Pilot Training Building Leadership Skills of the … · Pilot Training Building Leadership Skills of ... The Center for Creative Leadership ... edge about teamwork and management

Pilot Training Building Leadership Skills of the HIV/AIDS Healthcare Workforce

in Gambella Region, Ethiopia

Desert Rose Consulting Desert Rose provides transparent and accessible reporting on complex challenges in the Horn of Africa.

Center forCreative

Leadership

SurveyBaseline

Desert Rose Consulting - Baseline Report for CCL - Gambella HIV Healthcare - 5 January 2011

Introduction

The Center for Creative Leadership (CCL) has requested that Desert Rose Consulting PLC (Desert Rose) conduct an independent assessment of its pilot leadership training program in Gambella Region’s HIV/AIDS health-care sector.

The assessment will be divided into three reports that will build upon one another, culmi-nating in one comprehensive report.

This first report follows completion of the baseline survey and aims to:

• highlightopportunitiesforCCL’strainingtomakeanimpact;• underscorepossiblelimitationsontheimpactofCCL’straining;and• reportontheearlystagesofCCL’strainingprogram.

The second report will provide concise findings from a mid-term assess-mentofCCL’straining.

The third report willassessoutcomesofCCL’strainingandofferconclusionsabout the pilot project. It will incorporate large portions of the first and second reports in order to constitute a stand-alone, comprehensive report on the entire project.

Acknowledgments

This report was researched and written by Sam Ray and Martha Aynalem, consultants at Desert Rose. We are grateful for the assistance of translators Omod Amulu and Bang Ruei, and intern Mario Ray.

Photographs by Aaron White.

Published January 2011. Desert Rose Consulting PLC, Addis Ababa, Ethiopia.

Project contact: [email protected] / +251 (0) 923 082 374

2 • Baseline Survey

Background • 5


ContentsReport Summary 4

Background 5

Methodology 8

Quantitative Research 8

Qualitative Research 10

Ethical Considerations 11

Principal Sources of Bias 12

Quantitative Findings 13

Qualitative Findings 20

HIV/AIDS Healthcare in Gambella 20

Training feedback 34

Concluding recommendations 37

Glossary 40

References 41

Background • 5

Contents • 3


• There is demand in Gambella for more training in CCL’s areas of spe-cialty, particularly self-analysis, taking initiative, and putting knowl-edge about teamwork and management into practice.

• The impact of CCL’s training will be mitigated by deficiencies within the healthcare system that are not addressed by the training and by limitations external to the healthcare system such as infrastructure and funding.

• CCL’s training was welcomed in Gambella for being engaging, mem-orable and applicable, and for its planned follow-up meetings with participants, which are seen as a vital component of the training.

• Participants’ suggested improvements for the training included spending more time clarifying and recapitulating basic concepts, en-suring that all trainers fully understand the material, and future strat-ification of participants to cater for varying language backgrounds and abilities.

Report Summary



In 2006 the USAID-funded Leadership, Management and Sustainability Program pub-lished a report titled ‘An Urgent Call to Professionalize Leadership and Management in HealthCareWorldwide’.Thereportwarned,

Health care in developing countries is a multibillion-dollar en-deavor. Yet the people charged with leading and managing this work have little formal preparation to succeed. Until this truth is recog-nized, the billions of dollars being pledged by donors—plus the huge investments thatcountriesmakeinhealth—willnotachievethehoped-forresults.(Dwyeretal.2006)

Responding to such warnings, the governments of Ethiopia and the USA built strong leadership development goals into their collaborative 2010-2014 plan for tacklingHIVandAIDSinEthiopia.

TheUSgovernment’sleadershipdevelopmentgoalsinEthiopiaincludethestrengtheningor support of

• HRplanning,leadership,management;• traininginstitutions;• hospitalmanagementtrainingforCEOsandotheradministrators;• publichealthworkforcedevelopment;and• building the capacity of regional and sub-regional offices to plan and coor- dinate HIV/AIDS and health programs. (PEPFAR 2010) Catering to these goals, CCL has begun a pilot leadership training program for HIV/AIDS healthcare staff in Ethiopia’s Gambella Region. The project isjointly funded by USAID, World Learning and CCL.

BackgroundBackground • 5


Gambella is a warm, fertile and well-watered region in the south-west of Ethiopia. It shares a border with South Sudan and is similar in size to Rwanda, or Vermont, USA. The regional capital is Gambella Town.

A2007surveybyEthiopia’sCentralStatisticalAgencyrecordedthepresenceof85ethnicgroups in Gambella, spread among a population that it measured at just over 300,000. It divided the population among the major ethnic groups as follows:1

Gambella is renowned for its ethno-political complexity, a minefield of sen-sitivity for administrative processes in the region. Ethnic tensions principally arise from fears surrounding loss of identity, political power and access to material resources.2

Gambella population by ethnic group

Nuer

Anyiwak

Amhara

Kefficho

Oromo

Mejenger

Other


1 Ethiopia Central Statistical Agency 20072 Meckelburg2006,p.2


Second, the Darg regime relocated approximately 60,000 Ethiopian highlanders to Gambella as part of a broader scheme to relieve famine in the north and change lowland farming practices.8 The resulting pressure on resources became too muchandin1991,aftertheDarg’sdemise,200highlanderswerekilledinanethnicallyandterritoriallydrivenAnyiwakoutburst.Smallerscaleattacksonhighlanderswerecarriedoutin2003and2005.ThefirstwasansweredbyaretaliatorymassacreofAnyiwaks.9

Such is the ethnically charged and territorially pressured environment in which CCL is launching its pilot leadership training program for HIV/AIDS healthcare staff in Ethiopia.

“Population movement, pressure and interaction have played an extremely crucial role in the history of this country up to the present. Without taking this process into account, it is very difficult to un-derstand fully the politi-cal, economic and social history of the Ethiopian region.”3

Two events in the 1980s significantly exacerbated these tensions.

