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Expanding SCOPE Projects in Gondar:
The Gabriel Health Center Expansion and
Engagement of Health Extension Workers
Anna Bazinet, MS, MD candidate
Spring 2016
University of Washington
SCOPE Fellowship
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BACKGROUND
Strengthening Care Opportunities through Partnership in Ethiopia (SCOPE) is a
collaboration between the School of Global Health at the University of Washington,
the University of Gondar, the University Presbyterian Church in Seattle, and the
Ethiopian Orthodox Church. Since its initiation in 2009, SCOPE has worked tirelessly
towards its mission to expand community access to medical resources and
encourage community participation to reduce the rates of HIV through outreach and
education.
SCOPE was initiated in Gondar, a city of just over 200, 000 in the Amhara region of
Northern Ethiopia. Just under 90% of the population in Amhara identifies as
belonging to the Ethiopian Orthodox Church, an early sect of Christianity.4 Religious
leaders in that community are important influences on parishioner’s health seeking
behaviors. Because of SCOPE’s unique interdisciplinary approach to public health
problems, which works to bridge gaps between religious and medical communities,
the organization has been successful at working within this specific population.
SCOPE trains priests and religious women in Gondar to be health advocates,
reducing the stigma around HIV and improving community uptake of health
services like maternal-child health visits and HIV testing and treatment. This
proposed project will enable SCOPE to expand its current impact by increasing the
number of priests and religious women trained and improve community
engagement.
DEFINITION OF THE PROBLEM
Despite recent advances in alignment with the Millennium Developmental Goals for
2015, Ethiopia remains in relatively poor global standing in terms of health metrics.
The maternal mortality rate in 2013 was 353/100,000 mothers. Although this
number represents a 56% reduction since 1990, Ethiopia’s remains in the 50
countries with the highest maternal mortality rate.2 These deaths are largely
attributed to the 5 most common causes of maternal mortality including:
postpartum hemorrhage, sepsis, eclampsia, obstructed labor, and unsafe abortion
practices.2 The frequency of these afflictions can be partially explained by low rates
of Antenatal Care (ANC) use by pregnant woman. As of 2012, only 42.5% of women
were getting at least one ANC visit and only 19.1% received the WHO-recommended
4 ANC visits. Additionally, only about 10% of women delivered with a skilled birth
attendant and 9.9% of women delivered in a health care facility.6 Several reasons
are posited to explain this poor uptake of clinical services including: lack of
adequate transportation to facilities, cost of care, quality of care, and cultural
traditions.
To compound issues in maternal health, HIV remains problematic in Ethiopia. As of
2013, the HIV rate in Ethiopia was 1.3% according to the World Health
Organization. It is estimated that in 2012 alone 9,500 children were infected with
HIV largely due to poor use of Preventing Mother-To-Child Transmission (PMTCT)
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services. 60% of women living with HIV did not receive medications to reduce
vertical transmission and 80% did not receive medications to reduce the
transmission of HIV during breastfeeding.5 PMTCT services are available in Gondar
as a component of ANC services. However, both ANC and PMTCT services are
severely underutilized in the region.
PROBLEM and EXISTING EFFORTS
In an effort to curb this problem the Ethiopian Federal Ministry of Health (FMOH)
enacted several programs, most notably the Health Extension Worker (HEW)
program started in 2003. This program trained community members (HEWs) to
serve within their kebele (“neighborhood”) to perform antenatal care, connect
women with delivery services, and to complete post-natal follow-up visits. Adding
these health care professionals into the community is credited at least in part for an
improvement in ANC visits. The percentage of women receiving at least one ANC
visit increased from 26.8% to 42.5% from 2000 to 2011.1
SCOPE has approached the problem of poor ANC uptake by engaging the religious
community. By training religious leaders, priests and religious women about the
importance of ANC services, PMTCT and HIV testing and care, these influential
members of the community can encourage community members to seek
appropriate medical services. SCOPE has had measurable success at 4 clinic sites
around Gondar. At the Woleka health center where the project was initiated in 2013,
there was a 20% increase in ANC clinic attendance after the SCOPE trainings. The
purpose of the current project is to continue and expand the SCOPE projects to the
Gabriel clinic.
