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Ethiopia is one of the oldest sites of
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human existence known to
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scientists over the generations many
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different factors have played a
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significant role in its
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formation today Ethiopia is Africa's
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second most populous country with over
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80 million people 84% % of them living
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in remote rural
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areas and despite its Rich history and
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the stoic determination of its people
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it's still one of the most
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underdeveloped countries in the world
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but with the fastest growing
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economy the last two decades have
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witnessed some significant changes
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particularly in maternal and child
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health 20 years ago the maternal
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mortality rate was uh very high more
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than 1,000 per 100,000 life birges and
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under five mortality was also very high
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and above the subsaharan uh Count's
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average actually but now the two
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indicators are much better and even
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below the subsaharan
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average importantly these gains have
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been seen in all parts of Ethiopia due
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in no small part to a strong political
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will you know the health sector was the
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most ignored sector in the two previous
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governments but uh since the new
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government the prdf that government got
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formed in
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1991 he has become a central program of
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the government you know what you can see
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that in the last 20 years you know with
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that political will very ingenious and
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Innovative programs were developed on
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the basis of the understanding of the
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reality of the country the context of
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the country so the differences we have
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invested the past 20 years in Primary
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Health Care which is key in really
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taking Health Services to the Grassroots
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to the
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communities this focus on primary
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healthc care has led to some remarkable
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gains over 90% of the population now has
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access to Primary
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Healthcare in 2011 one government-run
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Primary Health Center served 29,000
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people down from 105,000 in 2007
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the number of outpatient Department
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visits has increased correspondingly and
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there has been a considerable increase
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in immunization
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rates but how has Ethiopia achieved this
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progress this was one of the key
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questions asked in the good health at
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lowcost book edited by London School of
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hygiene and tropical medicine and funded
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by the Rockefeller
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Foundation we find that countries that
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have pursued continuously particular
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Health policies tend to be more
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successful and um it is important to
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also ensure that these policies respond
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to the needs of the population so
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sometimes ndgs or internationally agreed
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targets are not the best thing for one
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particular country we have to think
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about
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context from the early 1990s the
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Ethiopian government recognized the key
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role that must be played by Health
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Improvement in the country's economic
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development at the heart of their
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strategy lay intersector moral action
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linking Health to progress in other
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sectors Health has to be embedded in a
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bigger agenda to improve development so
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while it's vital to improve health
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outcomes you also have to look at
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educating your women making sure
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agricultural development's concentrated
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on and the importance of water and
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sanitation so health is one component
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orbe it vital in a bigger picture the
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foundation of the intersectoral action
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was the government's drive towards
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decentralization and determined efforts
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to promote Community participation in
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development at the community level I
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think there's this historic uh example
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that even when it was more of a
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socialist country that you had
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committees at this level that were very
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proactive in shaping how the community
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operated so there's already those tiers
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or those systems or those structures in
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place whereby you are part of something
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bigger than just yourself your household
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you feed to your community which then
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feeds up and further and further up
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Community ownership is the
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central part of our not only health
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systems or the health sector but for our
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government and we try to ensure
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Community ownership in order to have
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really good impact we try to increase
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the awareness of the communities and try
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to understand the behavior religious or
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cultural beliefs and try to address
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those uh behaviors and mobilize
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communities around a goal that uh we
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want to achieve
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in terms of health the greatest
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manifestation of community ownership in
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Ethiopia is the health extension program
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which was designed with input from Key
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stakeholders in the environment water
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and
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education the health extension program
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is an Innovative community-based program
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with the aim of creating a healthy
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environment and healthy living by making
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Essential Health Services available at
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grassroot
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level the program is a typical example
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of a locally developed model which works
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across different cultural groups because
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it that does involve the people from all
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levels and uh the use of C that are
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locally
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recruited that understand the culture
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the language and so
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on
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spe
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foreign
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speee what we see from independent
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studies is that the health extension
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program is helping a lot in maternal and
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child health prevention of malaria
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tuberculosis HIV environmental and
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personal hygiene are all in the
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program community and personal ownership
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of health is one of the major changes of
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attitude that is playing a role in
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making the health extension program a
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success Ethiopia are very much of the
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idea that improving health is a
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collective effort so while the health
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system can certainly provide treatment
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and and preventative measures the onus
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is also on the individual and the
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household to make sure that they take
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full advantage of these services that
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provided and also to make some certain
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lifestyle uh choices in terms of the
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nutrition um and not always waiting for
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that remedy but trying to actually
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prevent the illness along with the
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facilities that are provided to them
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this is massive you know you know
