Hospital management in Ethiopia

In a country with some 76 million people and only 138 hospitals, Ethiopia is looking to make the most of limited resources by working with Yale and the Clinton Foundation to train hospital administrators.

By Ted O’Callahan

When Tedros Adhanom Ghebreyesus took his post as the minister of health for Ethiopia in 2005, one of the best ways he saw to improve health was to improve hospital management.

In a country of more than 76 million people with 138 hospitals, many of which lack adequate running water and reliable electricity, focusing on better management wasn't the obvious priority to everyone. Most hospitals are owned by the government, and they are usually run by physician medical directors, who spend the majority of their time caring for patients.

Good efforts on all sides were being wasted due to ineffective management structures. It wasn't uncommon to have a variety of donated drugs on hand, but without an inventory control system, the medical staff had no idea what was available. At one hospital, rubber gloves sat in a nearby warehouse even as the hospital had critical shortages.

Minister Tedros pitched his idea for an Ethiopian Hospital Management Initiative (EHMI) to the William J. Clinton Foundation's HIV/AIDS Initiative (CHAI). "We knew we needed an academic partner to help make this huge new initiative a success," says W. Edward Wood, special advisor to CHAI in charge of establishing the foundation's programs in Ethiopia. Through a Yale public health student, Kaakpema Yelpaala, Wood met with Elizabeth Bradley, professor of public health and director of the Health Management Program at the Yale School of Public Health. "Within days of meeting we had forged a strong partnership," Wood says.

Beginning with the idea that externally imposed solutions will ultimately fail, EHMI is founded on a partnership-mentorship model with the goal of mentoring Ethiopian hospital management staff so the improved practices can be sustained in the future. "Hospitals were being run on the strength of a few key leaders rather than on evidence-based systems of management," according to Bradley, who directs the Yale portion of EHMI. Twenty-four individuals with healthcare management experience, from the U.S. and other countries, were placed as Yale-Clinton Foundation Fellows in 14 public hospitals in Ethiopia starting in the summer of 2006. These fellows provided technical expertise, but the approach is very "bottom-up," aiming to educate and establish institutions that will grow to be self-sustaining. Projects designed and implemented in that first year culminated in a blueprint for changes that can be used in hospitals across the country. Drawing on standards for hospital management from the Centers for Disease Control and Prevention and the World Health Organization, the blueprint targets quality improvements for eight systems: nursing standards and practice, infection prevention policies, patient flow, medical records management, pharmacy inventory and warehouse management, human resource management, governing boards, and financial management.

As they work for change, the visiting EHMI fellows and the Ethiopian hospital staff must understand and cope with a lack of infrastructure, as well as organizational and management issues. The infrastructure is so tenuous that steps forward often require first taking several steps back. Infection prevention requires not just reasonable procedures for hygiene, but also installing plumbing for running water. Medical records management doesn't mean just training staff on a new software system; it requires computers, wiring the building, and backup for an unpredictable electricity supply. And it requires establishing records that can be accessed from one visit to the next — a challenge when names have to be transliterated from several languages, in a country with a literacy rate of roughly 43%.

The blueprint lays out clear steps, such as creating mission statements, organizational charts, and job descriptions. But hospitals, like any organization or business, need leadership to accomplish change. Bradley says, "For us, the hospital CEO implements the plan — but in Ethiopia, the role of CEO did not exist in hospitals, so there were limited management and leadership capacities inside the hospital." As part of the blueprint, there are new financial structures, even in some cases, global budgets that hospitals have greater control over. "It is a real change for them to really be thinking managerially at the hospital level — and entrepreneurially — 'How can we use our resources more efficiently?' It's a different mindset."

"Medical directors are not businesspeople; they're doctors and nurses," she adds. "And then there's an administrator who's the bookkeeper. So there was limited strategy in management."

This year Yale and Jimma University in Ethiopia have partnered to establish a master's in hospital administration program. The two-year, executive-style program will support the new CEOs at about 30 selected hospitals.

Sosena Kebede, a physician who holds faculty appointments at Yale and Jimma University, is directing the program. "This program will provide a much needed focus on healthcare/hospital management that has never existed before," Kebede says. "If we do our jobs well on this program, we will create motivated and empowered leaders whose sole job description will be to attend to and drastically transform the sad state of affairs our hospitals are found in currently."

Even with the blueprint and training for the new CEOs, hospitals must find ways to make the project their own, according to Temitayo Ifafore YC '03, one of the regional directors of the EHMI. "While some hospitals were able to make significant progress with little intervention, most needed time to digest the content of the changes we were suggesting. Those who were given the time to critique, dismantle, and reassemble the management concepts to fit their local circumstances became the greatest supporters of the initiative." This has given Ifafore a sense of how difficult the process will be. "In every country a comprehensive healthcare system takes decades to develop. Therefore patience is key."

Bradley points to measureable gains after EHMI's first year, but says she remains aware of ongoing and upcoming challenges. "We tracked 100 management structures that we had identified as central to good hospital management — if you have these, you're doing well. On 40 of them, we actually had substantial improvement; 60 of them were, 'Well, we've still got work to do.' But we didn't slide back on many, even as we moved forward on 40 of them.

"The goal of the minister of health is over five years to get every hospital in the country to have a CEO and have come up to standard with the blueprint. We'll see if we can help them achieve that goal."

Professor of Public Health and Director of the Health Management Program, Yale School of Public Health