THE GABRIEL CLINIC
The Gabriel clinic is a centrally-located clinic run by the Federal Ministry of Health
(FMOH). It is located just across the Lesser Angereb River from the Ethiopian
Orthodox Church diocese. However, despite its central location, the clinic catchment
area includes rural areas and at times women have to travel up to 7km to receive
care. It is estimated that the Gabriel clinic is only seeing 11% of the women residing
in their catchment area for ANC.3 The exact reason for this low uptake is unknown.
Possible explanations include difficult access due to poor road conditions, women
choosing to go to the University of Gondar hospital for ANC services, and cultural
beliefs and expectations within the catchment area.
During a prior University of Washington fellow’s stay in Gondar, the Gabriel clinic
was evaluated as a possible expansion site. A comprehensive SWOT (strength,
weakness, opportunities, and threats) analysis was performed. The full analysis can
be seen in Appendix A. The results were mixed during this evaluation. On the
positive side, several enthusiastic clinic staff were identified as well as a strong
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connection with the local HEWs was seen. Although the staff articulated an interest
in increasing their ANC services, during some visits to the clinic, ANC rooms were
locked and at times staff were not on site. Additionally, the SCOPE’s contacts in the
diocese expressed interest in this clinic due to its central location.3
Project Scope
A. PROJECT GOALS
The broad project goals which fit into the overall mission of SCOPE include:
1. Improve uptake of ANC services in the Gondar region with the end goal of
improving the maternal mortality rate and reducing vertical transmission of
HIV.
2. Help SCOPE refine and expand its projects and community connections.
3. Reduce stigma around HIV through increased education and awareness.
B. PROJECT OBJECTIVES
The primary project objectives include:
1. Expand SCOPE’s influence in Gondar by engaging the Gabriel Health Center.
2. Coordinate and conduct training sessions for priests, religious women and
HEWs.
3. Streamline SCOPE projects.
4. Conduct interviews with HEWs about their work, training and how they
engage with the religious community.
C. PROJECT APPROACH
The format of this project will be separated into a Pre-implementation Phase and an
Implementation Phase, a framework that was first developed by Emily Robinson, a
former SCOPE fellow in 2015.3 The Pre-implementation Phase will set the
foundation for the project by initiating relationships, evaluating the Gabriel Clinic’s
readiness, collecting data, and setting up details related to priest training events.
The timeline of this project will be focused between December 2015 and May 2016.
See section in this report titled “Timeline” for more specific information.
Pre-Implementation Phase
1. SCOPE Steering Committee: Discuss project with SCOPE’s onsite steering
committee. The SCOPE steering committee will be relied on to make final
decisions about this proposal. One important item on the agenda will be the
evaluation of Gabriel as the most appropriate next clinic site. The steering
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committee will be deferred to on this decision as they have the most current
information about ongoing projects, community needs and clinic capacity.
 Confirm Gabriel is an appropriate target clinic by learning about size
of current patient population
 Adjust project approach and methodology as needed per steering
committee recommendations
 **If the steering committee determines that a different clinic site is
more appropriate, this proposed project will remain the basic outline
for the project, but focused on another site***
2. Clinic Staff: Engage Gabriel clinic staff. Reconnect with prior SCOPE contact
at clinic
 Evaluate interest and commitment towards mutual goals
 Discuss roles of ANC nurses and other staff members
 Elicit suggestions or concerns surrounding project
 Evaluate readiness of Gabriel to implement SCOPE project
 Obtain historical data from Gabriel on:
 Catchment area, ANC services, HIV testing, and PMTCT data
 Evaluate experience of women visiting the clinic through observation
 Seek information to explain current low usage among pregnant
women in catchment area
3. Priests and religious women:
 Obtain commitment and support
4. Health Extension Workers:
 Meet with local HEWs in clinic catchment area. Learn about current
practices, trainings
 Evaluate willingness to participate in priest training sessions and
other SCOPE projects
Implementation Phase
The implementation of this project will heavily rely on outcomes of the Preimplementation Phase. It will depend on the strengths and weaknesses identified
during the first few months and the recommendations of the SCOPE steering
committee.
