Comboni Lay Missionaries working in Ethiopia

My ministry as a Comboni Lay Missionary here is in administration where I am serving as the manager of the social and development programs of the Church in the Vicariate of Awassa. With health care being one of the Church’s main activities, I have become more and more involved in the coordination of the Diocese’s health program, which comprises 13 health facilities, serving the health needs of 250,000 people who live mostly in the rural countryside. In the last year I became more involved with Bushulo Catholic Health Centre, the major facility of the diocese’s health program, located 6 km south of Awassa. Bushulo was established by the Comboni Missionaries in 1979 and the Franciscan Missionaries of Mary (FMM) took over the management of the Centre in 1987 and I have continued this over the last 25 years.

About 7 years ago, Bushulo began to focus its services towards “Mother Child Health” (MCH) with the introduction of the “Safe Motherhood Program”. Over the last years, accordingly, patient numbers have been growing rapidly – particularly pregnant women, new born babies and young children. The government tells us that we are now bearing 95% of the deliveries in the whole district. Bushulo has continued to focus more and more as an MCH Center, and the great reputation has followed.

We just finished an in-depth evaluation of Bushulo (April - August 2013) to determine the effectiveness of the program and what direction the Health Center should take for the future. The key recommendation was that Bushulo should upgrade to become a specialized Mother and Child Health Centre by forging a “public private partnership” with the government to jointly operated the facility. This would make Bushulo the first and only specialized MCH Center in all of southern Ethiopia (30 million people). The general health care services that Bushulo currently delivers would be taken over by the surrounding government health facilities. The Bishop, Mgr. Giovanni Migliorati, MCCJ, has accepted this recommendation as a noble strategy that contributes to a major need in the health situation of Ethiopia – that of reducing the high maternal and infant mortality. We have now commenced an “investigation of feasibility” to see if we, as a Diocese, are able to undertake this initiative. We have also engaged the Government and we already have an ‘in principle’ agreement from the regional state health authorities supporting the upgrade of Bushulo and we have started negotiations with them on how this will be achieved. I am leading the negotiation and planning team on behalf of the Church. The project has the full support from the National Ethiopian Catholic Secretariat, the executive office of the Bishops Conference.

That is the background on the project. After 34 years of consistent service, we are very confident that this specialization of Bushulo is a great strategy to be responsive the “gap” in the health system that the government is not able to fill at this time. But it will also call for a major investment of time, money, personnel and expertise of the Church to successfully achieve this upgrade.

As a way to promote the wonderful achievement of Bushulo up to now and to generate some exposure for support for the future upgrading, I have written the attached article. I really have a high appreciation for the work of the FMM sisters and have seen firsthand the huge impact that Bushulo is having on saving lives of women and babies here. I felt compelled to share the achievement as a shining star example of the Catholic Church’s contribution to the building up of a more dignified life and society through development of the whole human person.

Bushulo Catholic Health Centre:
Evidenced-based development
with beautiful results
for Ethiopian women and children

Evidence-based development
In the field of International Development, the coined-term “evidenced-based development” is often thrown around, but it is realized in practice far less often than you would think. Without being targeted and justified by evidence of both need and achievement, there can be a flurry of development activities, but they will remain just that – a flurry without concrete impact. My story today is about Bushulo Catholic Health Centre, an example of evidenced-based development that is saving the lives of women and children in Ethiopia through specialized obstetric and pediatric care.

Bushulo Catholic Health Centre, 6 km south of Awassa in southern Ethiopia, has been serving the community since 1979. As a health institution of the Diocese (Vicariate) of Awassa, it provides a multitude of health care services, extended to all, regardless of religion, ethnic affiliation and financial status, from the city of Awassa to the surrounding rural communities, with a preferential option for the poor. The Franciscan Missionaries of Mary (FMM) Sisters hold Bushulo in their loving hands and have guided the evolution of the health service over the decades, based on the changing health needs of the community.

High Maternal and Child Mortality
Health is a major challenge to Ethiopia’s development. Key health indicators are among the lowest in the world. Neonatal, infant and under-5 child mortality rates are 38,78 and 116 per 1,000 live births, respectively (Ethiopian Demographic Health Study 2011).

Ethiopia is in fact one of six countries that account for 50 percent of all under-5 child deaths worldwide, mainly from preventable and treatable infectious diseases complicated by malnutrition (USAID 2008).

This means 1 in 10 children do not reach their 5^th birthday. Progress is being made - under 5 mortality rate was 204 per 1,000 live births 20 years ago (UNICEF 1990) - but the current rate of child death is still morally atrocious given the fruits of medical innovation that the rest of the world enjoys (for comparison, under-5 mortality rate in western countries is 5:1000 births, WHO 2012).

