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Lalibela, Ethiopia’s twelfth-century capital, is a remote town situated at an altitude of 2,600m in the Ethiopian Highlands. Although the town itself is a thriving tourist destination, the surrounding area is very poor with 250,000 people eking out a subsistence living in the isolated countryside, which is mountainous, deforested and barren. This rural population, exposed to climate warming, loss of topsoil and the ever-decreasing fertility of the land, struggle to survive. It has been estimated that one million died in the Ethiopian famine that occurred around Lalibela in 1984.
The Lalibela Trust is a small charity, based in Glastonbury and founded and run by Dr Hugh Sharp, a former FMS volunteer, and his wife Catherine. Since it was established in 2003, it has been involved in a variety of projects in the area – spring improvement and irrigation schemes, the construction of schools and health posts, Safe Motherhood and the provision of anti-malaria mosquito nets.
FMS has supported the Lalibela Trust for a number of years and by 2013 had donated £54,000. Currently we are involved in health post construction; to date we have funded three posts at Bilballa, Culmesk and Beleh and work will shortly begin on our fourth at Guluha.
We receive regular updates from the Lalibela Trust on the progress of the projects we have been funding. Please see below:
Since 2011, FMS has kindly agreed funding for three new Health Posts in Northern Amhara Region, Ethiopia. FMS has received a total of 23 individual quarterly reports on projects.
The first three projects at Bilballa, Culmesk and Beleh are complete and fully functional.
For the fourth at Guluha, in Bugna Wahreda – with FMS funding – a complex administrative process is delaying the appointment of a builder but we are working to resolve this.
An audience assembled for the Opening Ceremony with mother-beneficiaries of the service provided by the Health ExtensiExtension Workers in the front.
Our fifth proposal is for a new Health Post in Kewabahara, Gazgibla woreda. This is our most remote location so far and we sense the most impoverished. The journey is 6 hours one way from our base in Lalibela, 3 hours on rough gravel roads, followed by 3 hours on foot or mule – whichever one chooses as the less uncomfortable.
In Kewabahara, the population is 6600. There is an existing dilapidated mud and stone building with one room for a store and one room for consulting. However, the consulting room is shared with the kebele Administrator! He has his charts on one wall, the 2 Health Extension Workers have theirs on the other and of course health consultations can only take place in the 50% of the time when the kebele manager is out.
We were appalled at these conditions but greatly encouraged at the “make it work” attitude of the Health Extension Workers. This is a perfect project for us and we are keen to agree it.
The new Health Post will be the same standard government approved specification as for the Bilballa, Culmesk and Beleh Health Posts, with breeze blocks, and stucco facing. The only possible downside at Kewabahara relates to the remote location which creates a difficulty of transporting the building materials, monitoring progress for stage payments etc. We always like to complete projects in 12 months but we hope that FMS will be patient if it takes longer. We will anyway report quarterly.
Our method of operation in this project would be identical to that in the other FMS-supported Health Posts and in the other 6 Health Posts where we have managed and partially funded the project. The local kebele community will agree to participate by collecting and shaping stones, making gravel by breaking stones, and providing all the unskilled workforce for construction. They must do all this without payment. We will not fulfill our commitment until we can see that they have completed their materials collection. Our commitment is to provide cement, corrugated iron sheets, reinforcing iron, doors, windows etc. plus the skilled Ethiopian builder. We also provide the locally made furniture.
Once the project is completed the wahreda provides staff and basic preventive medicine supplies including childhood vaccines, emergency baby nutrition, contraception etc. There is also a major educational benefit associated with the provision of basic healthcare and disease prevention. This education comes mainly in the house-to-house activities of the Health Extension Workers for 40% of their working days. They teach basic disease prevention, hygiene and latrine management, plus antenatal, birth and postnatal care. They are also responsible for the child immunization programme.
Health Extension Workers in Health Posts must have completed 10 years education and 12 months Health training. They provide a very valuable medical service in their locality. The nearest alternative centre is often more than one day travel away.
2015 Update (1)
Festival Medical Services kindly agreed in March 2015 to provide £18,000 funding towards the cost of a complete new stand-alone Maternity Unit on the Lalibela Hospital campus.
