Site Visit to the Black Lion Hospital, Addis Ababa, Ethiopia.

February 9-12th 2011

Associate Professor Jo Wilmshurst visited the Black Lion Hospital, affiliated to the University of Addis Ababa, to meet with the paediatric departmental staff to discuss training capacity.

The meeting was held with Dr Tefera (paediatric service HOD) and the Head of Department, Prof. Bogale. It consisted of a round table discussion, followed by a tour of the hospital and an off-site meeting later in the week to consolidate points.

Additional interactions were held with the head of the neurology department, members of his staff and a potential trainee (recommended by departments of neurology and paediatrics) at the SONA (Society of Neuroscientists of Africa) conference held in Addis Ababa at the same time.

Epidemiology and Health structure

Ethiopia has a population of some 80 million.

It is a resource poor country on the low income level according to the world bank.

Health services consist of a combination of primary health care clinics, regional hospitals and tertiary centres.

Referral pathways seem to work well with patients passing between levels of care and not bypassing services. There are challenges surrounding the lack of staff and facilities at all these centres.

Much of the care is delivered to the population by the government sector, there is access to private health care but this at a relatively small level.

Health trends in paediatrics:

Disease trends are very similar to South Africa.

Tuberculosis, HIV, rheumatic heart disease, gastroenteritis, hypoxic insults and traumatic brain injuries dominate. They also have many patients with malaria. Sickle cell is rare. Increasing numbers of patients with haematology / oncology complications (leukaemias, lymphomas) are seen and occupy many of the paediatric hospital beds.

Black Lion Hospital.

This tertiary hospital is the largest in Ethiopia. It has some 170 paediatric beds. The wards are divided in to an “under 5 year old” ward, an “over 5 year old” ward, a neonatal intensive care unit, a small paediatric care unit (3 beds), a separate cardiac unit with its own intensive care and a surgical ward for general surgery and orthopaedic patients. The wards are simple and organized, carers stay to give the basic care, most wards have a rotating staff of 10 nurses with 2 on every shift – for this reason performing any form of high care is basically impossible.

The neonatal care unit appeared the most equipped of the department with new equipment, incubators, strict sterile approaches and a separate section for kangaroo care. There is no weight cut off for intervention – it is based on the clinical state of the baby and they have access to surfactant.

The paediatric intensive care is challenged that the ventilators cannot operate currently as there is no pressure support. Syringe drivers and saturation monitors are scarce. There are a serious lack of access to medications, for example for epilepsy the main agents used are phenobarbitone, phenytion, and carbamazepine. There is no access to intravenous phenobarbitone so status epilepticus is managed with little beyond diazepine and no effective high care. Similarly most of the children with oncology disorders are managed at a limited palliative level.

I did not view the emergency department but understand it is busy and sees a number of acute, referred and unreferred patients.

The hospital has a CT scanner, no MRI on-site (access is available through private on a paying basis) and no EEG facility to date. EEGs are performed the local psychiatric unit and the studies are returned to the hospital for reporting. There is a plan through the adult department to develop a neurophysiology service in the future.

Paediatric department

This staffed by 14 doctors in total – including juniors and consultants. The interaction with the staff supported that they work well together as a motivated, dedicated and innovative team. For example they have already assessed their target health needs – the HOD is a trained sub-specialist in nephrology and Dr Tefera is undertaking a course in emergency medicine with a centre in the states.

Training needs – University of Addis Ababa

They identified needs in their sub-speciality areas – especially gastroenteritis, neurology, infectious diseases and haematology / oncology.

They already have an established general paediatric training scheme with an exit exam.

To date they have trained sub-specialists in collaboration with the parallel adult unit and then the second year abroad. This has provided good experience but has not resulted in qualifications and the funding for many of these overseas rotations has run out.

For example in paediatric neurology 1 trainee has completed his training – he spent one year in the adult department and a second year in Italy. He returned and is working as a paediatric neurologist at the hospital (the only one). His colleague has just completed a year in adult neurology, there is no further funding for him to go to Italy and he is keen to formally complete his training with an exit exam.

Concerns from the department

They have previously attempted to set up training collaborations with SA and failed due to the complexities of the paperwork, mainly limited by the HPCSA. Hopefully with the new APFP system this can be bypassed.

Future capacity

This unit – especially with its collaborations already established, has the capacity to establish its own training schemes in the future. The facilities are constantly being upgraded. The adult neurology department is already training with an exit exam – their training program has been overseen by an international panel and passed for accreditation. They have trained doctors from Rwanda. They have sent another doctor to Italy to become skilled in neurophysiology and aim to establish a neurophysiology unit in the near future. The department is keen to build similar capacity for the paediatric sub-specialities.

Recommendations

Linking the APFP to this university is in keeping with the vision of the scheme and would lead to some excellent collaborations. As with the other African centres linked with the APFP we can also learn much from how our colleagues in other centres work towards improving training.