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Good Practice Document

Name of the Implementing   Organization: Mahibere Hiwot for Social Development (MSD)

Address: Tel. 0118 699419 & 0918 353447, Email:

Donor: Simen Mountains Mobile Medical Service

Project Name: Expanding and Extending Medical Services in the Simien Mountains

Project Implementation Area: Amhara Regional State, North Gondar Zone, Janamora, Debark, Beyeda, Adi Arkay, Tellemt Woredas

Project Period of Implementation Including Current Status: August 1st 2015 to December 31st 2017 and the project is underway implementing its 4th quarter plan.

Total Project Budget: ETB 3,494,535

Objectives of the Project: To sustain free community based medical service providing treatment, referral and follow-up for common injuries, ailments and natal care, as well as basic first aid training and improved health and hygiene awareness for the people of the Simien Mountains of Ethiopia.

Strategies of the Project Implementation: The key strategies includes free medical service at clinic and through mobile nurses on preventive medical care, treatment, referrals, and follow-up care and health education, training in basic first aid, training and placement of midwives, networking of midwives and trained HEWs,  and collaboration with local officials, health facilities, and colleges. 

Project Beneficiaries:

Direct Beneficiaries: 250,000 people living in the remote areas of the Simien Mountains of Ethiopia who suffer from lack of even the most basic medical treatment and health care, especially women during pregnancy and child birth, as well as infants and children less than five years.

Secondary Beneficiaries: The secondary beneficiaries are the regional and local medical and health services who lack the capacity to deliver essential services to the underserved populations in these remote areas.

  1. Innovativeness

The Simien Mountains in the North Gondar Zone of the Amhara National Regional State of Ethiopia is a remote, largely inaccessible mountainous area, with a population of around 250,000. Lack of roads, electricity, communications and regular access to the health care and medical treatment are among the major obstacles of the community surrounding the mountain.  Consequently it is one of the highest risk areas of Ethiopia in terms of the lack of health care, infant mortality, premature death from preventable diseases and the consequent reduced life expectancy. 

Underlying many of these medical and health problems is lack of basic education and awareness of health and hygiene.  Ignorance about the importance of sanitation and hygiene results in many preventable diseases such as scabies, fungal infections, and gastrointestinal ailments.  Likewise, lack of understanding of the importance of early diagnosis and treatment of ailments and injuries often leads to further complications and even deaths that could be prevented. Before the project, the only access to health services was one remote government health post with two Health Extension Workers (HEWs) per Woreda. The role of the HEWs was to create awareness in the community by holding meetings once a month; their role was not to provide treatment or medical services other than information. Overcoming these significant problems in the challenging conditions of the Simien Mountains requires investment in the development and implementation of sustainable local medical and health facilities. The government’s health programs must also be supported through capacity building in order to ensure sustainability.

The project used innovative methods and strategies to curb the exacerbated health problems through a comprehensive strategy of utilizing mobile medical services and clinical services for free. The clinical facility founded by this project is conveniently located in Keyit, 67 km (12 hours on foot) away from the town of Debark. It provides delivery, Antenatal Care (ANC), Post Natal Care (PNC) and Family Planning (FP), free medical services, and health promotion services. These services meet the government’s standards and are provided for twenty four hours seven days a week for 70 patients per day. Among the services provided within Keyit clinic is safe delivery by locally recruited midwives accompanied with a local coffee and porridge ceremony that creates an emotional connection between the mother and her neighbors.

Meanwhile, the mobile medical service is provided across five Woredas by means of five professional nurses who provide scheduled services across clusters in their respective Woreda. The mobile nurses communicate with the focal person in the Kebele to decide the nurse’s schedule. The mobile medical services, together with innovative saddles with mules, made it possible for the nurses to provide services at the localities of the community rather than forcing the community to travel a long distance for the service. The twofold benefit of the saddle is demonstrated through transporting patients to the clinic and transporting mobile nurses with medications to the various clusters. The feedback collected so far from the community showed that the saddle used to transport patients is comfortable and functional.