First, the Sudanese civil war sent an estimated 355,000 Nuer across the border into Gambella over a period of seven years. These culturally pastoral and nomadic fugitives were ter-ritorially expansionist, socially integra-tive and highly mobile.4 This threatened the lifestyle of the traditionally sedentary Anyiwakwho share a strong cultural at-tachment to particular territories.5 Fur-thermore the adaptable Nuer were ad-ministratively favored by the Darg regime6 over the more protective Anyiwak, whowereviewedasreactionaryand‘feudal’.7

Background • 7

3 Shiferaw 1988, p. 128, cited Seifert et al. 2006, p. 3 7 Ibid. p. 114 Feyissa2003,p.37,citedMeckelburg2006,p.8 8 Ibid.pp.10-115 Ibid. pp. 8-9 9 Ibid. pp. 12, 14-156 Meckelburg2006:9


Methodology

A two-page baseline questionnaire jointly written in English and Amharic was pre-sentedtothe17participantswhohadarrivedatCCL’sthree-dayleadershiptrainingbythemorningbreakonthefirstday.

The questionnaire had four sections and participants were walked through eachsectioninsmallgroupsofthreetofivebybilingualAmharic/Englishspeakers.TheywereremindedthattheydidnothavetocompletethequestionnaireinordertoreceiveCCL’straining.

The questionnaire was designed to require as little writing as possible. Most questions involvedcirclingoptionsorcrossingboxes.Therewasalwaystheoptiontocircle‘other’whererelevantorcrossaboxtoindicate‘Idonotunderstand’.

Quantitative research



Methodology Section 1 recorded demographic information.

The final three sections asked participants to exercise skills that CCL aims to sharpen: assessing strengths and weaknesses of self and others; identifying strengths and weaknesses of institutions; and recognizing how to develop as a team.

Section 2askedparticipantstoevaluateaspectsofworkingculture inGam-bellaandthenaskedthesamequestionsoftheirpersonalbehavior.Participantswerepre-sentedwithalistofpositivestatementsbaseduponCCL’semotionalintelligencemodule(e.g.‘Irespondpositivelytocriticism’)andaskedtoselectanansweronascaleof1to5from‘Never’to‘Always’.

The aim of the exercise is to measure whether participants’ self-analysis becomes, not more positive, but more nuanced, and whether there is a change in perception of self relative to others followingCCL’straining.

Section 3 askedparticipantstorankattributesoftheirworkenvironment(e.g.‘Staffarepaidontime’;‘Patientsarecaredfor’).Theseattributesweredrawnfromthequal-itativedataonweaknessesofGambellaHIV/AIDShealthcaregatheredbyDesertRose.

Participantswereprovidedwith15cards,eachmarkedwithadifferentattribute(inEnglishandAmharic).Theywerethenaskedtoplacethreecardsoneachoffivezonesonasheetofpaper.Thezoneswererankedfrom1to5,‘Weakest’to‘Strongest’.The aim of the exer-cise is to measure whether participants record relative improvements in some areas of their work environment following the implementation of lessons learned from CCL.

Section 4 askedparticipantstoselectfrom8positiveattributes(e.g.‘Doesnotcomplain’;‘Communicateswell’)which3attributestheywouldmostvalueinanewem-ployee.Theaimoftheexerciseistomeasureanyalterationsinparticipants’perceptionsofwhichattributesareespecially importanttofoster intheircolleaguesfollowingCCL’straining.

Methodology • 9


Qualitative researchDesert Rose conducted 9 discussion groups or interviews in Gambella with the following23 informants (details disclosed asper informants’wishes) togain anunder-standing of the challenges currently facing HIV/AIDS healthcare in the region.

• HIV Patients (7) in Gambella Town• Acting Health Center Head,GatkhatDuoth,EtangDistrict.• Doctor in Gambella• Nurses (5) in Gambella Town Hospital• Pharmacy professional in Gambella• Health professionals (3) in Gambella • Health Extension Program Coordinator, Gambella Town• Gambella Region ART Coordinator, Adula Thwol Gilo, Johns HopkinsUniversity–Technical Support for the Ethiopian HIV/AIDS ART Initiative (JHU-TSEHAI), Gambella Town.• Gambella HIV Program Coordinator,OmotAgwa; Gambella District HIV Facilitator,OchangOdola; Gog District HIV Facilitator,JohnOkuch; EthiopianEvangelicalChurchMekaneYesus(EECMY),EastGambellaBethel Synod, Development and Social Service Commission (in partnership with Catholic Relief Services).

Audio recordings weremadeofalldiscussionswiththeinformants’consent.Mosted-ucatedinformantshadmoderatetogoodEnglishlanguageskills,butthediscussionswithHIVpatientsandEECMYwereconductedinAmharicandAnyiwakrespectively.

Ten training participants were informally interviewed immediately following completionofCCL’sfirstleadershiptrainingcourseinGambella.Someconversationswereheld in Amharic and others were held in English.



Ethical considerationsDiscussions and interviews in Gambella were arranged through appro-priate avenues. CCL facilitated introductions with the Regional President, Regional Health Bureau and Regional HIV/AIDS Prevention and Control Office (HAPCO). The Region-al Health Bureau issued letters to every district, requesting their assistance with the survey.

Desert Rose’s translators were paid 300 ETB per day. Informants interviewed intheirworkplacesduringworkhourswerenotmonetarilycompensated.Members of an HIV patients’ association wereaccessedthroughagatekeeper,GambellaTownHealth Centre, and compensated 50 ETB for a discussion group with Desert Rose, in addition to refreshments.

Discussions with health professionals in overburdened healthcare envi-ronments were kept short and held at times more convenient for them. It wasaskedofinformantsthattheynotinconveniencetheirpatientsbyparticipatinginin-terviewsordiscussions.Doctorsandnurseswereaskedhowmuchtimetheyhadtospare,and specifications were respected.

Informants were asked for their permission to record conversations and made to understand that the recording or conversation could be stopped at their request. At the endofconversationsinformantswereaskedforpermissiontocitetheinformationtheyhad shared in this report and to what extent they wished to disclose their identity. Some informants’identitieshavebeenobscuredmorethanrequested.

Translators were taught to follow interview protocol,askingtorecordconver-sations, orally negotiating consent, and discussing citation permissions.

