Zelalem Abera is the Healthcare Program Manager for Nuru Ethiopia. Zelalem earned his M.S. in Applied Human Nutrition and a B.S. in Public Health with distinction from Hawassa University. He also holds a Diploma in Nursing from Gonder University. He has worked in the health field at a clinical level at different government public health centers and with community health working at the Primary Health Care Unit (PHCU). Zelalem has extensive experience in disease prevention and knowledge of the government health system through his work at the community, district and zonal levels. Zelalem joined Nuru Ethiopia in January 2015 and became the Healthcare Program Manager in July 2015.

Here are excerpts from his recent interview with Kevin Nascimento, Education and Healthcare Program Specialist, Ethiopia.

What motivated you to join Nuru Ethiopia after working for the government for so long? 

When I came and visited Boreda as a zonal official, I heard about Nuru Ethiopia. The Healthcare Program had not yet started but I heard about Nuru’s Agriculture and Financial Inclusion programs and how they intended to integrate with the Education and Healthcare Programs.

I then tried to see what Nuru Ethiopia and Nuru Kenya were all about online. When I read about the integrated model and how each program contributed to the end of extreme poverty, I was really attracted to Nuru Ethiopia. The vacancy then came up and I applied!

You were involved in co-creating the Healthcare Program during our seven-month Program Planning Process. What did you learn about yourself during the PPP?

I learned a lot about healthcare from my peers and it really improved my understanding of healthcare in Ethiopia as well as how to design a program.

Even though I learned about program designing in university, that was more theoretical. This was practical and allowed me to see things from different corners. Especially when we consider the quality solutions criteria (QSCs) – the issues of impact, sustainability and scalability. All these things equipped and built my knowledge of program designing.

Even the process—from starting with the strengths and needs assessment all the way to budget creation at the end. The co-creation process was also supported by the expatriates who have diverse backgrounds and see things quite differently. Whenever we ambitiously raised an idea, the entire Healthcare team, including our expatriate, was asked to look through the eyeglass of the QSCs. I can confidently say now that as a result of the PPP, when I face another situation requiring program design in the future, I can contribute something to any organization I am a part of.

Similarly, the PPP has helped in program implementation. I know my program in great detail. Rather than having activities come from top-down, everyone is on the same page and has a deep understanding of the program and its goals.

What would your advice be to someone who is transitioning into a rural community?

Whenever and wherever you work in a rural community, you must think of the challenges.

In rural communities, you must consider the culture, the different literacy levels, and the beliefs and understandings. You must take into account the indigenous knowledge and experiences of the area. Some indigenous knowledge and experiences are very good and are incredibly useful when assisting in the implementation of activities. Some knowledge and experiences, however, may be misleading or based on misunderstood facts. In order to correct these, you must consider all points of view first.

You have to first learn about the similarities that everyone shares. This is where you begin to build from. Understand that some cultural norms may not be based in science – this is especially true for our program, Healthcare. In order to correct this though, you must first understand it and then approach it from a place of respect. If you are too straightforward to the community however, and it is contrary to their cultural norms, no one will accept you.

Therefore, in healthcare, to bring behavior change at the household and community level, you can see that it is not a simple task; it will take time. Their different backgrounds and cultures affect the way they receive information. Low literacy levels are indeed an issue that also affects them. You must ultimately be patient, respectful of the communities’ culture, value their insight, be flexible, and work with them. Whenever you face an issue, you must involve them as stakeholders in the solution by first making the problem clear to all. If they are clearly made aware of the problem, they certainly possess the solutions to it.

When you were younger, what did you see yourself as when you were grown up?

I wanted to be a teacher – especially of electricity, chemistry and biology. My electricity, chemistry and biology teachers in high school were amazing, their style of communication and passion for their jobs motivated me towards wanting to be a teacher in these fields. My wish was to teach.

When I was grade 10 though, my mother became seriously sick and I took her to the health center. There was one female nurse – she didn’t treat my mother’s illness as an emergency, she actually refused to give appropriate care and hospitality. I felt bitter about these things. I then went to our neighbor, a male nurse, and had him check on my mother. He agreed that she was seriously sick and together the male nurse and the female nurse ended up helping my mother.