The linking of monitoring and supervision of mobile medical nurses with respective Woredas Health Posts has been innovative and empowers the local posts to assess the performance of each nurses and report accordingly. In addition, a unique approach of recruiting midwives and nurses among the community contributed a great deal to the effective implementation of the project

Picture 1: (From left to right )Saddle transporting patient, a mobile nurse providing medical services at East Debark, while hundreds of patients are waiting for their turn, Keyit Clinic external appearance, and a mother and baby after delivery at the clinic  

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  • Scalability

The scalability of the project is proven through a continual expansion since its inception in a single Kebele of Keyit at Janamora Woreda in 2012.  The project was then expanded to another Kebele of Lori at the same Woreda. After a year of implementation, the project retargeted to reach a total of seven remote Kebeles across Janamora Woreda. Eventually the five Woredas of Janamora, Debark, Beyeda, Tellemet, and Adi Arkay were included as target locations of the project.  This smooth expansion of the project from targeting a single Kebele at one Woreda to various Kebeles across five Woredas justifies the possibility of replicating similar initiatives in any other communities with similar socio-economic conditions. As it is clearly indicated at the project title “Expanding and Extending Mobile Medical Services”, the three-year implementation plan will focus on expanding the services at least to three neighboring remote Woredas. The fact that there exist a large number of communities with remote access to health facilities stipulates the acute need for replicating such effective efforts. The cost effective strategy of the project also made the replication effort easier. It is this truth that initiated the North Gondar Zone Department of Health to start consulting with Mahibere Hiwot for Social Development (MSD) to replicate similar efforts across remote Woredas of the zone.

  • Sustainability

The sustainable outcome of the project is designed to be achieved through involving key actors of the community in every major stage through implementation and monitoring and evaluation. Fourteen midwives are selected among the community who are finalizing their third year classes and they sign a contract with MSD to serve their community for four years following their graduation. Although the midwives salary will be paid by the project for four years, the respective Health posts where they are going to be deployed will be responsible to monitor and supervise their performance as any full time employee. Thereby, the services of these midwives shall be effective even after the project closure as it is clearly indicated in the MoU signed with MSD, North Gondar Zone Department of Health, Debark District Hospital, and Simien Mountains Mobile Medical Service (SMMMS, the donor).

The strong involvement of Debark District Hospital is another strategy designed for the project sustainability. Accordingly, the hospital is playing its role through providing experts to train HEWs and mobile nurses using its laboratory. The hospital is represented in the quarterly key stakeholders review meeting where the stakeholders examine the project progress and suggest the way forward. The North Gondar Zone Department of Health, on the other hand, is fully obliged to follow up on the effectiveness of the midwives over their four year service and to coordinate the experience sharing sessions among the twelve midwives.

On the top of involving HEWs in health promotion trainings and linking with the project nurses, the active involvement of the community is ensured through training community scouts on first aid who have already started serving the community. The project’s step by step transitioning is carefully designed with a final day facilitation of a transition out workshop among key stakeholders.  

  • Cost effectiveness

The project is cost effective, as it provides minimal staff (2 clinic nurses and 5 mobile nurses) for maximum effect to each of the five Woredas. With a scheduled service across various clusters, a mobile nurse is able to reach 250,000 communities, on average. The saddle used to transport patients, medicines and mobile nurses is efficient since it replaces the cost of fuel and /or more than the six man power that is used to carry a single patient otherwise. In addition, extra time and labor that would be unnecessarily incurred otherwise is saved because of the mobile nurse reaching large numbers of the community at its own locality. Since the mobile nurses use local Kebele centers for service provision across clusters, extra cost of building facilities is saved. Furthermore, the contribution of health posts in providing FP supplies and HIV test kits as well as the Woreda Department of Health’s role in lending vehicles to transport medical supplies to the clinic is paramount to minimize the project cost. The health posts also minimized our cost for per diem and transportation through the regular monitoring of the mobile nurses.

