Finally it is complete only 4 days before I leave Axum! The process to creating the neonatal unit as been a long one with many challenges along the way. This is how I did it for those that are interested:
Step 1: Find out that a neonatal unit is what the main objective of your placement is. It took me a little bit of time to do this as it wasn’t specifically mentioned in my initial placement objectives and when ever I asked people at the hospital I was told to ‘tell us what you think’. After I had come up with an action plan for improvements following feedback from the hospital and VSO it was apparent there was one priority – creating a neonatal intensive care unit!
Step 2: Write a proposal for funding. Initially I didn’t know that funding was available. (I found out about four months into my placement that I could get a VSO small grant.) Once you find out you write the proposal using an example provided and data gathered about neonatal admissions and mortality by painstakingly going through the ward admissions book to get figures. Ask the medical director for help with the costing’s for items (you find out later not always entirely accurate!)
Step 3: Experience sharing visit. You are told that you can’t submit the proposal as an experience sharing visit to a neonatal unit already established by previous VSO volunteers has been arranged and you need to go on that first. (See blog: Travelling and exploring – Part 2)
Step 4: Submit the proposal and receive feedback. The feedback doesn’t seem to take into account that hospitals in Ethiopia are similar and also that neonatal units all need to be to the same standard and contain the same equipment. Lots of e-mails and conversations partly resolve this issue.
Step 5: Get told that you have been granted the funding. The money doesn’t actually appear in your bank account until a few weeks later. A week after you have used your own money to run the 1st staff training course (see blog What do you do with free weekends?). The money comes in installments and you have to prove how you spent each section of the money before you get the next instalment.
Step 6: Start refurbishment works. Following instructions for painting and putting lino flooring in the rooms designated for the neonatal unit spend frantic weekend cleaning the rooms before the painting is done (see blog With a lot of help from my friends). Feel like everything may happen quite quickly (you’re wrong!).
Step 7: Start construction works. Medical director decides that you can change the bathroom into a nurse’s station and that a new bathroom can be built (using funds from the VSO grant which requires much discussion to get approval). Since you are creating a nurse’s station can now have viewing windows into neonatal rooms. Lots of mess created by making windows undoing all of the work that was done in cleaning and initial refurbishment! Construction of bathroom outside and work needed in neonatal unit itself takes a long, long time. Progress is made and then stops and then continues in an ongoing cycle. Repeated discussions with the hospital CEO take place about progress with multiple warnings given to the contractors.
Step 8: Get equipment. This requires a couple of afternoons with the head paediatric nurse and the pharmacy stores manager poking around in the three different storerooms at the hospital. Lots of good and unexpected things found which will be useful. The remainder of the equipment requires a trip to Addis with the pharmacy stores manager to purchase. Although some things are not available in the country you manage to get most of the vital equipment. (See blog The ongoing building work.)
Step 9: Re-start refurbishment works. Once you finally have the neonatal unit building works completed (work is still ongoing on the bathroom block) start refurbishment work again. Spend a day and a half cleaning – including scrapping years of encrusted dirt off tiles in the old bathroom/new nurse’s station. Keep asking for other refurbishment works to be done. Explain can’t run neonatal unit until the works are completed.
Step 10: Organise staffing. Get the hospital to assign four nurses for the neonatal unit (1 for each shift looking after 10 babies). Try to ensure that you get good nurses who will be willing to learn and deliver good nursing care. Arrange for extra training in currently operating local (8 hours away) neonatal unit. Once they arrive on paediatric ward try to get head paediatric nurse to understand that they need to be scheduled on separate shifts – it doesn’t work if they are all on the same shift. They should not be covering the paediatric ward only the neonatal unit as the whole point is the babies need specialist nursing care with extra observation and monitoring.
Step 11: Give multiple warnings that you are leaving so project needs to be completed. First warning given with a month to go following which multiple warnings are given on a weekly basis. After returning from annual leave with only 10 days until you finish have a frank discussion with CEO expressing concerns that the unit won’t be finished before you go. Then spend three days following people around and repeatedly going back to harass people to get the odd jobs done so the unit is in a state where you can do final cleaning and move equipment into place.
Step 12: Buy floor for the neonatal unit. This actually takes the best part of the week even though it seems like a simple task. You go to the shop and see a good lino covering (thicker than the previous so less likely to tear hopefully). Then get told it will be brought later that day. Continue to go back to the administration/finance department to ask when it is coming. The following day get told that the price is above the market value (but also told it was the cheapest price and can’t get to the bottom of how the market value was reached). Get approval from the CEO for the extra cost. In the afternoon finally get collected and taken off across a muddy square to a different shop from the previous day. The lino is not the same and much thinner lino, which now is cheaper than the price you were told this morning. Go back to the hospital and speak to the CEO explaining the difference in quality and why the thicker flooring is better. Get the ok to buy the better material but told it will take another two days to go through the procurement progress again. Finally loose your temper. Get told they will speed the process if possible. Go on another trip with procurement people in tow to visit all three shops that sell the flooring you want. Get the costs for the correct type of flooring. (Out of interest the same price that you were told that morning). Back to the hospital as it’s the end of the day. Overnight awaiting the decision of the meeting to decide which of the quotes will be accepted. Ask in the morning when will get decision. Told would be two hours. Found by administrator to ask about the sample and if the floor brought could be different. Decided to go along to make sure the right floor brought. Taken back again to the same shop as yesterday and asked about buying the same poorer quality you were shown yesterday! Get pretty angry at this point. Convince them to go to the next cheapest quote shop. Find the flooring needed. Argument from hospital staff about the price with shopkeeper. Discover they’re arguing over 125 birr (£3.70). Offer to pay this to solve the issue but told no, just wait. Eventually the hospital gets the price they want and the floor is brought. In the afternoon fit the floor with the help of the nursing staff. Finally the worker who was meant to fit the floor turns up as you finish in time to glue the floor down. After three days the floor is complete!
Step 13: Final cleaning and organisation. Following the floor being laid co-opt nursing students, nursing staff and ward cleaner to do a final clean of walls and floor of unit (while the floor is still being glued down). Start to then move in equipment, which has been stored in various places around the ward. Make sure that equipment is cleaned before it is moved into nice clean neonatal unit first. Stick up posters of guidelines on the walls and try to remember what other equipment you may have that has been hidden so well you haven’t found it yet.
Step 14: Find leak into the critical care room. When you go in part way through the organisation of equipment find that there is another leak this time in the roof of the room which will house critical babies. (There had previously been a leak in the roof of the nurse’s station which required fixing.) Since this was found on Saturday have to wait over the weekend and public holiday for Eid before you can inform the hospital management and get it fixed. Surprisingly it’s fixed within two hours of you telling people about it.
Step 15: Open the neonatal unit for business! It’s taken over 10 months to get to this stage and so pleased that it has happened before I leave Ethiopia. This morning we moved babies and mothers into the neonatal unit. Hopefully with good nursing care, from enthusiastic nurses, the outcomes for babies at Axum St Mary hospital will improve. The next blog will contain photos of the functioning neonatal unit. Thank you to everyone that I know who has helped to make this happen through supporting me over the last year as well as donations of money and equipment.