last round in the Development Board’s assessment process I was unsuccessful at securing a place. But this did not wavier my interest or enthusiasm. I attended the ‘Wales for Africa’ conference in Cardiff and met an old friend who was involved with the Southern Ethiopia Gwent Healthcare Link. I was introduced to Vishnu Chandrabalan and Biku Ghosh. I started getting involved with the link by helping to develop intranet pages and then helping Vishnu to maintain the new web site. Aims and objectives The aim of the Southern Ethiopia/Gwent Healthcare link is to work in partnership with healthcare professionals, health officials and community and council leaders in order to improve the healthcare facilities in the poorer, more rural areas of Ethiopia. By working together, the links objectives of providing essential resources and a sound knowledge base, and for making healthcare accessible to the local communities, will in time make the health centres in Yirgacheffe, Alaba and Wondo Genet exemplar centres. The objectives of this visit were;
a) to secure commitment from the link and its Ethiopian partners to achieve those aims
b) to help in securing support to provide health centres with essential resources
c) to provide support in helping the health centres take ownership of their development
d) to undertake additional skills training in healthcare delivery
e) to appraise the work undertaken by the link to date and
f) to identify areas of further support and/or skills training.
My specific objectives during this visit had three major elements: The first was to install further e-learning materials (ELITE – the IT skills package, ALSO – the Midwifery package and Microsoft Office) as well as anti-virus and anti-spy wear and to identify and resolve (where possible) any computer ‘clichés’, such as problems with hardware or software not functioning properly. The second was to evaluate the use of the computers and the use of software and e-learning packages installed on previous visits and to evaluate the current skills levels of the staff at the three health centres. IT skills questionnaires and computer training exercises were developed to undertake practical assessments. Thirdly was to undertake additional basic IT skills training. This involved working with the staff, showing them how to use the software to improve both their computer skills and their knowledge in specific health related topics. The e-leaning materials previously supplied along with the newly installed packages were used for this. THE VISIT Our Arrival In Ethiopia
After a quick visit to the Healthcare Suppliers looking for Microscopes, we spent nearly all our first day travelling to Awassa. We arrived early evening, in time to get freshened up and head out to the restaurant. That evening my tasks were already starting. The Link had ordered a laptop for Misganaw, towards payment for his role in co-ordinating and organizing the Ethiopian side the trip. I had previously set up the laptop, initialized and installed various software. I showed Misganaw how to log on and what packages were on the machine. I helped him to access the basic IT skills e-learning package and we went through some of the exercises together.
Awassa
Our little sub-group spent the morning looking at the types of evaluation questions we needed to help us identify what has been done so far and whether any previous teaching is being put into practice. This will provide us with a base line for the Links eventual benefits realization. It was nice to have Meselech involved with us as her insight into Ethiopian practice, and native tongue, proved to be of great value. Others from the group were also working on their individual projects, such as the laboratory teaching seminars and the health centre’s management. Two members of the group were staying in Awassa for the week, and after our farewells the rest of us left for Yurgacheffe. On route, we paid a visit to Dilla Hospital where the initial birth of the link evolved through the commitment of key people like Abarra and Biku. It seems a shame that the teaching side has been moved to Awassa, as, on a personal view, there seems to be a less of a local commitment to improve the facilities at Dilla, although I appreciate that it is more central for the majority of healthcare students to attend at Awassa. The main doctor in charge was one of the Links previous midwifery students, and we were keen to see if any of the training was being used and developed in the hospital. Records seemed to be maintained and it was obvious they work in very poor conditions but changes were being implemented. One issue raised during our time there was in relation to the oxygen concentrators. Four were originally donated, two are still onsite: one was being used by a patient and the other one was broken. No initiative by staff was being undertaken as to the maintenance or the repair of equipment. Although the Link can offer support it cannot solely change internal systems thus there is strong need for the commitment from local Ethiopian partners.
Yirgacheffe Health Centre
After a quick initial visit to the health centre, we met with the Council Officials. Where thanks were given for the support by both parties to date and for the further opportunities of working together in partnership. This was my first visit with the link and what I noticed most was the friendless of the people associated with this project. It felt as if we were all greeted by ‘family’, this shows the commitment between the Link and it partners and the substantial progress that has been made.