1. Coordinate and conduct priest and religious women training
 Priest trainings will be conducted as outlined in SCOPE’s Standard
operating procedures (Appendix B)
 Coordinate with Geta Asrade and Adino Tesfahun (current University
of Gondar fellows) to learn about the curriculum used for training
 Attend training sessions
 Record process and information taught at trainings for future SCOPE
training manual
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 Include HEWs in training and conduct interviews
2. Confirm data collection methods and decide about priest referral tracking
system.
3. Consider measures for securing sustainability
4. Record how all steps are performed for development of training manual
D. DELIVERABLES
All deliverables will be finalized and submitted in the final project report upon
return from Ethiopia in June-July 2016.
1. Religious leaders, Clinic Staff and HEWs trained per SCOPE curriculum to
reduce stigma around HIV infections, testing and treatment
2. Preliminary data analysis of ANC visits, HIV tests, and the number of
deliveries performed in health care facility during early phase of priest
trainings. If possible this data will be compared to data from the prior year
to evaluate for change. This will be dependent of accessibility to data.
3. Sustainable operations at the Gabriel Health Center clinic, with continued
increase in ANC service uptake
4. SCOPE manual outlining approach to expanding to new clinics and
populations. Manual will include curriculum used by SCOPE fellows for
training events focusing on HIV, ART, PMTCT as per SCOPE’s mission
statement
5. Qualitative report on HEW interviews and recommendations for future
collaboration
E. CONSTRAINTS
The following represents a list of anticipated barriers to project implementation.
Other barriers that develop will be discussed with the on-site fellows as well as
during the weekly progress meetings with US based SCOPE staff.
1. Before implementing this project, details will be discussed with SCOPE’s
Ethiopian steering committee. If a different health center is further up on the
list of next training site, it is possible that Gabriel will not be the clinic that
this project occurs in. In this case, the pre-implementation phase of this
project may be prolonged as new relationships will have to be developed.
2. Language and cultural barriers
3. Dependence on others for translation during meetings, outreach activities,
and priest training
4. Cooperation and time dedicated by Gabriel’s clinic staff, members of the
diocese
5. Availability of University of Gondar Fellows
6. Timeline of project is limited to 5 months from December to May.
F. PERFORMANCE MEASUREMENT
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The success of this project will be seen by the degree to which it advances
SCOPEs broader objectives within the new target community. Specific metrics
that may be used to understand it’s performance may include:
1. Training sessions completed
2. Qualitative data collected on ANC visits, assisted births, HIV tests performed,
PMTCT, women started on ART
3. Continuing support and enthusiasm from stakeholders (Clinic staff, HEWs,
Priests)
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G. TIMELINE
Project Implementation Timeline
Nov Dec
Jan
Feb
Mar Apr
May
June
Project development
Project proposal due
Board Presentation
Pre-implementation Phase
Ethiopian steering committee meeting
Gabriel clinic engagement
 Evaluate interest
 Discuss roles of clinic staff
 Elicit suggestions and concerns
 Evaluate patient experiences
 Explore historically low ANC service rates
Priest and religious women engagement

Meeting with local Diocese
Health Extension Workers

Initial meeting
 Evaluate willingness to participate
Initial Data Collection
Implementation Phase
Facilitate priest training sessions as
outlined in SCOPE’s SOPs




Collaborate with current UofG fellows
Evaluate for areas of improvement
Update SOPs
Record steps for training manual
development
Secure reliable data gathering practices
and track progress
Perform HEW interviews
Enact measures for long-term
sustainability
Conclusion/Evaluation
Data evaluation
Summarize findings/outcomes in final
report
Final SCOPE board presentation
Final Report given to SCOPE
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RESOURCES
1. Bilal, N.K, Herbst, C.H., Zhao F. Soucat A., Lemiere C. Health Extension Workers in
Ethiopia: Improved Access and Coverage for the Rural Poor. Chapter 14. World
bank Ethiopia.
http://siteresources.worldbank.org/AFRICAEXT/Resources/2586431271798012256/Ethiopia-health.pdf
2. Caglia, J., Kearns, A. , Langer, A. Health Extension Workers in Ethiopia: Delivering
Community-based antenatal and postnatal care. Women and Health Initiative &
Maternal Health Task Force, Harvard School of Public Health, 2014.