This second report follows on visits to Lalibela and Bahar Dar during May 24th to June 6th, 2015. The final plan for the Maternity Unit (MU) in Lalibela Hospital has now been agreed by the relevant higher authority – the Amhara Regional Health Bureau (ARHB). From this plan a Bill of Quantities (BoQ) has been produced and hence a total estimated cost at today’s prices. We expected that the budget of £90k, produced at the time of the earliest simple plan, would be exceeded considerably – partly because of the basic nature of that plan; partly because of inflation since it was produced 6 months ago, and partly because of improvements we have requested. However the current budgeted total cost, which we believe is now close to reality, is even higher than we anticipated, at £152k.
We originally offered 80% of the total cost but no agreement has yet been signed and in the light of this large cost increase we wish to renegotiate a larger contribution from ARHB.
We felt that this could best be achieved by meeting the decision makers at ARHB in Bahar Dar, which is the administrative centre of Amhara Region. We met the Deputy Head of this 60+ hospital region and the relevant Finance Department official and then the Head of Infrastructure Process. They are all clearly very keen on this MU, which they see as a model for the smaller hospitals of the Region, and they understand our predicament. They proposed – and we accepted – that we now go to the tendering stage to ascertain, from the selected bid, the actual sum which will have to be paid. Each builder will see the BoQ without any prices shown – and then create his bid. At that stage, AHRB will negotiate with us, and hopefully a meaningful final sum can be agreed. We believe that with the contributions already agreed by JACCT and FMS plus additional funding from Lalibela Trust, the construction of the Unit will proceed. We wish to include in the contract that construction should be completed within12 months from the day the site is handed over. ARHB support this – but the contractor will also, of course, have to agree.
The next steps are to get the Construction Permits from the Local Authority and then to create the bid invitation document, which will be circulated to about 10 builders who are at the top of a “builder performance list” produced by an independent organisation in Bahar Dar.
2015 Update (2)
Great Ethiopian Renaissance Dam
We have commented before on this huge Ethiopian project to construct the largest dam in Africa on the Blue Nile. The greatest impact of the dam outside Ethiopia will be felt by Egypt and Sudan. The other 6 riparian countries will not be greatly affected – they all lie on the White Nile, south of the town of Khartoum which is at the function of the two Niles. These 6 countries signed an agreement with Ethiopia over the project in the early stages of the dam negotiations. Sudan and Egypt had not signed any agreement, however, with Egypt quoting always the 1929 treaty written by Britain which awarded Egypt veto power over any project involving the Nile by upstream countries.
After much further negotiation between Egypt, Sudan and Ethiopia, these 3 countries signed a declaration of principles in March, which gives an assurance from Ethiopia that the dam will not cause any harm to downstream countries. This signing was a surprise to some, after a long period of desultory negotiation. Perhaps the deal was helped by a realisation by Egypt that Ethiopia had ploughed ahead with construction during the period of unstable government in Egypt and the dam, now 42% complete, is on track to open as scheduled in 2017.
Greater Security – and the Construction Boom
Of course detailed negotiations are still necessary over the GERD but we believe this agreement of principles with Egypt is good news for Ethiopia. It reduces the risk of future conflict over Nile water rights at a time when Ethiopia is looking increasingly stable and secure. Its enemy Eritrea in the north is extremely weak politically and economically, and no significant threat to Ethiopia, and Ethiopia has been very little affected by the Muslim extremists across its borders with Somalia and Kenya. At our grassroots level, we see strong and seemingly well organised community and regional policing, and military strength. At grassroots level also the government is amazingly well respected. Of course there are concerns – mostly overseas – about human rights issues, especially freedom of speech – but these have little relevance to the 87% of the population who are farmers. What matters to them is the weather, and help in getting better seed and learning new agronomic practices – and over the last 5-7 years all these have been generally positive.
One result of this national and local security and stability has been huge new investment, often with overseas funding, in roads, a metro system for Addis Ababa and new railways (from zero functional, to 1500 kms over the next few years) – much of it with Chinese funding and construction. Another result has been strong inward commercial investment, e.g. Heineken, Clarks Shoes, Diageo, international financial institutions and oil explorers – also Indian and other entrepreneurs in the growing flower, herb and vegetable industry – and tourism.