Anonymity was preserved onthebaselinequestionnaire.Participantswereaskedto enter the last three digits of their phone number to facilitate comparison between their responses to the baseline survey and the follow-up survey.

No informants under the age of 18 were consulted.

Methodology • 11


Desert Rose was unable to secure a discussion group with health exten-sion workers in Gambella Town and was informed by the Health Extension Program Co-ordinatorthatthehealthextensionworkerscouldnotbespokenwithuntiltheyhadcom-pletedthelengthytrainingtheywereundertaking.UponreturningtoGambella,DesertRosestillhaddifficultiesaccessinghealthextensionworkers.

Desert Rose gathered few women’s perspectives as a result, since most women inGambella’s healthcare systemoccupy lower tier roles. FurthermoreDesert Rosewasalmost always introduced to male practitioners when requesting interviews or discussion groups. Desert Rose recognizes that, had it pre-empted this bias in its data, it could have takenfurtherstepstopursuewomen’sperspectives.

Desert Rose was careful to rectify this problem while conducting the baseline survey for CCL’swomen-focusedtrainingprogram,insistingonspeakingpredominantlywithwomen.

While gathering qualitative data, it was not possible to know who would be selected and sent by institutions to attend CCL’s training. Accordingly, at least one of the training participants had joined a discussion group previously organized by Desert Rose. This may have marginally biased the quantitative baseline data.

Extensive visits to Gambella’s different zones were beyond the scope of this survey. To gain some understanding of healthcare outside of Gambella Town, a visit was made to a health centre in Etang Zone. However, Gambella Town residents were principally relied upon to gain an understanding of rural HIV/AIDS healthcare in Gambella. They were nevertheless vocal about the challenges confronting rural healthcare.

In one discussion with health professionals, their supervisor wished to sit in on the meeting. This may have limited or altered the perspectives that they shared.

The sample selected for the quantitative component of this survey is not fully representative. The only realistic opportunity to implement the quantitative baselinesurveywasatthebeginningofCCL’strainingsessionsandsurveyingparticipantsat every session was beyond the scope of this survey. Desert Rose elected to survey train-eesfromthefirstoffourtrainingsessions,whichfocusedonhealthcarestaffandofficialsfromGambellaTown.Subsequenttrainingsessionsplannedtofocusonstafffromfurtherafield and further down the chains of command. No single training session contained a representative sample of trainees.

Principal sources of bias



• Participants appear to have some idea of the strengths and weak-nesses of people in Gambella and the attributes that are desirable for a smooth-running work environment.

• However, they appear to have an unrealistically positive perception of their strengths relative to those of others, and show wide variance in their perceptions of relative strengths and weaknesses in Gambel-la’s HIV/AIDS healthcare system.

Quantitative findingsQuantitative Findings • 13


Section 1 - Demographic Information16 participants were men and one was a woman. A few more women joined the train-ing late, after the survey had been carried out. The shortage of women at the training mirrored the observed shortage of women in the middle and upper tiers of HIV/AIDS healthcare in Gambella, though it is difficult to say how precisely. The marginalization of women in Gambella is discussed in the ‘Quali-tative findings’section.

Gender distribution

Men

Women

Age distribution of participants

0

1

2

3

4

5

6

7

20-24 25-29 30-34 35-39 40-44 45-49 50-54

Most participants were aged 25-34. It was observed during interviews and discussion groupsthatfewhealthcarestaffappearveryold.DesertRosewasunabletoobtainsat-isfactory answers as to why. Possible explanations include uncertainty about real age, staffleavingGambellaforbetterposts,jobcompetitionfromtheyoungergenerationandlower life expectancy.

Gender Distribution

Age Distribution of Participants


Work Place Distribution of Participants


Approximately a third of partici-pants came from work environ-ments where they deal directly with patients, (Health Post, Health Centre, Hospital) while another third came from administrative sites (Health Bureau, HAPCO). Several participants from the ‘Other’categoryrepresentedasso-ciations of HIV patients in Gambel-la Town. Desert Rose advised CCL of the strong potential of these associations to improve HIV/AIDS healthcare in Gambella.

Anyiwak speakerswerewell rep-resented at the training, perhaps reflectingGambellaTown’s situa-tioninAnyiwakZone.Participantswere split almost 50/50 between those with a local mother tongue and those with a highland mother tongue.

Mother Tongue of Participants

Work Place Distribution of Participants

Quantitative Findings • 15

Mother tongue of participants

Anyiwak

NuerAmharic

Oromo

Unspecified

Work place distribution of participants

Health Post

Health Centre

Hospital

Health Bureau

HAPCO

Other


Section 2 - Strengths and Weaknesses of Self and Others

Assessment of self and others

1 2 3 4 5

People here are good leaders

People here respond positively to criticism

People here like facing difficult tasks

People here are happy when others succeed

People here try harder when they fail

People here work well as a team

I try harder when I fail

I like facing difficult tasks

I am a good leader

People here keep going until they succeed

I respond positively to criticism

I keep going until I succeed

I am happy when others succeed

I work well in a team

Participants’assessmentof themselveshadameanvalueof3.88,whileassessmentsof‘peoplehere’hadameanvalueof3.03.Participants’assessmentoftheirteamworkskillshad a mean value of 4.63, an unrealistic figure for most groups of people. They assigned theteamworkskillsof‘peoplehere’ameanvalueof3.19.

Assessment of Self and Others

Assessments of self and others were especially disparate in the areas of leadership, responding positively to criticism, feeling happy when others succeed, andworkingwellinateam.

Disparity between perceptions of self and 'people here'

0 0.5 1 1.5

work well in a team

feel happy when others succeed

respond positively to criticism

lead well

like facing difficult tasks

keep going until success is found

try harder following failure

Disparity Between Perceptions of Self and Others



Section 3 – Strengths and weaknesses of HIV/AIDS healthcare in Gambella

Assessment of HIV healthcare in Gambella

1 2 3 4 5

Staff take initiative

Staff have access to counselling when they are stressed

The budget is sufficient

Staff are paid on time

Patients are cared for

Staff are paid enough

Staff have benefits

Staff can access equipment and medicine to treat their patients

Staff communicate well with each other

Leadership is good

Staff like their work

It is easy for staff to complain about problems

Women have the same opportunities as men

Patients can access healthcare

Staff have training and education opportunities

Participants believed that there is a relative abundance of HIV/AIDS healthcare education and training opportunities in Gambella. They appear to have low opinions of payment schedules,staffcounselingavailabilityandinitiativeamongstaff.