3. Robinson, E., Getahun Asres. Improving Health in Ethiopia Through Partnerships
with the Church. Sept 9 2014.
http://www.capitalcommentary.org/scope/improving-health-ethiopia-throughpartnerships-church
4. Savage, K.. Soul Fathers As Health Educators: A Pilot Project to Improve Uptake of
Antenatal Care and Prevention of Mother-to-Child Transmission Services at the
Woleka Health Center in Gondar, Ethiopia. Community-Oriented Public Health
Practice (COPHP) Program, University of Washington. 2014.
5. UNAIDS. Country Progress Report on the HIV Response, 2014. The Federal
Democratic Republic of Ehtiopia. 31/3/2014
http://www.unaids.org/sites/default/files/country/documents/ETH_narrative_
report_2014.pdf
6. Unicef . Ethiopia Statistics. December 24, 2013.
http://www.unicef.org/infobycountry/ethiopia_statistics.html
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APPENDIX A: GABRIEL CLINIC SWOT ANALYSIS
Courtesy of Emily Robinson SCOPE Report 2015 3
FAVORABLE
I
N
T
E
R
N
A
L
Strengths












E
X
T
E
R
N
A
L
ANC available
Follow up by phone for no show ANC
appts
Newer building and facilities
o Electricity and water
infrastructure
ANC specific room and delivery room
Staff – 1 HO, 5 Nurses, 1 Mid-Wife (does
ANC visits), 2 Lab Techs, 2 Pharm Techs
Good relationship and regular
interaction with HEWs
HEWs hold monthly meetings for
pregnant women in their community
HEWs meet with clinic staff monthly
HEW supervisor (Nurse) works at the
Health Center (this is his exclusive job)
Enthusiasm and honesty of head nurse,
Eskadr
o Honest about their struggles
and lack of equipment
Statistics being kept in cooperation
with HEWs
Located close to diocese just off main
road for easy access by fellows.
Opportunities




5 churches in the surrounding area to
work with
No lab services at time of previous
survey, now have lab minus centrifuge
– indicates improvements
Likely women in catchment area that
are not reached by HEWs because of
distance – priests could be more
effective
“If we ask pregnant women to come
they will not come, but if the priests
and religious women ask they will
come despite poor infrastructure.” –
Eskadr, Head Nurse
o Largely Christian population
who trusts priests
UNFAVORABLE







Low numbers of ANC – 92 1st ANC
visits in 12 months.
No ART – refer to U Gondar
Hospital without providing
transportation (3-4 km away from
Health Center) – Women don’t
like to travel to UG Hospital
No centrifuge in the lab
o Refer to lab < 1 km away
for labs requiring
centrifuge.
Women live up to 7 km away from
clinic without transportation.
They have done 7 births total
since opening of clinic – 99%
deliver at University of Gondar
Hospital
Plumbing was not working when
we visited, “repairs being done” –
no visual evidence of repairs and
sinks had dirt build up
No current NGO support
Threats




Have asked for government
funding for equipment and have
not received it
No prior experience collaborating
with NGOs
The health center serves a largely
rural population with
transportation challenges
“Funding problems” were
mentioned during the interview in
relation to equipment acquisition
and infrastructure building

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APPENDIX B: STANDARD OPERATING
PROCEDURES (SOP)
Courtesy of Emily Robinson Report 20153
I.
II.
III.
Ensure Project Legality - Ethiopia requires programs to obtain legal authorization for any
project implemented in the country.In order to ensure that the project is sanctioned and to
prevent implementation delays these letters and documents should be obtained as soon as
possible.
a. Obtain a letter from the University of Gondar or the North Gondar Diocese
explaining the project and sanctioning the project as authorized under Ethiopian
law. This letter should stipulate that the organization sponsoring the letter allows
this project to function under their certificate.
b. Obtain a letter from the Woreda Health Center sanctioning the project and
partnership with the health center/clinic. Provide a copy of this letter to the
participating health center/clinic.
c. Obtain a second letter from the Woreda Health Center stating its support for the
priests and religious women conducting outreach. This letter should serve to
increase the legitimacy of these leaders, thereby extending their acceptance in the
community.
