In Ethiopia, the majority of the VL cases are in seasonal workers who move from the non -endemic highlands of Tigray and Amhara to lowlands to work on the agricultural farms. As these lowland farming areas are endemic for VL and malaria amongst other diseases, these workers are at high risk due to the poor conditions they work in and the fact that most sleep outside or in very rough shelters. Transmission of VL is seasonal, and when the infected workers seek medical attention, the hospitals can suddenly have 40-50 patients needing 17 days of in-patient care.
Following health facility field assessments during the first year of KalaCORE implementation, two hospital sites in highly endemic areas in northern Ethiopia were identified as having insufficient space to cater for VL patients during the VL peak season.
Addis Zemen District Hospital, Amhara, had a capacity of 40 beds in total and was currently not treating VL cases due to shortage of space. Like other primary hospitals, the hospital was constructed without considering the additional disease caseload due to VL and cutaneous leishmaniasis (CL). These patients are therefore treated at the nearby health centre where there is no round-the-clock care available for them. The VL caseload in the area is around 150 patients yearly, and in the peak season there can be over 40 patients monthly.
St Mary hospital in Axum, Tigray, has been a model hospital with highly committed and well-trained staff but it is an old structure with a shortage of space where many patients with other diseases receive treatment. It previously accommodated VL patients in emergency tents intended for cholera outbreaks erected on a cement platform outside the hospital. The shortage of beds during the VL peak season is even more of a challenge as standard VL treatment requires patients to occupy bed space for a minimum of 17 days. In some instances, clinicians in St Mary's have been left with no choice but to treat HIV-VL co-infected patients (involving a different regimen to standard VL treatment), as outpatients following their first five consecutive doses of AmBisome. The outpatient treatment of HIV-VL patients can result in loss to follow-up of those patients and potentially severe and adverse patient outcomes.
As temporary PVC/cotton tents are seen as donor dependent and national authorities are less likely to take ownership to cover the maintenance and running costs, KalaCORE sought to find a sustainable, semi-permanent solution for use in low-resource settings providing value for money and which is acceptable to the Ethiopian Ministry of Health (MOH). A unique, innovative product was found, manufactured in the Netherlands by a specialist relief goods company, using custom designed sandwich panels inserted into an aluminum steel frame. A semi-permanent hospital ward structure offers value for money in a variety of ways:
- The unique sandwich panel material provides protection from cold and heat and reduces the need to purchase add-ons required for emergency tents such as winter linings etc. and are durable for up to 15 years;
- The advantage of having removable sandwich panels means they can be moved to other sites for emergency responses in case VL patients load decreases;
- Unlike an emergency tent, the MOH will take ownership of the structures, committing to maintain the running costs and utilities in future providing sustainability
- Manufactured to a high standard, they are currently being successfully used by MSF in other similar East Africa locations including South Sudan and are proving fit for purpose for use in disease outbreaks.
We encountered challenges in the process to directly procure the goods and worked closely with the Regional Health Bureaus and hospital administrations in Ethiopia including clearing of the hillside area in Addis Zemen and extension of the existing concrete platform in Axum. The risk of importation delays was mitigated by WHO Ethiopia acting as consignee for the goods, as well as reducing customs costs. The on-site assembly was undertaken by specialist engineers and when complete, the ownership was formally transferred to Ethiopian Regional Health Bureaus.
The semi-permanent structures were shipped to Ethiopia and assembly was completed in May 2018. Inauguration ceremonies were held in September 2018 for KalaCORE and the Federal Ministry of Health and Regional Health Bureaus to open the new VL wards.
Addis Zemen District Hospital (pictured below) now has an additional 20 bed capacity, allowing for the transfer of treatment from the health centre care to high quality, hospital based VL treatment.
St Mary’s Hospital in Axum (pictured below) now has an additional 10 bed capacity for VL patients, in time for the forthcoming peak season.