Qualitative research by Desert Rose suggests that women have far less opportunities than meninGambella,andthequantitativedata’scontradictionofthesefindingsislikelydueto most participants being men.

By requiring participants to assign three attributes to each value (from 1 to 5), this exer-cise was designed to yield data that shows relative strengths and weak-nesses. It does not show the absolute values that participants might assign to each attribute.

Theattributesthatexhibitedamorereliabletrendinrankingsarehighlightedingreen.


Assessment of HIV Healthcare in Gambella


Participants’ assessments of HIV/AIDS healthcare in Gambella varied immensely and it was common for attributes to be assigned a wide range of values.

Below are examples of attributes that showed more reliable trends and attributes that showed inconclusive ones.

Examples of inconclusive trends

Examples of more reliable trends

Variance in rankings for 'It is easy for staff to complain about problems'

0

1

2

3

4

5

6

7

1 2 3 4 5

Variance in rankings for 'Staff are paid enough'

0

1

2

3

4

5

6

1 2 3 4 5

Variance in rankings for 'Staff have training and education opportunities'

0

1

2

3

4

5

6

7

8

9

1 2 3 4 5

Variance in rankings for 'Staff take initiative'

0

1

2

3

4

5

6

7

1 2 3 4 5


Variance in rankings for‘Staff have training and

education opportunities’

Variance in rankings for ‘It is easy for staff to complain

about problems’

Variance in rankings for ‘Staff are paid enough’

Variance in rankings for ‘Staff take initiative’


Section 4 – Recognizing how to develop as a team

Participants’assessmentofwhichattributestheywouldprioritiseinanewworkcolleaguedemonstratedarelativelystrongappreciationofmotivation,teamwork,communicationand initiative—important values for CCL.

Valued attributes in a new colleague

Motivated

Works well in a team

Takes initiative

Patient

Calm

Does not complain Polite

Communicates well


Valued Attributes in a New Colleague


HIV/AIDS Healthcare in Gambella

Gambella is a challenging environment for a pilot project focused on improving HIV/AIDS healthcare. There are numerous weak links in the healthcare chain and strengthening some of these may not necessarily improve the structure’s strength as a whole.

Aliteraturereviewtoidentifywaysofattractingandretainingstaffinremote,weakenedand under-resourced health systems argued that “because of the complex interac-tion of factors impacting on attraction and retention, there is a strong argument to be made for bundles of interventions...”10

ThesameappearstrueforCCL’sbroadergoalofleadershipcapacitybuildinginaremote,weakened and under-resourced health system. The complex collection of challengesmeansthatbundlesofinterventionsaremorelikelytomakeameasurableimpactonthesystem as a whole.

ThisisnottodiscounttheimportanceofCCL’scurrentcontributiontohealthcareinGam-bella. Comprehensive strategies are extremely rare and there is a shortage of ini-tiatives focused on improving management and working conditions in such healthcare systems.11

However, CCL should proceed with an awareness of the numerous factors that will limit the direct impact of its pilot project in Gambella, unless those factors are simultaneously addressed by partner initiatives.

Qualitativefindings20 • Baseline Survey

10 Lehmann et al. 200811 Ibid.


HIV/AIDS Healthcare in Gambella

QualitativefindingsBelow are outlined 3 categoriesofkeyproblemsfacingthedeliveryofeffectiveHIV/AIDShealthcareinGambellaattheoutsetofCCL’straininginitiative:

1. Short-term opportunities - those problems in HIV/AIDS healthcare thatCCLdirectlyaddressesinitstraining;

• Team-buildingneeds• Managerialneeds• Trainingneeds

2. Short-term limitations, long-term opportunities - those problemsinHIV/AIDShealthcarethatarenotdirectlyaddressedbyCCL’strainingandmay initially limit the direct impact of the pilot training on HIV/AIDS healthcare. In the long-term,ifCCL’sprojectwasexpanded,thenitistenuouslypossible(andnotpredict-ed)thatsmootheroperationofthehealthcaresystemresultingfromCCL’strainingmightindirectly address these problems.

• Motivationchallenges• Harshclimateforinitiative• Discontinuityofmanagement• Basiccaretrainingneeds

3. Long-term limitations - those problems whose source is outside Gam-bella’shealthcaresystemandwhichCCL’strainingisthereforeunlikelytoaddress.

• Accessbarriers• Fundinggaps• Materialshortages• Marginalisationofwomen• NGOreliance

Thecategorizationsareonlyrough,sinceelementsofsomeproblemsfallunderdifferentcategories.

Qualitative Findings • 21


ThePresidentofGambellawelcomedCCL’scontributiontowardsmoreeffectiveteamworkwithin HIV/AIDS healthcare. Current levels of alignment vary significantly between institu-tions, districts and rungs of the healthcare ladder. HIV patients in Gambella Town reported theireffectiveassociationnetworktobeoneoftheirstrongestassets.Duothreportedaquarterlyevaluationsystemwherestaffevaluateoneanotherandtheirleaders.Thechal-lengesraisedarelargelysuitedtotheskillsthatCCLteaches:

• HIV patients bemoaned the handling of patients’ files (some of which had been lost) and medicine distribution at the Gambella Town Hospital.

• Health Extension Workers face a special challenge in making their views heard sincemanyonlyspeakAnyiwakorNuer.Theyoftenrelyonnurses,whomayspeakalocal language as well as Amharic, to liaise with higher authorities on their behalf.

•Adoctorsaidhebelievedthatgoodteamworkinvolvesablendofdemocracyandhierarchy, but that hierarchy dominatesabittoomuchinhisworkplace.

