INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025
Page 2066
www.rsisinternational.org
The Silence That Costs Lives: How Clannism and Hushed
Acquiescence Undermine the Health Care System: Dollo Addo
Hospital
Adan Hussein (PhD, Candidate)
Jig-jiga university, Ethiopia
DOI: https://doi.org/10.51244/IJRSI.2025.120800186
Received: 25 July 2025; Accepted: 20 Aug 2025; Published: 18 September 2025
ABSTRACT
This is an investigative piece of narratives that presents a firsthand field-based assessment of the Dollo Addo
primary hospital, a vital health facility for the cross-border and refugee population in the area. The hospital
accommodates a vast number of specialized medical personnel despite its remote setting and devastating health
facilities. The hospital suffers from operational dysfunction, severe infrastructural decay, and systematic
mismanagement. Employing a qualitative approach, including staff interviews, facility walkthroughs, and
patient case reviews, critical service failures and operational troubles were observed, such as issues with water
hygiene and sanitary systems, emergency services, procurement governance, discretionary financial
expenditure, power supply irregularities, poor chain of command, and communication channels. Specialist
staff remain idle due to a lack of surgical and basic diagnostic tools. Moreover, two-thirds of the hospital's
budget is disbursed for informal salary top-ups and an under-the-table pay procedure, thereby sustaining the
dysfunctional system. Documented informal payments during the field assessment, along with an inconsistent
supply chain, further undermine patient trust and equitable access. Additionally, the internal governance
system is marred by weak transparency, fragmented accountability, and a lack of prioritization. Thus, the
report urges an immediate realignment of resources towards equipment provision, infrastructural rehabilitation,
and a transparent governance system. It also calls for actionable strategies in line with Ethiopia’s Health Sector
Transformation Plan II (HSTP-II), including service readiness, need-based and comparable hiring procedures,
and an optimistic referral network. In a nutshell, the report advocates for substantive investment in lifesaving
system installation rather than symbolic staffing for political visibility and financial informalities, thereby
restoring system functionality and dignity in frontline healthcare.
INTRODUCTION
This report presents an independent, professional assessment of Dollo Ado Primary Ho spital, a vital
healthcare provider for border and refugee populations in the Somali Region. It aims to identify the
facility's operational strengths and systemic weaknesses through staff interviews, patient case reviews,
and a structural evaluation. The findings are presented in the spirit of constructive engagement and
institutional improvement. They aim to foster constructive collaboration and evidence -based solutions,
not for partisan judgment or fault -finding, and will support informed decision-making through data-
driven, solution-focused reflection. The hospital operates within the region’s health system and has an
expanded service mandate due to its proximity to major refugee camps and cross-border populations.
However, a notable concentration of well-qualified specialists in such a remote rural setting seems
unusual.
1. General Surgeon
2. Internist
3. Pediatrician
4. Gynecologist
5. Psychiatrist
6. Radiologist
7. Orthopedic
8. Dentist
Despite its peripheral and remote rural setting, the hospital accommodates atypical profiles. While it
may seem puzzling, these experts earn the highest unofficial wages of any other professional
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025
Page 2067
www.rsisinternational.org
undertaking in the country. Despite the service and a physically vulnerable situation of the hospital,
the specialist staff receive an average monthly salary ranging from 150,000 to 170,000 ETB. This
workforce is a vital human resource for regional healthcare, yet it currently offers largely irrelevant
services due to a lack of essential diagnostic and treatment instruments.
Objective
The primary objective of the assessment is to evaluate the operational functionality, service delivery capacity,
resource governance, and infrastructural adequacy of Dollo Ado Primary Hospital, providing actionable
insights for strengthening the health services system.
Methods
The assessment employed a qualitative observational approach, featuring on-site facility walkthroughs, case-
based documentation, and structured staff interviews. Information was triangulated across departments and the
overall hospital units. Additionally, available hospital records and budget expenditures were reviewed when
accessible.
Figure 1: The Main Entry Gate Of The Hospital
Key Findings
Physical Infrastructure and Structural Vulnerability
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025
Page 2068
www.rsisinternational.org
Dollo Ado Primary Hospital provides clear evidence of significant physical deterioration, far exceeding the
expectations for a referral hospital. The system requires in-depth improvement and upgrades as it is
disintegrating and jeopardizing the ongoing provision of healthcare. There is no established water system to
maintain proper sanitation. Most departments rely on makeshift buckets for cleaning and patient use.