  • Community attachment, networking and partnership

The sense of ownership and attachment of the community is strong in contributing their own part. Among others, the community constructed the clinic fence, with estimated worth of 20,000 ETB, and they regularly volunteer to transport medical supplies to places that are inaccessible by vehicle. The mules for the saddle are rented with list cost among the community. There is a project advisory committee established across every Woreda where the community is represented by the head of the Health Post (chairperson of the committee), the Kebele administrator, HEWs, a Focal Person, the Health Post Pharmacist, and the project mobile nurse (secretary of the committee). The committee is responsible for mobilizing the community through the local “got leaders” and HEWs, supervising the appropriate allocation of medical supplies, and monitoring the mobile nurses’ monthly performance.

The partnership and networking is effected through the active involvement of North Gondar Zone Department of Health, Debark Hospital, Woreda Health Posts, Kebele administrations, University of Gondar, and Hamlin Fistula Hospital. Whereby the zonal Department of Health is coordinating the health posts to supervise the mobile nurses and the upcoming midwives,  Debark Hospital is responsible for facilitating the technical support, referral services and regular capacity building of HEWs and mobile nurses. The Kebele Administration in consultation with the project advisory committee is responsible for mobilizing the community and providing centers for medical services while University of Gondar and Hamlin Fistula Hospital are contributing by offering training for 14 midwives for four years. The health posts in their respective Woredas are responsible for providing medical supplies such as FP supplies and HIV test kits to Keyit Clinic and mobile nurses. Expatriate medical doctors from European Universities are also part of the network in providing volunteer service at Keyit Clinic while SMMMS is responsible to facilitate short on job staff training at European universities.

  • Outcome/Impact

Among the major outcomes registered across the elapsed project implementation is provision of health education for 81,328, free medical services for 11,526, family planning service for 594 mothers, free ANC services for 258, 92 free delivery services for 92 (89 at clinic and 3 by mobile nurses), PNC for 24, and immunization services for 928.

All in all, the maximum travel time of 10 hours to reach health posts across the five target Woredas is significantly reduced to 1 hour.  Delivery at health posts, including the project clinic, is increased while maternal death is significantly reduced. The number of participants in health education is steadily increasing. One of the Mother delivered at Keyit Clinic said:

 “The delivery here is relatively easier as compared to my previous experience where I have lost my baby at delivery. The comfortable saddle service supplemented with all inclusive medical services helped me a lot in having a beautiful baby. The traditional coffee ceremony with my neighbors and relatives is  colorful where I felt like I am at home. I will be back in my 42 day to get a baby care supplies.”

  • Gender sensitivity and inclusiveness

The project is gender sensitive since 12 out of 14 midwives and 2 out of 5 mobile nurses are female. The first objective of the project is also designed to give priority to women. For example, expectant mothers and babies have access to and receive maternal and natal care before, during and following childbirth. Accordingly, out of the 94,750 community members provided at least with one medical service 86 percent were women. Inclusiveness is demonstrated prioritizing those physically disabled and providing comfortable saddle services. With the support provided from Afya Foundation, crunches were provided to 20 physically disabled people and a wheelchair is available at the clinic.

  • Strategic/Programmatic Alliance with National and Global Development Plans

Alliance of the project with national development plans is clearly shown in its synergy with the Health Sector Development Plan under GTP II. The general objective of the health sector development plan is to ensure the benefits of the societies through provision of equity, accessible and quality health services, enhance awareness and ownership of the health services and create enabling environment for societies to prevent diseases. This project is aligned with its objective to improve access to health services, improve hygiene and environmental health, and reduce the incidences and prevalence of communicable and non-communicable diseases.

The project goal is also in line with the Sustainable Development Goals. For instance, Goal 3, Section C states, ‘Substantially increases health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries’. This is directly related to our project strategy of training 14 midwives from among the community and offering professional development to ground level medical staffs. The project, as it is clearly put in Objective 2, strictly follows WHO’s standards in quality service delivery.