• Nurses at Gambella Town Hospital lamented the unexplained termination of monthly meetings within the hospital to evaluate problems. The responsibility for organizing these meetings lay with the Medical Director. Greater cooperation among HIV-related departments (as well as between the HIV and the tuberculosis department)isneeded,theybelieve,toavoidproblemssuchaslosingtrackofpa-tients. A long-term coordinator is needed since doctors are seldom at the hospital for very long.

Short-term opportunitiesTeam-building needs



•ApharmacyprofessionalobservedthattheweeklymanagementmeetingattheGambella Town Hospital does not provide enough time to discuss all relevant issues. He believes that there is always an information gap between top managers and lower managers and that this is because there are not daily meetings or follow-up procedures from the top manager.

•Hefurtherstipulatedthat,inordertomeetpatients’needsformedicine,allpart-ners including the Regional Health Bureau, Bureau of Finance and Economic Plan-ning and healthcare-related NGOs need to work together to ensure the budget is sufficient.

• Supply chain frustrations are strong. Nurses complained about the hospital’sseemingly arbitrary policies and mechanisms for the distribution of medical mate-rials upon their arrival, such that sometimes materials are withheld when urgent-ly needed. A pharmacy professional noted that the gap between purchasing and demand of materials was partly due to coordination problems between hospital departments. However he also believed that it owed in part to the mismanage-ment of medicinebyhospitalworkerswhoneedmoreexperienceadministeringthem. A common complaint among HIV patients was the damaging variance in type and availability of HIV medicine.

• Duoth noted that consistent supply of materials, medication and ART to health centers can be a challenge.

• Health professionals reported that communication within districts is poor and that more organization at the district level is important. They held Etang and Gog Districts to be the best administered.

• They also complained that while peers in Gambella Town get paid on time, they had not received their overtime pay for the last two months.



TherewasanunderstandablereluctancetogivecriticalfeedbackaboutHIV/AIDShealth-care management in Gambella, though a pharmacy professional said that top manage-mentlacksknowledgeofhowtomotivatestafforcareforhealthcarestaff,andGilonotedthat JHU-TSEHAI is unique in having advisors circulate and assess the healthcare it delivers. Informants were more forthcoming about what they perceive good management to be, largely citing skills that CCL imparts through its training.

• One doctor described good management as (a) respecting patients, (b) showing compassionand(c)seeingothers’perspectives.Heemphasizedthateveryonefromthe guards at the gate to the doctors need to appreciate that the patient should beheardandempathizedwith;healthcaresystemsoughttohelprelievebothpa-tientsandhealthcarestaffoftheemotionalburdenthatcomeswithpoorhealth.Headdedthattheworkenvironmentcouldbemademoreaccommodatingbyprovid-ingeasiermethodsforstafftovoicegrievancesandmakesuggestions.

•Insomenurses’eyes,goodmanagingdirectorshavegoodrelationshipswithstaff,are good at problem solving, have time for everything, meet needs and respond to requeststoimplementbetterteamwork.

• The Health Extension Program Coordinator for Gambella Town said that good managementmeansknowinghowtoassigndifferent responsibilities,promotingsharing and discussion of problems in order to bring solutions, good time manage-ment,beinganexampleandknowingone’sjobproperly.

•Apharmacyprofessionalsaidthatmanagersshouldhavegoodinterpersonalskillsand give positive punishment, such as verbal warnings coupled with guidance, to higher professionals who do not observe their duties properly.

Managerial needs



Training was highly valued among informants, especially given the high cost barriers to furthereducation.RepresentativesofEECMYpraised the recent use of training through pictures and provision of toolkits(similartoCCL’sstrategy)byCatholicReliefServices,whichtheyfoundtobeveryeffectivefordeliveringteaching.DuothsaidthattheRegionalHealth Bureau consulted his health center about training needs and felt that HIV/AIDS-related training is made available relatively frequently. However, such training is usually of atechnicalnatureandnotcomparabletothatofCCL.ThereisdemandforCCL’sfollow-upapproach to training:

• Nurses said that they required follow-up ‘pushing’ and evaluation to ensure the effectivenessoftraining.AtameetingwithCCLtheRegionalPresidentechoedthisbelief in theneed for internalizing knowledge learned.HIVpatients inGambellaTown said that putting training into practice was a problem among health profes-sionals.

This may partly owe to how money can distort training incentives. Gilo reported that training provided by JHU-TSEHAI pays 490 ETB/day whereas training provided by the Regional Health Bureau or HAPCO pays 150 ETB/day. One HIV patient in Gam-bella Town sees the discrepancy as problematic:

“The problem here is there is a lot of money for HIV. They say you can’t finish it even by burning it. They don’t want to attend other trainings. If it is training on HIV they come running because they will get paid a lot of money.” (translation)

A patient cited the example of training carried out by the World Health Organization in 2002/2003, which included instruction on how to treat patients. A lot of money wasspenton15daysoftrainingfordoctors,buttonoavailinthepatient’seyes:

“professionals were given 250 ETB daily and 150 ETB for us. They were over-joyed and partying. There was no follow-up.” (translation)

Much of the money poured into training appears wasted on people whose primary motivation for attending is not to learn and who are not pressured to develop through monitoring.12

Training needs


12 NonethelessEECMYrepresentativesstressedtheneedforaccommodationtobetakeninto account when calculating training stipends, since when receiving training far from home at least one informant had run himself into debt by paying for a bed each night.


• Reflecting widespread concern about awareness, Duoth said that community con-versation training to help improve understanding of HIV would be of most value, underscoring the usefulness of CCL’s preventative program in Gambella that will train women as mentors.

Short-term limitations, long-term opportunities

• Nurses reported that they all required more training in recognizing the symp-toms of AIDS since many patients are not accurately diagnosed upon first visiting the hospital.

• HIV patients in Gambella Town added that usually nurses administer treatment and that there are no permanent specialists on staff; rather, theyvisiteveryone tothree months.

• Nurses reported a need for training that addresses stress and burn-out.