The absence of piped and potable in inpatient water at emergency areas and its surrounding significantly
undermines infection prevention and control, maternal healthcare, and surgical readiness. Medical waste
disposal is compounded by the region's unreliable plumbing system, worsening the biohazard threat.
Additionally, the facility suffers from disorganized departmental units instead of a well-equipped functional
setup.
Spaces are shared by units such as psychiatry, pediatrics, surgery, and more, without physical separation. This
arrangement is not conducive to infection control, restricts clinical privacy, and causes operational confusion,
especially when the clinic becomes crowded or faces urgent cases. Essential actions like intra-hospital triage,
wound management, and laboratory deliveries occur in shared or non-dedicated areas, negatively impacting
care quality and increasing health risks. Dirty roads lead to the facility from all directions, unpaved and
challenging for ambulances; patients must navigate through dust clouds as if there were no police station. The
buildings show surface poor sanitary and wornness, inadequate roofing, and a lack of rainwater drainage,
which affects internal cleanliness.
Central clinical departments, including maternity, pediatrics, and surgery, face seasonal flooding and soggy
indoor conditions. Ventilation is either nonexistent or severely lacking. There is virtually no temperature
control in the high-volume maternity area; if anything, it’s terrible. Countless patients and providers endure
extraordinarily harsh conditions with no alternative options. The power infrastructure is equally inadequate.
Frequent blackouts occur, and the hospital lacks the automatic backup power needed for conducting
operations, neonatal care, and emergency stabilization.
Staff commentary, “We frequently clean using buckets since we have no stable piped water. We even have to
use torches during delivery when the power fails.” It's not just a hassle; it's a safety risk.
The area surrounding the facility is insecure. Due to the lack of a controlled entry system, overcrowding,
sardine-like packing of patients and families, and occasional disruptions to the safe flow of clinical care have
become the norm. Overall, the hospital presents a scene of operational disrepair, not from human inadequacy
but from significant infrastructural decay. The hospital's condition is not merely a background issue but a
central aspect of service disruption. Addressing structural weaknesses and establishing environmental health
must be integral to any service investment, as staffing levels or budgets will not change health outcomes, no
matter how high. Electricity is unreliable, with frequent outages and no emergency power backup systems for
surgeries. The plumbing is outdated and more prone to leaks, compromising essential facilities like delivery
rooms and operating areas. “We clean using buckets in the maternity ward because there is no steady water
flow through the pipes.
Midwife commentary: At deliveries, power failure often forces us to use torches. This is not just an
inconvenience; it’s dangerous.”
Compounding these vulnerabilities is the hospital’s failure to secure its perimeters, which leads to safety and
crowd-control issues, particularly in busy departments like emergency and outpatient care. The physical
structure of the hospital is profoundly fundamental. Without a functioning facility, it doesn’t matter how
talented your staff are; satisfactory health outcomes cannot be achieved. The facilities' complete physical
rehabilitation and systemic retooling cannot and must not be delayed for life saving purpose.
Severely Compromised Emergency and Theatre Capacity
Although the hospital is the primary referral center, its emergency and surgical operations are nearly
immobilized. The emergency room lacks essentia l life-saving equipment, including functional
defibrillators, working oxygen cylinders, suction machines, and sterile trauma kits. In several
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025
Page 2069
www.rsisinternational.org
observed cases, the “sickest” OFCs (i.e., those who required immediate intervention) were rehydrated
with IV fluids and discharged for referrals.
Case Report: Bladder Mass and Catheter-Associated Hematuria
A 73-year-old man was hospitalized due to urinary retention and catheter-borne hemorrhage. Initial
assessment using ultrasound showed a suspicious bladder mass, accompanied by kidney function tests
indicating complications. Surgical treatment was first planned according to the imaging findings.
Nonetheless, on the day of surgery, visible hematuria through the catheter prompted new concerns,
which necessitated further evaluation. The surgeon on duty said a decision could not be taken until the
source of the bleeding was known. Regrettably, vital follow-up diagnostics were unavailable,
including urinalysis, coagulation, and cystoscopy. The patient was, therefore, re ferred to Hawassa
“almost 700 km.
Surgeon Commentary: "We encountered a straightforward surgical indication complicated by
unexpected bleeding. We could not move forward safely without basic lab or endoscopic tools. The
only clinical course was to refer him, but that pathway might cost his life.”
Case Report: Patient with Septic Wound in a Dolo Town Clinic.