Initial impressions of this health centre seemed to indicate very little co-ordination and/or leadership. There seemed to be different ‘responsible’ people in charge of different keys to different areas such as the IT room and the main office, and because I had to wait to get into the rooms, I can emphasise with the staff when they said ‘lack of access to the facilities prevented them from using the PC’s more regularly’. When I did eventually get into the room it was very dusty and unclean although the computers were protected to some extent with plastic covers. There was also no electricity thus I lost a lot of actual computer time on day one, so I undertook a verbal evaluation of the staff’s computer skills, questioning staff in relation to their computer usage and ability, not ideal, I would have preferred to undertake practical assessments. The staff still had a very busy health centre to run and queues of patients to attend to thus trying to arrange a schedule for staff to visit the IT room also proved difficult. I then encountered the same problem on our second day – unable to access the training room due to initial non attendance of the key holder. We were informed previous to our visit that one of the monitors was broken but after initial assessment it was identified that it was in fact the hard drive of the CPU that was not working. The office monitor was flickering badly and was causing difficulty for staff to read the screen and would eventually cause eye problems thus the monitor from the IT room (attached to the non-working PC) was swapped with the one in the office. This meant that we only had one working PC at Yurgacheffe, although the windows package on this machine was not running properly. I tried to reset the windows settings but this meant I had to reinstall the package, this would have meant any data already installed would be lost. I did not have enough time to do this so I left it but the computer was still usable. All software was installed successfully and I created short-cut icons on the desktop for easy access to the newly installed training packages. An area of concern is the socket as it is very dangerously hanging off the wall, staff might have an electric shock from it and it was pointed out to some of the health clinicials.
The computer log in indicates that the computers were used on a sporadic basis. It is difficult to identify to what purpose they were used, as the log only records log-on data. The evaluation of skills identified that staff had varying levels of IT ability, some very basic and some had reasonable skills which they learnt previously at university. Staff from the following areas were seen; Midwifery, Under 5 Opedics, Emergency, Pharmacy as well as the Environment Technicians, Lead Midwife and Lead Nurse. Evaluation of the questionnaires highlighted that some staff seem to use the PC regularly for accessing the e-learning materials and use this knowledge for improving patient care. Whilst the majority of the others cited lack of access to the room prevented them from using the computers. As mentioned earlier, a more through assessment of practical skills would have provided a more comprehensive analysis of e-learning appraisals and training needs evaluation. I trained a few of the staff with IT skills on how to access the e-learning packages and how to use the software to teach themselves additional computer skills and I asked a few of these if they could then cascade this training down to the other staff. I left a training logbook at each of the health centres, to record what training the staff were undertaking and for how long. I am hoping both these initiatives will be carried forward.
Two other meetings were held during our time at Yurgacheffe: one was with the health centre staff in which praise was bestowed on the staff for achieving vast improvements under difficult circumstances since our last visit and to discuss with them their needs in relation to the support they require, not only from the link but from the local health and political officials, and, community groups and leaders as well. This acted as a spring board for the next meeting which was to build commitment between the groups, for developing a stronger partnership for the benefit of the health centre and the local population. It was a very productive meeting and representatives from all parties signed a Memorandum of Association.
Alaba Health Centre
Although very basic the health centre at Alaba seems to run more effectively. Access to the IT room and computers was readily available to all staff and most of them used the computers to varying degrees of competency, this was backed up by the computer logs and their evident skills when undertaking the evaluations and training. Some staff were able to access the e-learning packages from the icons on the desk top and worked their way through the basic introductory exercises with reasonable confidence. All software was installed on both computers and all equipment was working. One of the PC’s Windows software had been reset. The monitor was displaying large icons on the desktop, some folders would not perform certain functions and some settings options in the start menu were missing. The problem here was due to the fact that the PC had been locked down, not sure who by or if it was done accidentally. The passwords I was given didn’t allow me access so I had to leave it but it was working and staff were able to access both machines. I also created icons on both machines for easy access to the new e-learning materials and this would also bypass the requirement to access the files through windows.
Evaluation of the questionnaires indicated that most of the staff at Alaba used the computer – although work commitments rather than room access, would dictate the length of training undertaken. Staff in; pharmacy, midwifery, as well as a laboratory technician, the secretary, the health officer and several clinical nurses were seen in Alaba. Some had accessed the e-learning materials left previously but I did not have enough time with the staff to undertake the e-learning evaluation tasks set. Evaluation of skills highlighted that most of the staff had very basic computer skills although some had very good IT ability; these were also trained to act as cascade trainers to other staff. The Health Officer had very good computer skills and in her evaluation she identified using spreadsheets as one of her training needs so the training I did with her was more user specific. We used the health centre data to design a computerised version of the wall chart. I have asked if she would also act as a catalyst to help train and improve the IT skills of some of the other staff. All of the staff assessed seemed keen to learn. I spent a lot of the time training and assessing skills via practical observations all completed the ELITE introductory sessions. Only managed to have about 15 minutes of training with most members of staff as they also had a very busy health centre to run with lots patients to attend to thus like Yirgacheffe, arranging a schedule for staff training also proved difficult so staff were just dropping into the room when available. Another training log book was left at Alaba, all training undertaken was recorded as an example of the information required and like before it is hoped the initiative to continue with the training will be maintained.
