When Meseret Cherkos gave birth in the maternity ward at Addis Hiwot Health Center in 2016, her friends and family came to visit. In the bright, sunlit recovery room, the clinic staff prepared genfo, a traditional Ethiopian porridge, and held a coffee ceremony to celebrate the arrival of her baby. Addis Hiwot used not to be so welcoming: opened in 2012, the health clinic is in Gulele in the northern section of Ethiopia’s capital, Addis Ababa. It has a catchment area that includes some of the city’s most underprivileged communities but, despite the area’s desperate need for health services, in its early years, Addis Hiwot did not enjoy a good reputation. “We didn’t like to come here because the service was so poor,” said Meseret. The health center was short on staff and frequently ran out of medicine and water. Power outages were common, and a disorganized registrar system meant patients had to wait a long time before they could see a doctor. Mistrust was also rife between health center staff and their patients, fueled by stories of medical malpractice. Meseret herself had experienced trauma in 2012, when her first pregnancy turned out to be a still birth. “The doctor at the health center didn’t realize the baby had already died, and sent me to a referral hospital in another part of the city. I learned there that the baby had already passed away.” Using Trust Funds In 2013, the Addis Ababa Women’s Association, as part of the World Bank-supported Ethiopian Social Accountability Program (ESAP), chose to partner with Addis Hiwot to improve the quality of its services. By design, ESAP uses Civil Society Organizations (CSOs) to arbitrate the relationship between government service providers and the communities they serve as a way of fostering greater government accountability. The program works with over 110 CSOs in 233 woredas (districts) across Ethiopia, in schools, clinics, and other settings. The CSOs that participate in the program first work to sensitize communities so that everyone, including the most vulnerable women and children, are made aware of their right to better services. CSOs then meet with service providers and community groups separately so that each can identify the issues they would most like to address. After this, the CSOs host consultations, during which community members and service providers meet, face to face, to discuss the issues. “The hardest part of the process is building trust, that takes the longest time,” said Mussie Yasin, project coordinator for the Addis Ababa Women’s Association. “During the initial meetings at Addis Hiwot, all of our discussions were ‘heated’.” Community members accused doctors of misdeeds, and the doctors felt attacked and responded in a defensive manner. “But after a while, the tone changed, and the consultations began to be about finding solutions to the problems together.” Midwives and other inputs These efforts culminated in the creation of a joint action plan, which community members and health staff worked on together to put into place their desired changes at the clinic. A power generator was installed, as well as a water pump. A participatory budgeting exercise led to a bigger budget being set aside for medicine. More midwives were recruited, so that fewer mothers got referred to other hospitals. These, and other changes, have led to Addis Hiwot being recognized as a model health center: since 2013, the number of patients who visit the clinic daily has tripled, and there has also been a jump in the number of women who opt to give birth there (from three a week in 2013, to 17 a week in 2017). The clinic scored 87 percent in its most recent Customer Satisfaction Survey. “Prior to this program, doctors used to resist feedback from their patients,” said Yehualashet Mekuria, director of the clinic. “But now there is attitudinal change; doctors see that you get more done when you involve the community. Our rapport has improved so much, we get requests saying we should provide more services, like minor surgeries.” Given Addis Hiwot’s success with “social accountability,” the woreda administration has set aside a budget to scale up the approach to other activities, such as improvements in schools and sanitation. Alex Kamurase, Task Team Leader for ESAP, says the evolution in policy dialogue on social accountability, and results at the point of service delivery over the last eight years, are ways in which the Government of Ethiopia can make social accountability more systematic at local levels in woredas and kebeles (neighborhoods). He said the government had now laid out a roadmap for medium-term expansion, designing a third phase of the program. “Living and working in Ethiopia for the last four years gives me the conviction that this is doable,” said Kamurase.
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