Project Budget
a. Create a budget including payments to be made to the participating health center,
participating religious leaders, room rental for training, and trainers leading the
instruction. This budget must be submitted for SCOPE board approval.
Pre-Project Meetings
These meetings serve to refresh partnerships, introduce new parties, and explain the
project’s mission.
a. Meet with the North Gondar Archbishop to explain the project and obtain his
consent
b. Meet with head of the participating health center or clinic to explain project and
obtain verbal consent.
c. Meet with health center/clinic head nurse and ANC nurses to explain the project and
their role.
d. Obtain baseline ANC and PMTCT data from participating health center/clinic. Data
for the last year should be recorded, as well as any data from years past.
e. Confirm the willingness of the head of health center/clinic and ANC nurses to
document when a religious leader was responsible for encouraging a woman to
attend ANC. Explain that you will provide a unique indicator on the referral card and
obtain their consent to accept and store these cards.
IV.
Select Priest and Religious Women for Project Participation
a. Partner with the North Gondar Diocese to select one priest and one religious woman
from each kebele. Provide the diocese with specific selection criteria. Should the
North Gondar Diocese have trouble identifying priests and religious women for
project participation, obtain the contact information for the head of the local
diocese.
b. In the case that the North Gondar Diocese is unable to obtain a priest and/or
religious woman from a specific kebele, put the diocese in contact with the Health
Extension Workers (HEWs) for that kebele. The HEWs should provide the names of
potential priests/religious women for approval by the Diocese.
i. The North Gondar Diocese should contact priests and religious women to
inform them of their selection, project goals, participation requirements,
and compensation to be provided.
ii. Obtain names, kebele of residence, and contact information for each
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c.
religious leader.
Speak with each priest and religious woman independently to verify his or her
understanding of the project. Obtain verbal agreement for project participation.
V.
Conduct Baseline Interviews
These interviews serve to establish a baseline of individual perspective and practices before
the intervention.
a. Conduct one-on-one semi-structured open-ended interviews with participating
religious leaders. These interviews should focus on their knowledge and
perspectives. Interviews can be transcribed or recorded, depending on IRB
approval.
VI.
Religious Leader Training
a. Establish location for training. Location should be easily accessible for participating
religious leaders as well as facilitators.
b. Confirm availability of training location with whoever is in charge.
c. Assign trainers to each training section.
d. Obtain slides or training documents for each trainer.
e. Confirm refreshments and meals as necessary.
f. Purchase notebooks and pens for each participating religious leader. Extra
incentives (such as a bag and umbrella for outreach) can be provided as desired.
Project-Specific Referral Card Mark – Decide on a strategy for tracking patients referred by
priests and religious women. This can either be a separate referral card given to the women,
or an identifying mark on the referral cards used by the HEWs, such as a stamp or sticker.
a. Establish a system for distributing cards to the participants. If the HEWs are willing,
they can maintain a supply that the priests and religious women can access if they
need additional supply.
b. Ensure that all clinic staff know what to look for on the card, in order to accurately
track numbers of women referred by religious women or priests. – Have a visual aid
in the prenatal visit room in order to prompt the nurses and midwives.
VII.
VIII.
Priest Training
a. The trainings must be opened with a prayer. Identify someone from the diocese to
attend the training and give his blessing to the participation of religious leaders.
This prayer must take place before any other introductions.
b. Trainings should focus on HIV, ANC, PMTCT, assisted birth, strategies for conducting
outreach, and project roles. Structure the training to be interactive and allow room
for discussion and questions. See Appendix for sample training guide.
c. Use participants from past trainings to help for at least one day of the training in
order to promote buy-in and ownership.
d. Include at least 1 HEW from each participating kebele in at least one day of the
training in order to promote relationships between the religious leaders and health
workers.
e. Provide a pre-test and post-test to measure the trainings’ impact on knowledge and
perspectives. Offer “reading” assistance before participants begin the pre and post
test, as some participants may be illiterate. See Appendix for sample tests.
