Maidema Eye Health Centre

Background

The very first initiative to start an eye health programme in Eritrea came from the co-ordinator for Eritrea Peoples Health Programme Dr. Nerayo Teklemichael in 1987. Contacts were made, discussions carried out, which finally led up to the signing of the first agreement, between the Ministry of Health in Eritrea (MOH) and the Norwegian Association of the Blind and Partially Sighted ( NABP) in March 1993.

The overall goal and purpose of this project is to reduce the prevalence of blindness to 0.5% in the southern zones of Eritrea. This will be accomplished by providing curative and preventative eye care, accessible and affordable eye health services, and by training local ophthalmic assistants who will eventually support the MOH in rendering services to the people.

Purpose/objective

Maidema Training Centre and Eye Health Clinic (hereafter referred to as Maidema or "Maidema Centre") was officially opened on 1st April 1996. The planning period of the project was unfortunately strongly influenced by the border conflicts with Ethiopia. Communication difficulties and the fact that authorities were often staffed with inexperienced personnel did not make the planning smoother. A major milestone was therefore reached when the first patients were treated at the clinic.

Following a recommended from Norad, the Norwegian Association of the Blind and Partially Sighted (hereafter referred to as NABP) took early 2004 the initiative to conduct an evaluation of Maidema.
The review does not go into details of the start-up period of the clinic. One reason for that is the turbulent political and security situation that influenced all forms of communication and planning at that time.

Methodology

Interviews, field visit, documents and reports.

Key findings

There is no doubt that Maidema has been a major centre for reduction of blindness in Eritrea. The present report has documented the review team's impressions of the development of Maidema in a wide range of activities. The following is list of some of the findings:
• Maidema has operated under very difficult conditions with open conflicts in the area between Eritrea and Ethiopia (in 1998 and 2000), and with severe damages to and looting of the premises. The way the management and staff have responded to the war conflicts is an example for other clinics.
• The physical structures at the clinic are very satisfactory. A total of approx. NOK 3.4 mill has been invested in new buildings, repairing buildings and replacing looted equipment due to war damages, etc.
• Since its start of operation in 1996, Maidema has treated more than 50.000 OPD patients and performed more than 16.000 major and minor operations. Although there is no study available to confirm it, blindness prevalence seems to be on the decline - at least in areas from where Maidema has drawn its clients.
• The training course for ophthalmic assistants is well structured and has comprehensive and professional contents. The "chemistry" between the doctor and the present group of students has created unnecessary frictions.
• Prevention activities (outreach activities) have not yet started.
• All activities have been carried out under a "low cost"- policy. The quality of services to the patients does not seem to have suffered from this policy.
• The average number of IO-surgeries has been between 150-200 per month. The volume of patients treated at OPD and in the clinic has gone down rather strongly in 2002 and 2003, and has for that period been about 65.
• The 72.000 OPD-patients and 16.000 operations have been carried out at a total running cost (1996-2003) of approx. NOK 6.9 mill. This figure also includes training expenses, and any attempt to calculate an average client-cost will therefore be misleading.
• Maidema must increase its outreach activities to prevent blindness.

Recommendations

The questions of sustainability and national hand-over are major topics in the discussion of the future of Maidema Clinic. It is therefore necessary to deal with that challenge first. Depending on the outcome of that challenge, other recommendations may be of less value as government plans, rules and regulations may conflict with our recommendations. If there is a national hand-over, Maidema's activities and development will be part of the national and regional health plans.
These are some of the recommendations:
• We recommend that NABP and MoH start the planning of a national hand-over of Maidema Clinic as soon as possible. This process must focus on both NABP's out-phasing, and MoH's in-phasing policies.
• The present "Management Committee" (MC) should act as the governing body as from 1st January 2005. The MC should consist of not more than 5 representatives, of which NABP appoints 2, and MoH 3 persons.
• If one party is unable to fulfil its obligation during the hand-over process, the process stops. Past experience shows that none of the two parties have been prepared to stop activities at the clinic if one party does not deliver. In order to put force behind the clause, we recommend that in such a case Maidema will be closed until the hand-over process is resumed.
• We recommend to maintain - and to strengthen - the contact with Asmara Hospital to have the two clinics complement each other both with regard to ways eye-treatments are carried out in Eritrea.
• We recommend that training of ophthalmic assistants continues - and increases in quantity. This must be done in co-operation with the Eye Department at Asmara Hospital, (as is the case today) and with the Faculty of Medical Science of University of Eritrea. To do so the training schedule must be amended to start a new group of students every year.
• We recommend to strengthen the programme for outreach activities.
• We recommend that the agreement of 1998 to retain patients' fees for Maidema should be enforced - as a principle of following up an agreement, and as a basis for establishing a new fee-structure when MoH opens up for that. We also recommend to increase patient fees for major operations as a principle of focus on own generated income for the hospital.
• With the present project mix, two doctors are needed at the clinic: one for surgery and one for training purposes.
• ERNAB should be invited to play an active role on a board level (governance or advisory) for the Maidema.