A prominent community elder from the Dollo Ado district, suffering from a septic shoulder wound that
showed signs of tissue necrosis and systemic infection, came to the emergency room seeking care. The hospital
lacked essential wound care supplies, such as sterile gauze, antiseptic solution, gloves, or fusidic acid. As a
result, the wound could not be treated, and the patient was asked to purchase the necessary materials if he
wished to continue receiving care.
Emergency staff commentary, “When he took his shirt off, we knew it was serious. But we didn’t have
anything even to clean or cover the wound. It felt wrong to send him home, but we can’t do anything without
tools.”
This was not a unique instance but a common obstacle for providers and patients. It serves as a poster child
for a hospital that does not align with its operations. The unit's service was limited to oral advice and
stabilization, without formal care guidance. These cases are not outliers; they reflect everyday challenges
faced by the patients.
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025
Page 2070
www.rsisinternational.org
Human Resources vs. Operational Readiness
Despite the Hospital hosting a wide range of highly skilled professionals, the gap between their
expertise and the existing infrastructure has led to a significant underutilization of knowledge.
Specialists often express frustration at their inability to perform essential clinical tasks due to a lack of
equipment, malfunctioning support systems, or power outages. Most lack a functional operating
theater, an initial diagnostic lab, or imaging backup; as a result, valuable medical knowledge remains
untapped.
The current human resource complement results more from systemic momentum, political exposure,
and inter-hospital rivalry than from the rationale of evidence-based need. According to staff and
internal observers, the designation of specialist has become a symbol of prestige rather than a
functional healthcare system. The existence of multiple leadership vacuums has led to a preference for
human resources over investments that enable services.
“Staff Commentary: "The community doesn’t need titles, it needs tools. We are here in full dress, and
cannot use it. "We are there to show strength, and it is showing us to be quite feeble."
It is only 230 km from Filtu Zonal Hospital, a more suitable referral center fo r advanced tertiary care
conditions. This proximity makes it unnecessary for Dollo Ado to duplicate the staffing structure of
the tertiary level without complementary services. Under these circumstances, spending over two -
thirds (2/3) of the hospital's working budget on salaries while patients lack oxygen, IV fluids, delivery
beds, and diagnostics can be more accurately described as a strategic miscalculation, a failure of
leadership, and a deficiency in a well-structured monitoring system. Instead, reallocating investments
toward physical infrastructure, essential equipment, and service systems would be more effective.
Why is staffing at the tertiary level (specialist staff) are less important than investing in facilities and
equipment now?
1. Specialists Need Tools to Do the Job: Highly specialized professionals cannot do their jobs without
basic tools to perform procedures, diagnose, and manage care.
2. Referral network, only 230k from Dollo Ado is the Filtu Zonal Hospital, where more complicated
specialist care can be readily referred, avoiding replicating advanced skills at Dollo Ado without
commensurate infrastructure.
3. Return on Investment Fit: Specialists are too costly, but do not help to provide better service with a
poor facility.
4. Sustainability and continuum: Investments in infrastructure, such as surgery theatres, labs, and
diagnostic supplies, are still useful over time and between staff rotations. No system can
compensate for skills alone.
5. Utilization and Retention of Staff: When the hospital provides staff with tools to enable meaningful
practice, frustration and turnover are reduced, and workplace morale improves.
6. Equity and Essential Access: Infrastructure prevents you from needing advanced care until routine
and emergency care are available to the general population.
7. Strategic Health System Strengthening: This phase establishes foundations, such as clean water,
power, maternity wards, and diagnostics, that will serve as a base for all the other upgrades.
Thus, we need leadership to put its energy into costly, outcome-focused investment, not just symbolic
top-up staffing. You don't have a staffing strategy if you don't have a sound infrastructure, service
readiness, and vice versa.
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025
Page 2071
www.rsisinternational.org
Critical Medical Supply Chain and Procurement Gaps
Additionally, a significant discrepancy in supply pricing and availability worsens concerns about
supply governance at the hospital level and equity of service access. Anecdotal and ad hoc price
monitoring suggests that the cost of critical products available through some transactions is priced
substantially above typical purchasing benchmarks and at levels much higher than the price at a local
pharmacy A significant discrepancy between donated supplies and those sourced or sold internally has
resulted in a lack of transparency and trust regarding the origins of supplies.
“Some of the gloves and IV fluids we used were donated. Today, the same items are available only at
significantly higher prices, if at all. There’s no explanation. Patients feel they are paying twice for
services they already deserve.”