IX.
Identify Pregnant Parishioners
a. Provide religious leaders with criteria for parishioner selection
b. Specify that religious leaders are responsible for identifying pregnant parishioners
through their own networks. They should not reply on names provided by HEWs, as
women identified by HEWs will likely already be integrated into the medical system
and have received some information regarding ANC and HIV.
c. Each priest/religious woman pair will identify 10 women per month to whom they
will conduct outreach.
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d.
Obtain list of names from each priest/religious woman pair at follow-up meetings.
X.
Conduct Baseline Interviews with Parishioners
These interviews serve to establish a baseline for individual perspective and practices before
the intervention.
a. Obtain contact information for Health Extension Workers (HEWs) from respective
Health Center or clinic. There should be two HEWs for every kebele.
b. Contact one HEW from each kebele. Explain the project and request their assistance
in meeting with pregnant parishioners.
c. Randomly select two pregnant women from each kebele. These names should be
taken from the list provided by the priest/religious woman pair.
d. Visit the homes of selected pregnant parishioners with the assistance of the local
HEW and a translator (if necessary). The HEW should introduce you. Introduce
yourself and your project and obtain verbal consent from the woman (and her
husband if present).
e. Conduct baseline interviews with pregnant parishioners. All baseline interviews
must be completed before project implementation begins. Interviews can be
transcribed or recorded, depending on IRB approval.
XI.
Project Implementation
a. At the end of religious leader training, specify job roles and expectations of religious
leaders. Each priest and religious woman will be paired by kebele of residence. Each
pair must:
i. Identify 10 women every month. These women should have a “known
pregnancy” but NOT be currently using ANC. These women should be
identified through the priest’s and religious woman’s networks. They
should not obtain lists from HEWs.
ii. Visit each woman’s house twice a month.
1. During these visits they should discuss HIV and its transmission,
the importance of attending ANC and the number of visits an
expectant mother should have, the importance of having an HIV
test while pregnant and participating in PMTCT if they are HIV
sero-positive, and the woman’s birth plan.
2. If possible priests and religious women should talk to the husband
and explain the importance of supporting his wife in attending ANC
and saving money for an assisted birth.
3. If a woman or her spouse says no, inquire as to their reasons why.
Listen actively. Give the best possible answer and try to convince
them of the importance of ANC attendance.
4. If the woman or her spouse continues to say no, tell them that you
understand, and that you will come back another day to speak with
them if that is okay.
5. At the end of the visit priests/religious women should provide the
woman with a project referral card. They should direct the
pregnant woman to give this referral card to the ANC nurse at the
health center and tell the nurse that a religious leader referred
them.
6. Priests/religious women should record the name of the woman
they saw, whom they spoke with in the home, the date on which
the visit took place, and any challenges they encountered.
iii. Attend bi-weekly meetings with the project implementation team for the
first 2 months, followed by monthly meetings for the following 4 months,
and bi-monthly meetings for 6 additional months. An appropriate schedule
for recurring meetings will be decided after 12 months of implementation.
Each meeting date and time should be set at the previous meeting so as to
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ensure that every participant has information about when they are next
expected to meet.
1. Include HEWs, clinic staff, a diocese representative and U. Gondar
implementation team in these meetings.
iv. These meetings should include focus groups discussing experiences
conducting outreach, challenges encountered, and responses of the women
and their families. They may serve as opportunities for strategic planning
and for religious leaders to share stories and examples of what did and did
not work during their outreach.
v. Emphasize that these meetings are mandatory, and that pay will be
deducted accordingly by absence.
XII. Project Evaluation – See project Monitoring and Evaluation Plan
i. Collect most recent health center data on ANC, PMTCT, and assisted birth
ii. Conduct exit interviews with religious leaders.
iii. Conduct exit interviews with pregnant parishioners. The parishioners interviewed should be the
same as the ones interviewed in the beginning.
iv. Analyze interviews using open coding.
v. Compare pre and post tests from priest training
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