This entire situation was painful to me. At that time, there were so many people suffering, like me, in such a way. I was fortunate that my neighbor was a qualified nurse. However, there are many people who don’t have neighbors who are nurses or who know qualified health professionals—they may suffer more than me. This caused me to start thinking more about becoming a health professional.

In Ethiopia, when you complete your high school education and matriculate to university, you are required to fill eight fields of study that you would like. I filled numbers one to three with the healthcare field. I fortunately received my first choice, nursing, and the rest is history.

What’s the biggest challenge you’ve faced here in Nuru Ethiopia? The biggest success?

The biggest success I’ve faced here in Nuru Ethiopia first of all is the designing of the Healthcare Program. As you know, when Healthcare started, there was nothing and we had to create it entirely. The frame and activities exist now – maybe slight modifications will be required when scaling but those won’t be too challenging.

Another success is our capacity building trainings for the healthcare professionals we work with. The trainings are going very well, the community is well-mobilized, and in spite of our many challenges, the rest of the program is also going well.

Notably in the trainings is that the Health Extension Workers (HEWs) are improving in their abilities to cascade the trainings down to the Health Development Team Leaders (HDTLs) and Health Development Army (HDA). Usually trainings don’t make it down the chain to them despite HDTLS and HDAs being the most community-facing aspects of the health system.

When I look towards my biggest challenge, it has to be our staff turnover. Within a span of four months, four people resigned from the program. Especially at the beginning of our program, this caused a lot of challenges. However, this challenge did teach me a lot. My recruitment style has changed and I’ve begun to notice different things in our interviews with potential hires.

Another challenge has to do with the status of the healthcare system in place here in Ethiopia. The Ministry of Health has laid down a structure for HEWs, HDTLs and HDAs. However, when we began implementing our program to work within these systems, it was not like what we imagined. The structure was weaker than we had planned for. We adapted our program to help strengthen the system first and then work within that same system.

What has surprised you about working with firenjis (foreigners)? What’s the weirdest thing you’ve learned about firenjis?

My surprise is that when I was in high school, we learned that firenjis need a comfortable and sophisticated kind of lifestyle – that was my expectation. From my previous job, I know all of the woredas (counties) in the Gamo Gofa zone. I know for a fact that Boreda woreda and another woreda are the most rural in this zone. The infrastructure is poor. I’m not expecting firenjis to be able to live and work here for a long time.

This has certainly been my biggest surprise. The firenjis are experiencing all the challenges of daily life here – they are walking to work all the time, they have to take turns for using the car down the mountain, et cetera. I believed that they would have their own car and such. I didn’t think they would be able to withstand this rural lifestyle. When I’ve observed that the firenjis are indeed withstanding this kind of lifestyle and heard that some of the firenjis are even staying for around two years, I was surprised.

My other surprise is that I believed that firenjis would see themselves as the boss—that they were bossy. That they might not receive feedback and such things like that. This is what I expected. However, here in Nuru, the firenjis are always asking for feedback. “How can I improve?” and “How can I help you?” rather than “Do this, do this, do this.” Therefore, it’s a big surprise. This has really helped us work and be motivated.

Why do you think healthcare is a key aspect of ending extreme poverty?

As we have defined poverty, it is a multidimensional issue that requires a holistic approach to ending it. Healthy communities can work, can be productive. The rural community is preparing land, harvesting their crops and they need to be healthy for those activities.

If you take the rainy season, malaria typically emerges soon after it ends. The end of the rainy season is also a very important working time for our farmers. If our farmers are impacted by malaria, for example, during the farming season, they will not be productive in agricultural components. If they don’t produce enough in their agriculture components, they will not be able to sell their crops and therefore feed their families. Children might not even be able to go to school because of the lack of school fees. Therefore, keeping a healthy community and raising their awareness on the prevention of malaria, diarrheal diseases, et cetera. allows them to avoid these issues in the first place or better deal with them should they arise.

On another level, healthcare has a huge impact on the education of the next generation: the children. A well-nourished, well-fed child has improved cognitive development. The child is more alert during school. Malnourished children are more likely to underperform and perhaps have poorer school attendance versus a well-nourished child within the same environment.

As we know, poverty is multidimensional. Therefore, if begin by creating a conducive environment with healthy children and adults, the cumulative effects of the remaining programs in Nuru will certainly be felt.