Internet access could be available here as there is a communications link in the town and there is a telephone in the room they use, The Health Officer will look into the possibility of having the necessary communication infrastructure link to the health centre and to its cost. We also had a meeting with the health centre staff, the health officials, community leaders and, community and women’s groups. It went very well and open discussions were held, decisions were made as to the roles and responsibilities of the different partners and the Memorandum of Agreement was also signed by representatives of all groups.
Wondo-Genet Health Centre
First impressions of this final health centre were surprising. After the dry and dustiness and the dilapidation of some of the buildings in the previous health centres, Wondo Genet looked very pleasant and colourful as we turned into the drive. The grounds were abundant with flora and forna. The whole layout of the facilities had been carefully planned (albeit by a group of monks in years gone by). The running of the centre was very well organized and disciplined and there seemed to be a sense of friendship and camaraderie between the staff. Some have not been there long but all enjoyed working there. Most of the rooms are locked in the evening but keys are available from the Health Officer if/when required. After initial viewing of the centre and its buildings I headed for the IT Room, it was a lot cleaner than at the other centres and definitely not as dusty. Therefore indicating better cleaning regimes in the centre, one point noted to the Health Officer was the possible risk of fire. Where the cleaners had mopped the floors there were pools of water under the power surge protectors and the electrical extension leads. Upon review of the machines, I discovered one was not working. After investigation, it was in fact the monitor that was not working. This could be down to the bulb having blown inside due to fluctuations in electricity supplies. I swapped the monitors between the two PC’s in order to install all the software on both machines. I also installed the printer on the fully functioning machine and installed the printer driver from the CD, as the printer was not connected to any PC at the time. The printer cartridge also needed replacing so this was done as well. One very disappointing end to our visit was when we also had the second monitor stop working near the end of our second day but we did manage to arrange for the monitors to be replaced with those left at Awassa. The Health Office came to collect them from us. We also supplied her with another printer and cartridge and another power serge protector for the monitors.
Analysis of the evaluation questionnaires indicated once again that most staff had really very basic IT skills and there were also a few staff that were able to use the computer more proficiently. Again most had learnt these basic skills at the college when undertaking their professional qualifications. Some had accessed the internet at college – albeit for sending and receiving e-mails and not for study or research. Some staff knew where to find the e-learning materials installed last time and were using them regularly and also used some of this knowledge to improve patient care. Once again didn’t manage to undertake the full practical assessments of the e-leaning evaluations due to time. Again varying levels of IT skills, those staff that had good computer skills were able to complete the self assessment on the programme, although I did help in the area of Microsoft Outlook as they were unfamiliar with the package. The staff with very basic ability were eager to complete the basic introductory modules. Of the staff assessed most completed the ‘mouse’ skills tests and some went onto the keyboard sessions. Most tutorials had various elements of games for trainees to develop skills and this made it fun for them. Once I started training it was obvious that the staff here were very keen to learn new skills lots were coming in for training which was very encouraging. It was nice to see the staff interested and most kept coming back into the room when there were breaks in their normal duties. All said the ELITE skills training package was very good and they would use it again. Those that completed the introductory sessions and self assessment tests were given certificates. I also left a training log book in the IT room and we were completing it after training was undertaken so they could see how to record the information required and encouraged them to use it. Staff in the following areas were assessed and trained; Clinical Nurses, Pharmacy, Druggists, Environmental Health and the Health Officer.
The Health Officer at Wondo Genet, was very organized. She had prepared a coffee festival for us at lunch times and also arranged for the staff, health officials, church and community leaders as well as other community groups to be in attendance at the meeting. It was very well attended by a large number of diverse groups. Their local Memorandum of Association was also signed by group representatives, and agreement was reached as to the responsibilities of each of the groups.