• While there is not large demand for health officers (one per health center), Duoth noted that health officer availability is low. This may be, he suggested, because thetrainingisexpensiveandthosewhocanafforditoftenchoosetocontinueintoaMastersprogram,afterwhichtheycanworkintheRegionalHealthBureau.Fundingfor health officer training through the Jimmy Carter Center program has stopped, he said.

• A pharmacy professional said that educational advancement opportunities are not equally distributed in the medical profession.



Staffretentiondidnotappearespeciallychallengingforlowerrungsofthehealthcarepro-fession(thingsmaylookdifferentinthemostmarginalizeddistricts).Doctorsoftendotwoyears’service(someleaveearly)andthenmoveontospecializeelsewhere,butthissetupis common worldwide and can be planned for. Even so, numerous motivational issues do confrontHIV/AIDShealthcareinGambella,whicharelikelytodampentheapplicationofCCL’straining.

• Turnover among non-healthcare professionals in healthcare institutions was reportedly higher. This is partly because they do not qualify for the same benefits (notbudgeted),makingithardtoholdontostaffthatareneverthelessvitalforde-liveringeffectivehealthcare.Forafinanceemployeeworkinginahealthcareinsti-tutionitwillalwaysbemoreattractivetoworkatthegovernmentFinanceOfficewhere they would be eligible for benefits (Duoth). Principle benefits appear to be training, overtime pay and housing.

• Inequality within the healthcare professionappearedtofrustratestaff.Healthprofessionals reported that overtime pay is higher in Gambella Town than in sur-rounding districts for the same positions and that the government should pay more attentiontograssrootshealthcarestaffinmoreruralareas.Meanwhile,inGambellaTown, the perception is that overtime pay is more consistently administered in other regions.Amongnursesthelackoftransparentselectioncriteriafortrainingwassaidto be demoralising.

• Uncertainty about professional development is another demoralising influ-ence on nurses. With unsteady budgeting and training provision (often sporadic by NGOs),planningandfollowingacareertrackfeelsimpossiblewithoutlargefunds.According to some health professionals, those without degrees (health extension workersandsomenurses)haveparticularlysmallchancesofprofessionaladvance-ment.Askedaboutcandidateselectiontransparencyinthehealthcareprofessionand why people from other disciplines have been selected in place of more suitable candidates, Duoth reports that this problem is being remedied in places.

Short-term limitations,long-term opportunitiesMotivation challenges



•LowsalariesdiscouragesomeoftheHealthExtensionProgramCoordinator’sstaff,who believe they give a lot for what they get. He explains to them that as citizens they are responsible to bring change to their country and that mental satisfac-tion will come for what they achieve. He also believes that individual performance amongstaffshouldberewardedandsaysthatthisisafuturestrategyoftheUrbanHealth Extension Professionals program.

•Stressandburnout was a pertinent issue for nurses. It is easy to forget the often traumatising environments in which healthcare staff work. Previously, they ex-plained, the District Health Office would give them a refreshment course, which in-cluded stress and burnout counseling. This no longer occurs. Nurses said they need self-assessment and stress training where they are given time for reflection and self-examination.Theyfeltthatthereisalackofconcernandcarefortheminthehealth-careprofession.Onenurseexhibitedstrongdisaffectionregardinghisworkandsaidthat his two requests to change department had been refused.

•Commitment to helping HIV patients find employment was stressed as a problem by the HIV patients in Gambella Town. For healthcare success stories, there remains the issue of how such people should support themselves and stay healthy going forward.

Short-term opportunity•Lack of encouragement for initiative was said by nurses to be demotivating. Theyrecountedhow,noticingdemandfortheirHIVcounselingserviceatweekends,they set up a rota and voluntarily provided the service. However, following a period without verbal or financial encouragement, they lost momentum.



Harsh climate for initiativeA culture of punishing initiative, because of the challenge it poses to authority, predomi-natesinmanyEthiopianworkplaces.CCL’straineesmayhavedifficultyreturningtotheirworkplaceandactinguponnewperspectivesiftheyfearlosingtheirjobandlivelihoodfordoingso.Asadvised,CCLisimplementingitstrainingfromthetopdowninaneffortto first increase the number of senior healthcare professionals who encourage initiative amongtheirstaff.

Discontinuity of managementBecause there is more opportunity for advancement in the higher echelons of the health-care profession, there is also more turnover. Well-qualified professionals enter and leave the region far more regularly, and the expertise they learn in Gambella leaves with them. Thus,itisadvisablethatCCL(a)makestraineesfrommiddleandlowerlevelsofhealthcarea strong priority and (b) considers how to continuously reach the new cohorts of upper managementanddoctorsthatcyclethroughtheregionandheavilyimpacttheworken-vironment.



Basic care training needsA pharmacy professional said that there is a need to build the capacity of healthcare staff to counsel, communicate with and provide special care for HIV patients.

• HIV patients in Gambella Town had the most to say about basic patient care in Gambella, which appears to require urgent attention. They cited several examples of patient neglect, which they put down to poorly trained nurses or downright mis-treatment by care providers:

“…they used to treat patients with good manners but now there is mis-treatment and insult.” (translation)

“Onelady,herwholebodywaswounded.Theyjustcoveredherwithablanketand left her. We facilitated a group of four people and washed her body and treatedherfortwoweeks.Nowtheladyhasfullyrecovered…”(translation)

“ForexampleIwasgiveninappropriatedrugsonceandtheyquicklygotusedtomybodyandcouldn’tbeeffective.Icametoacriticalconditionandwasreferred to a hospital in Addis where I was given another drug. This terrible thing happened to me because they put an intern nurse in place.” (translation)

HIV patients further noted that hospital ward cleanliness levels are low, that the smell is very bad, and that patients must bring their own latrine. Patients without friends or relatives do not get cleaned, they say. If severely ill patients have no one to move them in, to and from their bed then their body may decay further. The hospital,fromthese(albeiturban)patients’perspective,shouldbeafocusforHIV/AIDS healthcare improvement measures.

•Askedwhetherfears of contracting HIVaffectedpatientcare,nursessaidthatfearof contracting hepatitis, particularly when assisting with childbirth, was stronger.



