A "Matter of Life and Death": Health Governance in Ethiopia

 {Photo by: MSH Staff}A team from West Hararghe provincial health office discusses professional licensing and accreditation of health facilities.Photo by: MSH Staff

Jemal Mohammed calls governance in the health sector a “matter of life and death.” That’s what drives him to do the work he does. 

Jemal has worked in the global health sector for 21 years — more than seven of those at MSH. He has dedicated his career to working on sustainable health interventions that can improve entire health systems.

He has worked in HIV/AIDS, emergency health, and other health development programs in his home country of Ethiopia, and in South and North Sudan, Somalia, Burundi, Democratic Republic of the Congo, and Swaziland. Now, as country project director of the Leadership, Management, and Governance (LMG) Project for MSH in Ethiopia, Jemal works with health leaders, managers, and policymakers to help ensure that investments in leadership, management, and governance lead to stronger health systems.

[Jemal Mohammed gives opening remarks at a final results presentation workshop at Black Lion Teaching Hospital in Addis Ababa (June 2015).] {Photo credit: MSH staff}Jemal Mohammed gives opening remarks at a final results presentation workshop at Black Lion Teaching Hospital in Addis Ababa (June 2015).Photo credit: MSH staffJemal explained how one piece of that puzzle — governance — is essential to global health.  

“In the health sector, we need governance which is very participatory, which is based on accountability, and also which involves a very clear way of overseeing the scarce resources we have,” said Jemal.

Governance is a collective process of making decisions for organizations or health systems.  A lack of good governance will make large-scale health improvements impossible, and in the health sector, it is a widespread problem.

“The health sector is led by clinicians and physicians whose training is very strong in terms of clinical science, but not in leadership and governance,” said Jemal. “Having a project like LMG is critically important to developing their skills and capacities.”

In global health, he adds, the stakes are high — bad governance can lead to people not getting the care they need to stay healthy, leading to higher rates of illness and mortality.

The workshops run by the LMG Project train leadership teams at hospitals, medical facilities, and health bureaus, focusing on improved understanding of a facility’s mission and vision; changes in management systems; and responding to the needs of the community through good governance.  The project, officially launched by the US Agency for International Development (USAID) in 2011, is led by MSH and implemented by a consortium that includes the African Medical and Research Foundation, International Planned Parenthood Federation, Johns Hopkins University Bloomberg School of Public Health, Medic Mobile, and the Yale University Global Health Leadership Institute.

“Once there is an improvement in the work climate, in the management systems, and in being accountable to the community,” said Jemal, “then the other [health] area outcomes — like maternal and child health, HIV/AIDS, family planning , and sanitation — will come.” 

And Jemal says they have.

One example is an improvement in sanitation. Open defecation has long been a problem in Ethiopia. In 1990, 93 percent of the country’s population practiced open defecation, according to UNICEF. Open defecation pollutes groundwater and has been shown to spread disease and illness, including diarrhea — the country’s leading cause of death of children under five.

After the LMG workshop, health workers mobilized communities to build latrines using local resources, and entire villages have become open-defecation-free. In just over 20 years the open defecation rate — down to 45 percent as of 2011 — more than halved. This, in turn, has led to lower maternal and child mortality rates.

“If there is no good governance,” he said, “you may find a very clean household, but you can't find a very clean community.”

The project has also worked to develop a standard curriculum for uniform leadership and management training across the country.  The Federal Health Ministry of Ethiopia mandated the LMG Project to lead a technical core group as part of revising the national health policy in the area of leadership and governance, which Jemal described as a “landmark victory.”

“LMG is not only a name of a project in Ethiopia, but it is one the priority areas, and a key pillar of the national health policy for the next 20 years,” he said. 

The working group led by LMG Ethiopia comprises 18 member organizations, and after more than a year of preparation and testing, the materials have been approved by the Federal Health Ministry as national curricula and modules.

Earlier this year, Jemal received a fellowship from the Mo Ibrahim Foundation to attend a course on Governance for Development in Africa at the University of London.

In his 21 years in the field, Jemal has seen health sector improvements on a large scale, and these changes are what drives him to continue his work in global health.

And underlying these successes, he said, is good governance.