When combined with these discrepancies and the lack of system-wide internal price regulation or
public inventory transparency, it is no wonder that there is a perception of systemic mismanagement
or at least inefficiency. The absence of consistent pricing for medical items and the inability to
differentiate between donated, publicly purchased, and privately sourced products have created a
haphazard system that unduly punishes the most vulnerable populations. The response also highlights
underlying issues regarding priorities in procurement, supply tracking, and accountability at the
facility level. Concerning the procurement process, staff mentioned that the hospital's deliver y,
distribution, and allocation of supplies remain opaque and inconsistent.
Supplies may arrive unexpectedly, but not swiftly, at the points of care. There is growing concern that
a disconnect exists between what is being procured and the service requirements, and that oversight of
stock deployment is lacking. This cyclical problem of irregular supply flow, inefficient in -house
distribution, and weak inventory control leads to service disruptio ns, even for basic procedures. It is
not uncommon for providers to begin treatment only to have to stop midway due to a lack of gauze, IV
fluids, catheters, syringes, or other necessary items.
Staff commentary, “We are in the middle of treating a wound, and in the middle of the procedure, the
saline bottle is being shared between rooms, or there are no appropriate gloves. This is not a luxury;
this is a continuation of care.”
Such supply chain debacles jeopardize patient care, undermine trust, and deflate clinical staff.
Reliable access to essential medical commodities should not be an admirable aspiration but the
cornerstone of a functional healthcare system.
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025
Page 2072
www.rsisinternational.org
Documented Informal Payment Practices
Multiple reported mavericks in some testimonies and shadow check-out audits have indicated a rising
trend in cash under-the-table payments. Patients claimed they were asked to pay cash for medications,
laboratory investigations, and even bed space in emergency units. These allegations were consistent
between sources and were recorded and reported for confidential review by a high-ranking hospital
official.
Internal Governance and Resource Management
The facility-based planning review showed sharp discrepancies between planned budgets and the
resources of the actual clusters. According to staff, procurement and distribution are still not well
synchronized with departmental needs, even though an operational budget is allocated annually, with a
significant part based on internal revenue. Though the hospital has been positioned to compete with
other urban and Semi-Urban health centers, this has skewed the focus from an appropriate service
delivery model to visible staffing.
The Primary Hospital has an annual budget of approximately 64 million ETB allocated by the regio nal
Health Bureau, along with an IGR generating a yearly income of 1.5 to 2 million ETB. If used
correctly and strategically, these funds should be sufficient to provide primary healthcare to over 85%
of the population. However, the hospital’s budgeting process does not reflect operational priorities.
Funds were not geared towards infrastructure, essential equipment, and core care delivery processes;
instead, a significant portion of the operational budget was diverted to facade -related expenditures and
nominal human resources to illustrate the facility's level in disguise.
Despite these funds and manpower inputs, the hospital has not been optimized. A vulnerable physical
infrastructure, a misaligned operation, and a weak institutional governance mechanism drive the
degradation of the institution's performance.
The buildings are in poor physical condition, and the walls, structure, and features are deteriorating
and urgently need repairs. Additionally, the asbestos ceilings, high moisture levels, and other utilities
are outdated and malfunctioning. Structural deficiencies can affect patient safety, infection control,
and staff operations. Much of the operating budget has been redirected to cover inflated specialist fees
instead of reinvesting in facility infrastructure and vital services. According to payroll records,
specialist staff earn between 150,000 and 170,000 ETB per month, more than twelve times the official
pay scale of similar academic rank in the health sector. These salaries are not processed through the
HR system; they are drawn from the hospital’s operating budget to retain staff, compromising service
and basic functionality.
Admin officer: “We don’t have a pay scale approved for what we pay.” It’s a fudge, what we call
‘retention packages’, yet they hoover up most of the money we should spend on equipment,
maintenance, emergency readiness.”
This informal setup highlights the underlying problem of governance: institutional vanity and
competitive display rather than a sustained impact on services. Hiring high-profile specialists has
increasingly become a symbolic gesture to signal regional visibility and competitiveness, both with
other hospitals and in comparison, to competitors like Filtu Zonal Hospital. However, these experts
are underutilized in practice due to a lack of diagnostic tools, operating theaters, and clinical systems
to support patient care. Additionally, hospital governance lacks accountability and suffers from
limited transparency in budgeting.