Awassa College
This hospital has only been opened for about 2 years and is still in its infancy, but seems to be very productive from what I have seen so far. Very difficult to really appreciate now far it has come especially when there are still lots of rooms empty, but nonetheless it is doing well considering the resources available. Very disappointed that the computer room had hardly been used since it was set up so it was decided to leave it and concentrate on finding the equipment needed for Wondo Genet. The equipment in the store room was checked and out of the four PC’s stored only two monitors were working. One was damaged and one was not working. Most of the equipment was taken out of the hospital and stored with Abarra. The equipment we took for the health centres consisted of the two monitors, one printer and ink cartridge and two sets of speakers. These were collected by Metasebia when she joined us for lunch at the hotel in Awassa. I returned to the college in the afternoon with some of the others who were visiting the labs. One of the medical directors, Dr Tizarzo had requested during our visit in the morning, to have the anti-virus and anti-spy wear installed which I did and also ran the virus check on both his computer and that of his secretary’s. I was unable to install this software in Dr Yifu Berhan’s PC and it was all taken apart due to his office renovations. OUTCOMES OF THE VISIT Substantial progress has been made on this visit. With such successful meetings at all of the centres in establishing and furthering commitment to the investment of all of the health centres, firmer links have now been established between the Southern Ethiopia Gwent Healthcare Link and its Ethiopian partners. Further progress can now be made towards developing these centres as ‘centres of excellence’.
Memorandums of Association were signed after firm agreements were made by all parties to improve the infrastructure, resources, facilities and conditions at each of the health centres. These responsibilities range from the supply of basic resources, such as clean water, sheets, curtains and other provisions right the way through to road and transport improvements. Training was undertaken in areas such and laboratory lectures midwifery, trauma as well as basic computer skills training. By providing additional learning resources such as books, e-learning packages and equipment such as training dolls/dummies, trained staff at all of the health centres are able to deliver additional training themselves and individuals are able to undertake their own personal development. Evaluations were undertaken in all areas and by each member of the visiting group. From the reports submitted, full appraisals can be made of the work undertaken by the link not only from previous visits but also from all that was achieved this visit. These reports will also identify areas of concern, from which a programme for further development in the way of support and/or training can be provided to the health centres either by the link or from their local partners.
As for the objectives of my role, I was very busy and I did have a very productive time at all centres and I felt all the elements were achieved, some in more depth than others partly due to lack of resources such as electricity supply, some due to not having the necessary computer parts and some down to the difficulty in securing the time of the healthcare workers away from their clinical duties. Computers do sometimes have their own inherent problems and working with then under normal circumstances can be very frustrating, this is exacerbated when working in a third world country when a constant and regular supply of electricity, components or sufficiently qualified maintenance personnel are not available. Nonetheless, the software was installed on all of the machines at all of the health centres and provided the new monitors were installed at Wondo Genet, all the computers were working, apart from one at Yurgacheffe.
Evaluations of computer usage were completed also to varying degrees. It was straight forward to get printouts of the computer logs but these did not indicate what the computer was used for only that is was logged onto on a particular date. Apart from the questioning of the staff there was no documented evidence of how long staff used the computer or what they were using it for. Thus training logs books were left at all the health centres. Evaluation of IT skills was also achieved to varying degrees. Lack of time at Yurgacheffe, due to power supplies and the available time with all staff due to securing their time away for their normal duties, inhibited progress in this area. The practical e-learning assessments proved far too time consuming to undertake as did a full evaluation of the IT skills of all the staff. Skills’ training was successful in the areas of:
a) The questionnaires and identifying the IT skills level of the staff. I did manage to have some time within each of the three health centres, using the practical skills assessments. These identified that throughout the health centres staff have different abilities in IT skills, although all had a basic understanding of logging on and accessing relevant learning materials and
b) Training staff in the use of the e-learning and basic IT skills packages installed. All staff trained were shown how to access the new software, all undertook the introductory sessions of ELITE. Some with more reasonable skills undertook higher levels of skills training and were asked to be cascade trainers to other members of staff.
A training log book was left at all of the health centres so we can have a record of any basic skills or e-learning undertaken by staff on our next visit. Three unplanned activities requested were;
a) To visit the IT room at the local school in Yurgacheffe, they wanted assistance in sorting out some of their computer problems, but unfortunately when I visited the school on the Monday afternoon, there was no electricity supply. And due to my workload at the health centre, I was unable to arrange another visit
b) The installation of the anti-virus and anti-spyware software on Dr Yifru’s and Dr Tizarzo’s computers. Unfortunately due to office renovations I was only able to install this software on Dr Tizarzo’s and his secretary’s computers. I also scanned both computers for any computer viruses.
c) Additional computer training for Misganaw. Misganaw brought his computer along with him when the party regrouped at Wondo Genet. He wanted me to go through the ELITE e-leaning package in more detail explaining how to do some of the tasks involved. I spent another few hours with him and he progressed very well. When I returned to work, I also sent him additional training materials for the powerpoint software package so he is able to undertake computerised presentations.