Long-term limitationsAccess barriersProbably the greatest challenge to improving the delivery of HIV/AIDS healthcare in Gam-bella is the difficulty that patients experience accessing treatment in the first place. While CCL may contribute to better patient care for those who can reach treatment centers, many will remain unable to access them in the first place. Some examples of access chal-lenges are as follows:

Regional level challenges•Some districts are very disconnected from the administrative center of Gam-bella.AkoboDistrictisdifficulttoreachbyroad,hasnocellphonecoverageandnoelectricity. Part of the journey must be completed by boat or on foot (Duoth).

•Testingtomeasureapatient’sCD4countandseeifs/heshouldstartAntiretroviralTherapy (ART) or be monitored with other drugs is only available in two sites–onein Mejenger Zone and one in Gambella Town Hospital (Gilo).

• Health centers have no facilities for transporting patients (Duoth).

District level challenges• Only the Gambella Town Hospital and the district health centers are permitted to administer ART. Most districts only have one health center and Jor District has none (Gilo). More health centers are planned, however. Patients must visit these health centers on a daily basis to receive treatment (Duoth). Thus, while ART is free, the transport or time-related costs of visiting the centers can be too high for many.

• Patients may also be unable to attend treatment appointments due to social prob-lems, lack of close support from friends or family, or the weakening side effects of the drugs. Furthermore they may simply lose heart owing to slow health progress (Nurses). Desert Rose understands from its translators that people often turn to tra-ditional or spiritual health practices in such instances.



Funding gapsFunding and budgeting issues were repeatedly raised by informants. They heavily contrib-ute to many of the problems listed here, paralysing initiatives that might address them. Certainly the region would benefit from an overhaul of the way the budget is managed, sinceitoftenappearsto‘runout’.Howmanyproblemsowetoasimpleshortageoffundsis difficult to say. Worryingly, reliance on fluctuating NGO funds to bolster the healthcare budget appears to be growing.

Funding can also be a challenge from the patient side. One HIV patient in Gambella Town noted that, in order to regain health, patients often require supplemental treatment for which they must pay if the cost exceeds 100 ETB.

Material shortages One doctor had a high opinion of HIV/AIDS healthcare in Gambella considering the scar-city of resources. This scarcity appears to be chiefly a funding concern.

• Accordingly, the hospital pharmacy reported having to prioritize ordering what it perceives to be life-saving medicines.

• Nurses reported a shortage of healthcare kit in general, although they said that ART care at Gambella Town Hospital is well-supported by JHU-TSEHAI.

• Shortages of basic stationery,likepens,werewidelyreported.

• The Health Extension Program Coordinator said that a baseline survey to inform his staff’sworkhadstalledbecausetheyhadbeenunable to print sufficient copies of the questionnaire.

Marginalisation of women Very few women appear to occupy positions in the upper and middle rungs of HIV/AIDS healthcare.Theirunder-representationwillremainaweaknessofHIV/AIDShealthcareinGambella until deeply entrenched cultural norms are shifted.



Women are pressured to marry while they are young and often before they have complet-ed a secondary education. This tends to lower performance in school and eliminate pros-pects of further education. The shortage of women educated beyond secondary school level reinforces the belief that they have limited intellectual ability—a belief that heavily male-dominatedNuerandAnyiwakculturehaslittleimpetustochallenge.Womeninter-nalizesociety’svaluationoftheirpotentialanddeveloplowlevelsofself-esteem,whichdampens the self-belief required to challenge stereotypes.

Furthermore Duoth reported that, except for during the latter stages of maternity leave, womenmaynotworkpart-timeingovernment-fundedhealthcarepositions.Thismakesitverydifficultforthemtocontinueworkinginthepublicsectorwhentheyhavechildren.

NGO relianceNGOsareheavilyreliedupontofillhealthcaregapsinGambella,makingthehealthcaresystem vulnerable to their funding cycles. The Health Extension Program Coordinator pre-dicted that there would be gaps in healthcare provision, such as material supplies, and insisted expectantly that NGOs needed to fill those gaps.

JHU-TSEHAI is the principle NGO supporting the clinical side of HIV/AIDS healthcare while NGOslikePactandCatholicReliefServices(partneringwithEECMY)havecampaignedforgreater prevention and awareness measures (Gilo).

Gilo reports that JHU-TSEHAI is often drawn into further supporting activities which it planned to hand over to local health services (e.g. advisory supervision of healthcare), because the Regional Health Bureau and HAPCO have exhausted their budgets. JHU-TSEHAI is currently expanding provision of ART, Prevention of Mother to Child, and HIV Counseling and Testing services to more sites. Its mandate is also growing to include more promotion of community awareness, a responsibility initially left to HAPCO (Gilo).

HIV patients in Gambella Town have contacted the regional government with regard to providing support for AIDS orphans but were told to try contacting The Global Fund to Fight AIDS, Tuberculosis and Malaria.



ParticipantfeedbackonCCL’strainingwaslargelypositive.Oneparticipantexclaimedthat he did not feel tired after this training.

Participants praised the training for

• how it combines theoretical and practical training, putting learning into prac-tice throughactivities;

• relevancetodailyactivities;and

• promoting critical thinking about goals.


Training feedback


Participants particularly recalled lessons about• social identity;

• giving feedback;

• ‘fixed vs. growth mindset’;

• the core concepts of direction, alignment and commitment;and

• the illustrative role-plays designed around the character ‘Mamoush’.

Participants identified goals of their own usingCCL’sgoal-set-ting exercise. These goals included:

•hiringanewemployeewithintwomonths;

•producingafilm;

•pursuingstudies;

•bringingtogetherleadersandteachingthemtoleadtheHIVAssociation;

•ensuringthatyoutharenotfoundinareasandsituationsthatcanhurttheirlives;

•establishing120mainstreamingofficersthroughoutdifferentofficesinGambella;and

•achievinggoodteamworkintheworkplacewithinsixmonths,ensuringthatalltheteam is aligned around one purpose and one goal.

Some participants were confident that their goals were feasible, while others were aware of large obstacles in the way of achieving them.