Internal review mechanisms are often rudimentary, concentrating on administrative accountability
instead of strategic resource allocation. As a result, structural deficiencies persist, and frontline
readiness declines.
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025
Page 2073
www.rsisinternational.org
Senior staff commentary: "We have personnel for whom we don't have equipment." We have budgets,
but no transparency about priorities and where this budget goes. We say we need lab reagents and an
oxygen system each year, which gets passed over for cosmetic things.”
Such a governance environment undermines returns on public and partner investments, threatens
patient engagement, and harms provider morale. Revamping internal budgeting and ensuring
transparent resource use are essential for transforming the hospital from a paper -based reality into a
functioning health facility.
This informal structure reveals a fundamental governance letdown, prioritizing institutional prestige
and competition while overshadowing sustainable service impact. Hiring well-known specialists is
also symbolic and helps demonstrate regional relevance and competition with other regional hospitals
of equal or greater stature. However, the potential of these experts is often not realized in practice, as
they lack diagnostic tools, surgical facilities, and clinical support services.
CONCLUSION
Dollo Ado Primary Hospital presents an ideal opportunity as a regional anchor institution due to its
human resources, geographical significance, and budgetary positioning. However, the persistent gap
between its professional image and functional reality necessitates immediate strategic action. This
paper serves as a collective and evidence-based call to action, informed by professional observations
and the voices of the community.
RECOMMENDATIONS
1. Prioritize Core Infrastructure Rehabilitation. Invest in rehabilitating water supply systems, electricity,
sewage, and the rearrangement of spaces. "No clinical investment will make any sense without
functioning infrastructure.
2. Rebalance Budget Toward Equipment and Essential Services. Divert excessive specialist pay to
essentials such as oxygen systems, advanced diagnostics facilities, surgical kits, and maternity
kits that can save lives.
3. Improve Internal Governance and Financial Monitoring . Establish a transparent budget planning
based on participatory needs assessments and ensure compliance with national salary scales and
procurement procedures.
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025
Page 2074
www.rsisinternational.org
4. Optimize Human Resource Allocation: Match the staff profile to the actual capacity of the facility.
Specialist deployment should be demand-driven and infrastructure-readiness, not profile-driven.
5. Adopt Minimum Service Readiness Standards. Test readiness is assessed annually by applying the
WHO SARA benchmarks for water, sanitation, emergency response, and maternal health care.
6. Engage in Strategic Referral and Facility Network Planning: Leverage proximity to zonal hospitals,
Filtu, where advanced cases can be referred, to focus Dollo Ado facility development towards a
well-staffed center for general care.
7. Engage in Strategic Referral and Facility Network Planning: All planning, budgeting, and
infrastructure development should follow Ethiopia’s HSTP II and other national health quality
frameworks to promote systemwide consistency, equity, and quality healthcare.
REFERENCES
1. FMoH. (2021). Health Sector Transformation Plan II (HSTP II) 2020/21–2024/25. Ethiopian Ministry
of Health, 25(February), 96.
2. Indicators, A. H. O. (2010). Monitoring the building blocks of health systems. Geneva, Switzerland:
WHO Document Production Services.
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=World+Health+Organization.+%282010
%29.+Monitoring+the+Building+Blocks+of+Health+Systems%3A+A+Handbook+of+Indicators+and+
Their+Measurement+Strategies.&btnG=#d=gs_cit&t=1749891383174&u=%2Fscholar%3Fq%3Dinfo
%3AS0sb4bXeYpoJ%3Ascholar.google.com%2F%26output%3Dcite%26scirp%3D0%26hl%3Den.
3. Abazinab, S., Woldie, M., & Alaro, T. (2016). Readiness of health centers and primary hospitals for
implementing proposed health insurance schemes in Southwest Ethiopia. Ethiopian journal of health
sciences, 26(5), 449-456.
4. Stierman, E., Shiferaw, S., Ahmed, S., Yihdego, M., Seme, A., Zimmerman, L., & Creanga, A. (2023).
Readiness, access, and use of facility childbirth care in Ethiopia: results from nationally representative
linked household and health facility surveys. Journal of Global Health Reports, 7, e2023041.
5. Stierman, E. K., Ahmed, S., Shiferaw, S., Zimmerman, L. A., & Creanga, A. A. (2021). Measuring
facility readiness to provide childbirth care: a comparison of indices using data from a health facility
survey in Ethiopia. BMJ Global Health, 6(10), e006698.