Maternity Unit in Lalibela Hospital
We wrote last time about our now well-developed relationship with the UK charity, Lalibela Trust (www.lalibela.org.uk), who ring-fence any money they may receive for our projects. Lalibela Trust also has some of its own projects and one is a new Maternity Unit in Lalibela Hospital. This does not involve any of our funding but we are assisting in the management of the project from England and through Derebe, our Project Manager in Lalibela.
So far a general plan for the building has been produced based on proposals developed jointly between Lalibela Hospital and (medical) Dr Hugh Sharp, who is Chairman of Lalibela Trust. This general plan has been agreed in principle by the Amhara Regional Health Board (ARHB) and we are now moving to a detailed plan and bill of quantities. When this has been approved by Dr Sharp and ARHB, we can approach selected, trusted builders to tender, and construction can commence. This sounds simple but the bureaucracy involved surpasses even EU intensity and there is poor management and frequent staff changes. The need for the Unit, however, is huge. The existing hospital is dilapidated and seriously under-resourced. ARHB will supply all of an agreed list of equipment for the Maternity Unit plus 20% of the building capital cost and all trained staff. Lalibela Trust is providing the remaining 80% of the capital cost.
The existing hospital deals with around 500 births per year of which 80% are referrals requiring surgery. The infant and mother mortality rates are both high. There is no separate accommodation for any stage of childbirth; mothers post surgery may even be in a ward with an open door to another ward housing TB patients. An equally important justification for the new unit however is the great success of the government’s Health Post policy, which we see working very effectively at grassroots level. The Health Extension Workers in the Health Posts are succeeding very well in persuading rural mothers not to give birth in their own homes (99% of which are mud floor tukuls) but to attend the local Health Post or Health Centre or, where complications are anticipated and time permits, to attend hospital.
Improved roads and the availability of at least one ambulance per woreda (70-100,000 population) is making it increasingly possible to implement this policy. Taking account of these developments, the local government forecast, with which we agree, is that the current level of 500 births per year in Lalibela Hospital will increase to 1500 over 3 years.
Spring Improvement Projects [52 completed; 6 under construction; 4 agreed. Total beneficiaries over 25,000]
At one location, which we agreed last autumn, a problem has arisen. The spring there is about 2 metres below ground level and we agreed, with the advice of the woreda hydrologist, to dig down and create a hand dug well (a well with a sealed top on which there is a hand pump, which villagers can easily use to fill their containers). The contractor arrived to start the first stage – overseeing local people who would dig a deeper well – but almost immediately struck impenetrable rock. Luckily the surrounding area is such that soil and rock can be cleared around the spring and this will become a spring improvement project (with capped spring and reservoir) rather than a well. Much hard labour (unpaid) is needed from the locals and there was grumbling about itinerant users of this spring, who only come here in the last few months of the dry season when their own spring dries up. Those guys refused to help with the hard labour at “our” spring on the grounds they are not major beneficiaries. However, we met the Water Committee Chairman and we think she will persuade them. This all sounds very trivial but in communities like this, where there is absolutely no outside entertainment, minor squabbles and a new concrete structure become big issues for hours, days, and maybe years – only surpassed as a news item by a neighbour’s trespassing goat or an adultery (always in the next village).
Health Posts [13 completed; 1 under construction]
At an opening ceremony for our latest Health Post in Guluha, over 500 people attended. Many sat in the shade of a huge fig tree. Others took shade under a makeshift awning, which provided minor excitement for the children and local goats present when it blew down during a speech. Opening ceremonies can be quite impressive if we can organise them on a Holy Day, when school children and farmers must not work. Then we are guaranteed a good attendance, so long as we arrange them for around 12 noon or later, by which time the Church service, and the immediately following kebele meeting in Church, will be finished.
The date of this latest occasion was in Ethiopian Orthodox Lent so we could only have dancing by young people and the music was melancholic, but the occasion was still colourful and enjoyable. To emphasise the importance of the Health Post for childbirth, the Health Extension Workers organised all imminent and suckling mothers to sit at the front – there were quite a few! Speeches by the woreda Head and myself (translated by Derebe) emphasised the value of using the Health Post and the need never to be afraid. Then food appeared magically but it was not as nice as loaves and fishes – it was njera!
Schools [22 classrooms completed]
Small Scale Irrigation Projects [2 projects completed] No news to report.
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