Participants shared constructive suggestions for im-proving the training, which included:

• brief recapitulation eachmorning of lessons learned from the previous day’straining;

• more detailed explanationanddiscussionoffundamentalconceptslike‘goals’;

• more experience sharingbyparticipants;

• fully translating teaching and toolsintolocallanguages;

• giving training to groups with the same language ability;and

• ensuring that all trainers have the same level of understanding with regard to material.


Training feedback


Numerous participants urged that this training be taken to different sectors and all the way down to the grassroots levelinGambella’sruralareas.Oneparticipantrepeat-edly emphasized the importance of follow-up support to ensure that training is imple-mented.

CCL wishes to explore how it might combat wrong motivations for attending training and restorevaluetolearning.ItrequestedthatDesertRoseaskparticipantswhether, in the future, they would be prepared to pay for training of similar quality instead of being paid to receive it.

Most participants said that they would pay for such training, but the topic was difficult to explain and navigate, and it was difficult to measure to what extent answers were thought through.Measuringthevalueofsomethingthathadbeentakenforgrantedwaschallengingatamoment’snotice.



ConcludingRecommendations

• The practical application of ideas is a strength of CCL’s and should be central to its training objectives in Gambella. Surveyed participants showed some understanding of the problems with HIV/AIDS health-care in Gambella and of theoretical solutions—what makes a good manager, for example. Where participants appeared weak was in ap-plying this understanding to their work. Self-analysis skills appear low.

• CCL’s training would likely bring greater improvements to the delivery of HIV/AIDS healthcare if its training was conducted in collaboration with initiatives that target other problems listed in this report. Much initiative for change is handicapped by problems that CCL’s training will not address. For example, inequality and career uncertainty are hugely demoralizing within the healthcare system, while budget allo-cation and infrastructure present huge external barriers to improve-ments in healthcare.

Concluding Recommendations • 37


• In this hostile climate for initiative-takers, the quality of follow-up sessions with trainees is vital. CCL’s new ideas will need momentum if they are to spread.

• CCL should be aware that, if it expands its program in Gambella, identifying and coaching suitable Ethiopian trainers who speak local languages will be a lengthy and costly process. CCL already appears aware that many of its ideas do not easily translate across cultures. It is gradually developing ways of simply communicating these ideas. However, there is a big difference between the understanding re-quired of a trainee and that required of a trainer. One participant felt that not all CCL’s trainers understood its material to the same degree, despite the fact that they had received substantial training.

For this reason CCL’s training appears difficult to cascade. Because it is not simply passing on knowledge, but rather seeking to develop new mindsets and applications thereof, the quality of CCL’s trainers is paramount to its success. By piloting various tools for CCL in different cultural contexts, Desert Rose has noted that an in-depth understand-ing by the trainer of what s/he wants the trainees to begin grasping is fundamental to the efficacy of training activities. Trainers must have enough expertise to be flexible amid unforeseen outcomes and still help trainees draw the right lessons from them.

• This report provides a rough catalogue of some of the greatest chal-lenges confronting HIV/AIDS healthcare in Gambella. There was wide variation in training participants’ assessments of which challenges are greatest. CCL might consider directly helping leaders to evaluate these challenges. For example, it might offer its training to a multi-sectoral collection of regional officials (with strong health sector representation) and then follow this with focused workshops where officials are assisted in applying CCL’s tools to identifying and discuss-ing solutions for the problems that confront HIV/AIDS healthcare in Gambella. Follow-up trainings could help participants review their progress.



Concluding Recommendations • 39


ART Antiretroviral TherapyCCL Center for Creative LeadershipCD4 count A measure of white blood cells that indicates the stage of HIV, among other things EECMY EthiopianEvangelicalChurchMekaneYesusETB Ethiopian Birr (currency)PEPFAR TheUSPresident’sEmergencyPlanforAIDSReliefHAPCO HIV/AIDS Prevention and Control OfficeJHU-TSEHAI JohnsHopkinsUniversity–TechnicalSupportfortheEthiopian HIV/AIDS ART InitiativeUSAID United States Agency for International Development

Glossary



Dwyer, J., Johnson, S. and Vriesendorp, S. (2006) ‘An Urgent Call to Professionalize LeadershipandManagementHealthCareWorldwide.’ManagementSci ences for Health Occasional Paper No. 4. Available from: <http://pdf.usaid.gov/pdf _docs/PNADI689.pdf>. (Accessed 4 January 2012)

Ethiopia Central Statistical Agency (2007) Population and Housing Census Report, Gambela Region. Available from: <http://www.csa.gov.et/index.php?option=com _wrapper&view=wrapper&Itemid=590>. (Accessed 8 December 2011)

Feyissa, D. (2003) ‘Identity Discourse and Practices Comparing the Anywaa and the Nuer.’In: Bruchhaus, Eva-Maria (Hg.): Hot Spot Horn of Africa. Between Integration and Disintegration. Münster: LIT. S.26-40.

Lehmann, U., Dieleman, M. and Martineau, T. (2008) ‘Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention.’BMCHealthServicesResearch,8:19.Availablefrom:<http://www. biomedcentral.com/1472-6963/8/19>. (Accessed 4 January 2012)

PEPFAR(2010)‘Five-YearPartnershipFrameworkinSupportoftheEthiopianNational Response to HIV/AIDS 2010 - 2014 Between The Government of the Federal Democratic Republic of Ethiopia and the Government of the United States ofAmerica’.Availablefrom:<http://www.pepfar.gov/frameworks/ethiopia/ 158572.htm>. (Accessed 4 January 2012)

Meckelburg, A. (2006) ‘Changing Ethnic Relations. A Preliminary Investigation of Gam bella,SouthwestEthiopia.’Asia-AfricaInstituteofHamburgUniversity.

Bekele, S. (1988)‘AnEmpiricalAccountofResettlementinEthiopia(1975–1985)’.In: USSR Academy of Sciences, Africa Institute (Hg.): Proceedings of the Ninth InternationalCongressofEthiopianStudies.Moscow:NaukaPublishers.

References

References • 41

Documents

Pilot Training Building Leadership Skills of the … · Pilot Training Building Leadership Skills of ... The Center for Creative Leadership ... edge about teamwork and management