On the side of the mothers, the picture is equally grim. Only 6 percent of babies are delivered at some type of institution assisted by a trained birth attendant or health professional. The vast majority of Ethiopian women deliver at home in less than ideal circumstances and because of this 20,000 mothers die giving birth each year. The Maternal Mortality Rate (MMR) is 673 per 100,000 live births (Ethiopian Demographic Health Study 2011), one of the worst in the whole world (for comparison, the MMR in western countries is around 12). Given this backdrop, two of the ten UN Millennium Development Goals (MDG), numbers 4 and 5, relate to reducing child mortality and improving maternal health - noble and critical goals towards which to work in Ethiopia.

Bushulo Safe Motherhood Program
Zoom in now on Bushulo. Seven years ago, the Catholic Church decided to improve her contribution towards these two MDG by focusing the services of Bushulo towards mother and child health (MCH) through the initiation of the Safe Motherhood Program. The multifaceted program included enhanced ante-natal care (ANC), post-natal care (PNC), community outreach to educate and inspire mothers, an expanded infant/child immunization program, natural family planning, infant growth monitoring and nutrition services, and the pinnacle of the program - 24hr obstetric/gynecological services at international quality standards by specialist doctors, midwives and nurses. The goal was clear and the plan ambitious: reduce mother and under-5 child deaths. Its realization demanded a significant investment of personnel, money and love in abundance.

From April-August 2013, a thorough evaluation of Bushulo’s Safe Motherhood Program was completed, with the objective of assessing its impact and helping guide the future strategic direction of Bushulo. Conducting this type of professional evaluation in itself promotes an evidence-based development approach. As part of the evaluation, a detailed household level survey was conducted on the women in reproductive age group (15-49 years) in the catchment area of Bushulo who gave birth in the past 2 years. The results of the study demonstrate the tangible impact:

Source: Bushulo Safe Motherhood Evaluation 2013; Ethiopia Demographic Health Study (EDHS) 2011 result for the same state (SNNPR)

When compared to the regional state, the achievement is impressive. The results are clear: if women have access to high quality ante-natal care (99% of all pregnant women received ante-natal care in Bushulo catchment area!) through community level outreach, the risk of complications can be detected and these women can be advised to deliver at the institution.

Last year 1818 deliveries were performed at Bushulo of which half were by caesarean section due to complications. This high number of complicated deliveries is attributed to the increased reputation of Bushulo whereby other institutions refer their high risk women for management. Another surprising result is this: of the women who delivered at Bushulo, 100% returned for post natal checkups (compared to 57% of women who delivered at home) and these mothers would then continue with regular immunizations, growth monitoring and health care for their children.

Conquering Mother and Infant Deaths
Ethiopian women prefer to deliver at home due to a complex set of cultural and traditional reasons. For example, the tradition of the Sidama people, the dominant ethnic group around Bushulo, is to bury the placenta immediately after birth in the soil floor of the family’s house, definitively marking your family roots. With institutional delivery, this tradition is broken. That is why changing the place of delivery has been so difficult. Both the government and NGO’s have poured millions of dollars into changing behavior but with little results.

So what is the reason for Bushulo’s success? Top notch Ethiopian obstetricians, experienced personnel, the community based outreach education, the sincere care and love that the FMM Sisters pour into their service – all these are factors. But I would suggest that outcome is the key. Last year (2012) at Bushulo there was only 1 maternal death, and this year up until today with over 2000 births, not one mother has died, despite the fact that the majority were high risk (e.g. ruptured uterus, eclampsia, breech and complicated presentations). This outcome is nothing less than outstanding! It is only such positive outcomes that will truly change the behavior of more women towards institutional delivery. If they see with their own eyes that they are more likely to survive by delivering at the institution, then most of them will choose it, despite the cultural yearning to deliver in their home and village. And you can bet that they will tell their sisters, their neighbors and their daughters to do the same. This is how high mother and infant mortality will be conquered in Ethiopia.

The Exciting Future of Bushulo
Building on these encouraging results, the Diocese of Awassa is moving forward to forge a collaborative partnership with the government to upgrade Bushulo into a fully specialized “Mother and Child Health Centre”. It would be the first and only specialized MCH Center in the whole south of Ethiopia (30 million people). It would be a “Centre of Excellence” in obstetrics and pediatrics offering the best care, along with opportunities for research and training of doctors, midwives and nurses. The Diocese is now seeking donor partners who believe in the initiative and are willing to help fulfill the large investment of funding required to upgrade the facilities, which are now old and outdated. There is a lot of work ahead to realize the noble vision of this specialized MCH Center, but one thing is certain: if ever the term “evidence-based development” could be aptly applied to a project, it is for the future of Bushulo, where need and opportunity meet at the service of the poor.
Mark Banga
Email: mark.awcs@gmail.com