Case study: Public Health Emergencies Preparedness in Gambella, Ethiopia

The numbers seemed alarming when the rapid reaction health team gathered in the remote Ethiopian town of Itang for their weekly meeting in mid-April this year: 286 cases of malaria reported over the previous seven days.

But as team members pored over the figures from across local communities, collated by a small army of health workers, they faced a dilemma. In this region of Ethiopia, where the mosquito-borne disease is common, that number alone was not high enough to qualify as a major outbreak that would trigger a national government intervention.

Yet from the graphs pinned up on the walls of the one-roomed health post building the team – who include a clinical nurse, a lab technician and district health officials – could see that there had been a significant rise in cases over the previous week. It looked as if a serious outbreak was on its way.

So they put into action a local plan, using a network of local health posts and hundreds of health workers and community health volunteers to spread the message urgently across the affected area: unless everyone did more to prevent malaria right now, from using mosquito nets at night to eliminating areas of standing water where the insects breed, there was a risk of a serious outbreak.

The high-quality of health data collection and the well-trained network of health workers in this remote Gambella region – one of Ethiopia’s poorest – are among the results of a project that aims to provide early warning of potential disease outbreaks, and to support the health ministry in delivering a rapid and effective response.

It is among 14 capacity-building projects of the Disasters and Emergencies Preparedness Programme in 10 countries that are particularly prone to crisis – supported by the UK government and all but one of them coordinated by Start Network. The programme has been running for just over two years and is due to conclude early next year.

For Okello Okuri, 32, the successful effort to stave off a major outbreak of malaria was a vindication of his work as an unpaid community health volunteer. Married, with two children, he said: “I became a volunteer because many children in my village have suffered from malaria and other diseases. I see all the village children as my own, and I want to see them healthy and happy.”

He said he was proud to have been able to influence members of his community, who had put his advice into practice. “I have shown my fellow community members how to build latrines and how to get rid of stagnant water near our houses, to prevent the spread of diseases,” he said.

Along with some 700 other volunteers and paid health workers in the six districts – known as woredas – covered by the project, he has received training in how to spot the warning signs not just of malaria, but of the myriad other diseases endemic in this region. Cholera, Guinea worm, dysentery, typhoid fever and rabies are among them; and all are made worse by frequent acute malnutrition, especially among children, another problem that volunteers and health workers must look out for.

The Gambella region, home to more than 300,000 people, has more than its share of problems: it’s prone to flooding and drought, and many thousands of refugees who have fled fighting and social breakdown in nearby South Sudan. It was chosen for this DEPP project, Public Health Emergencies Preparedness (PHEP), partly because disease outbreaks were not being reported on as quickly or as fully as in other regions of Ethiopia. This made effective response by the national health authorities or other agencies far harder – and the health problems that afflicted the region reduced communities’ resilience to the other challenges they face.

Training the existing health teams in better disease identification is one way the project has worked to improve surveillance against possible outbreaks. Another is the use of informal “rumour logs” in every health post – where second-hand reports of suspected illness are systematically recorded for review and investigation. Information that someone’s baby is sick, or that a farmer has taken to his bed for a few days, may be nothing of importance, or it may be a crucial early warning sign. An increase in the incidence of meningitis last year, with 15 deaths reported, spurred the rapid rollout of a vaccination programme, which put a halt to the outbreak.

The DEPP programme has spurred faster investigation of suspected cases and the use of new technology - including tablet computers to speed web-based reporting to the health ministry, ultimately to its headquarters in the capital, Addis Ababa. As a result, disease surveillance across the project’s six districts now exceeds national targets.

Akane Ujulu, 25, a paid health worker, can see that the project is yielding benefits for the resilience of her community that go beyond reducing the incidence of disease, important though that is. Married, with three children, she was born and grew up in Itang district, and she is passionate about the wider impact of her job.

“For my village to flourish, people must be healthy so that they can work,” she said. “Because of the training we have received, we health workers are better able to identify symptoms of diseases. I’ve also seen an increase in the reporting of rumours about sickness, and the recording of cases. This is why I have become a health extension worker, to help prevent disease outbreaks so that people can work and my village can prosper.”

A second strand of the DEPP project has been to support a diagnostics laboratory in the region. A small laboratory already existed, but it lacked the specialist equipment and trained staff it needed to analyse medical samples. Instead they had to be sent to Addis, 400 miles to the east by road, for testing. Now there is a working microbiology unit with diagnostic supplies and properly trained staff. It is able to check on specimens more quickly and effectively, saving vital time in confirming suspected disease outbreaks.

In a further development, the project has supported setting up fully-automated weather stations in the region. The government had begun building a network of such stations across the whole of Ethiopia, aiming to provide a steady flow of data to the National Meteorological Agency. Accurate information on weather can guide health officials on heightened risks of disease outbreaks, enabling them to launch pre-emptive interventions. But the Gambella region was lagging significantly behind other parts of the country.

Tamrat Terefe, the DEPP project manager in Addis Ababa, said: “Weather data is a crucial factor in predicting the risk of disease and enabling early intervention. Rainfall leads to predictable flooding and increases the risk of malaria and other diseases. Hot weather increases risk of meningitis.” Two new stations have now been set up.

The hope of those working with the DEPP project in the Gambella region is that it will prove sustainable when the current funding ends. But even with political support of the Ethiopian government, resources are tight, with problems sourcing all the supplies that are needed on the ground. Meanwhile the project’s success means there are demands for a similar approach to be introduced in regions of Ethiopia beyond Gambella.

“The DEPP is indispensable here,” said Tamrat Terefe. “Its work is huge, dealing with system development and capacity. It needs to be extended to other areas, and to be sustained and continued so as to strengthen and further deepen the work we have begun.”

About the project

PHEP Gambella is a DEPP project led by Christian Aid, in conjunction with the international medical agency Amref, the Ethiopian Ministry of Health and the National Meteorological Agency.

It aims to develop a resilient health system with the capacity to anticipate and respond to health emergencies. The project is strengthening the capacity of the government’s preparedness, early warning and rapid response systems at the community level, to enable the health system to predict, detect and respond to public health emergencies.

HEP Gambella is increasing the number of health facilities able to cope with emergences in the project target area by developing the capacity of staff to carry out timely and effective disease surveillance, and to respond to health emergencies. The project also aims to strengthen the linkage between health and weather information by investing in automatic weather stations and creating health preparedness and response plans for the six project areas.