Key Impressions
This was my first visit with the link and what I noticed most was the friendless of everyone we met. It felt as if we were all greeted by ‘family’, this shows the commitment between the Link and it partners and the substantial progress that had previously been made. A coalesce of a wider group of local partners, to work in collaboration for the benefit of the health centres and ultimately the local communities as a whole, was certainly evident this visit. It was also evident that the three health centres were managed and maintained with completely different leadership qualities and styles.
Yurgacheffe seemed to be run on a very ad-hoc basis. The centres seemed very busy with queues of people at each of the centre’s buildings; it was difficult to really see who were patients, although some areas seem to run efficiently, such as the pharmacy and the lab. There was a lack of personnel care, a pregnant woman was left for a whole afternoon in an unsuitable room with no regular visits from a clinical nurse or midwife. There also seemed to be a lack of cleanliness in some areas. Alaba seemed to be run more efficiently, but all of the above issues were also evident here. The centre was busy and some patients were left unattended or unsupervised for a long time. One gentleman was on a hospital bed with a drip of some kind in his arm and his companion kept asking for a doctor or clinical nurse to attend to him but again seemed to be left without regular visits. Wondo Genet seemed to be well managed and far more organized. Rooms were clean and grounds maintained. Did not see much of the patient waiting areas so I cannot comment on the staffs’ personnel care of their patients. All of the health centres lacked clean basic public amenities and some even lacked basic water supplies.
In relation to IT, I was very surprised to discover that nearly all of the staff assessed did have at least basic IT skills. All knew how to switch the computers on, navigate their way around the computer and access the e-learning materials. All were very keen to learn more skills to be able to use the computer better and all enjoyed the training package I was using. Finally, though, it was very disappointing to visit a well equipped IT centre in Awassa to be told that the room is very rarely used. Further analysis would need to be undertaken next time to establish why and what initiatives could be put in place to make sure this resource is used in the future. Future work plans From the evaluation of this visit the following should be undertaken; Audio cards and appropriate software needs to be installed on all PC’s. Most of the e-learning materials have video clips and/or narration which would undoubtedly improve the understanding of the topics being learnt. Install power surge protectors for the monitors as well as the PC’s, this should help alleviate the issues the health centres have with the monitors breaking down. Computer maintenance. Here lies the dilemma, without IT literate staff who are able to use the PC’s confidently and competently, problems with computer malfunctions and software errors are going to continue. If most of our time each visit is getting the functionality of the machines working properly again then we have less time for the evaluation of skills and particularly skills development. Less time for training means what little computer skills the staff already have will diminish. With regular reports coming in from the health officers maybe a more structured programme or set of learning initiatives can be established ready for our next visit. Regular development time for each member of staff to undertake at least one hour of training each week should ensure that IT skills levels are not lost.
Each health centre has a reasonable size IT training room, thus there is the possibility of making these rooms into more effective leaning centres. Additional books, training equipment and other resources could be donated to provide additional learning resources. A facility for each for the health centres so health officers can contact either their local community partners, or a contact at Awassa hospital, should be established so any computer parts required or any computer repairs (such as faulty monitors) can be obtained locally.
The following should be taken out on our next visit; a hard disk for the Yurgacheffee health centre PC and a printer driver disk for the Alaba health centre. A request for e-learning materials in relation to drugs was made by Yeshitila at Wondo Genet. A review of possible software should be undertaken and this should also be taken out on our next visit. CONCLUSION I developed personally by working with a diverse group of skilled professionals. Each with substantial experience in their fields and most having experience of working with the link and its Ethiopian partners on previous visits, their support and encouragement was gratefully received. I have benefited from the holistic view of how the health centres run which will also provide me a clearer understanding of how our health centres and hospitals operate.
Working with Staff from the health centres and seeing the conditions they have to work in, is a truly humbling experience. Many have worked hard to improve the facilities and conditions of the heath centres and to the commitment they provide to improve the health of the local population. Having this opportunity will allow me to encourage diversity and equality in relation to our work back in Wales and to the workings of the Link and how we can provide support.
Hopefully the links made and the Memorandums of Association signed by representatives of the local Ethiopian partners, will mean more local ownership can be developed and that a more substantial infrastructure can be provided for the heath centres and the local communities. I would just like to finish off by thanking the Southern Ethiopia Gwent Healthcare Link for providing me with such a fantastic opportunity to work with our partners in some of the rural health centres and to the team of staff for being a wonderful group to work with. I would also like to thank all the partners and staff I was fortunate to met and work alongside at the health centres and hospital, they all made me very welcome and I thoroughly enjoyed the experience.
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Visit Reports 