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changing the mindset of people within a
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short period of time is very very
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significant because you know once it
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changes the mindset of people that they
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can be responsible for whatever they
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want to do including health I think this
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a big one since it was first introduced
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the health extension program has scaled
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up rapidly its success was due in no
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small part to the training of huge
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numbers of community-based Health
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extension workers we trained more than
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38,000 Health extension workers we have
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deployed two Health extension workers
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per Village and the health extension
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workers are teaching our communities on
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how to promote their health and prevent
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disas TR transfer skills and knowledge
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so they can produce their own health so
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we have already implemented it but we
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have to really work hard to really uh
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use the full potential of the sales
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extension program that was meant
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actually to enable communities to uh
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produce their own health strategy is
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that as a health post which is in the
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village they're supposed to focus on
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teaching the people on health and
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disease prevention environmental
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sanitation and then family health so the
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health extension workers or working the
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health post live with the people and the
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health center also works on prevention
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but also does treat patients so it is a
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service delivery
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chain prior to the health extension
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program it was extremely difficult if
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not impossible for people to get any
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health services at all in the rural
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areas there was very limited access to
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family planning to clean and Safe Water
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to immunization to treatment for common
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childhood illnesses that those Services
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either didn't exist or they were very
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far from where people lived and so now
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people have those Services right in
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their communities a crucial ingredient
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making the training within the health
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extension program successful is Task
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shifting task shifting is taking one
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task that one Health worker does perhaps
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a doctor and moving that task down to a
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lower level uh provider so that the
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doctor's time is freed up for
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emergencies uh or critical skills that
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only they can provide for instance
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Caesar and section is traditionally or
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normally done by uh surgeons proper
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surgeons with you know uh general
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practice initially and then specialize
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in surgery but now we're training non
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physician clinicians for 3 years to
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acquire that that skill so we're
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shifting that category cesarian section
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for instance to our health officers
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because we don't have enough uh surgeons
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I think task sharing and task shifting
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in this country have been tremendously
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successful um especially when you were
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talking about the primary preventive
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healthc care uh such as immunization for
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instance prior to theth Health extension
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program immunization was always done at
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a health center uh and it meant that
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people had to travel a long way to get
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uh to get immunization or it was done in
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campaigns which meant once or twice a
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year they would have access to
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immunization now that they have shared
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that task with a health extension worker
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people can get immunizations for their
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children in their communities or are
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very close by to their communities and
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they can get it at any time during the
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year so that is greatly improved
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coverage of immunization in this
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country although Ethiopia spends more
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per capita on health than World Health
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Organization recommendations
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16.1% it still has a long way to go
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before for example it can ensure
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Universal free access to healthare for
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its population our government uh is
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committed to uh achieving universal
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access to all uh communities that's the
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equity issue and we have already built
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one Health post for 5,000 population
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which mainly focus on health promotion
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and his prevention and also we have
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built Health Centers one Health Center
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for 25,000 population which mainly focus
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on basic Curative services so fulfilling
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these two the first line the uh Health
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post and the second line the health
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center uh makes the access to Primary
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Health Care complete resource is a major
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challenge because the the country is so
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ambitious the government is so ambitious
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that it it wants to do so many things at
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the same time and the health sector has
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been very much dependent on funds coming
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from Global Health initiatives like gav
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Global fund paa Def and other European
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countries a recent study reported a
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decrease in Government funding for
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health between 2002 and 2006 while
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during this same period Ethiopia
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benefited from a rise in international
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health aid it has been estimated that
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between 2003 and 2009 Ethiopia received
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over4 billion US from International
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funding Partners donors like a success
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story so what they have found when they
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invest in Ethiopia is programs such as
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the health extension plan come about and
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show immediate benefits and immediate
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health
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gains further substantial funding has
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come from United Nations organizations
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the gavi Alliance formerly the Global
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Alliance for vaccines and immunization
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and bilateral development agencies in
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particular those of Ireland Spain Italy
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and the
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Netherlands a great deal of these funds
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have been provided to the health sector
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development Partners like the United
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Nations Children's Fund UNICEF and the
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United States agency for International
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Development us Aid have also supported
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the training of Health extension work
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workers with technical support from
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World Health Organization I know that we
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do bring quite a bit of resources in uh
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in 2011 I think our budget is about 300
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million that we're bringing in a large
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part of that is for HIV AIDS but uh it
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also supports Health System
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strengthening so it's supporting the
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entire Health
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System strong leadership in the
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Ethiopian government means that it has
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the confidence to plan for its people
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and not BL mindly follow various donor
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preferences they're not a passive uh
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recipient that certainly came across
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during my visit and during the
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interviews and in The Wider literature
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it seems that the Ethiopian government
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have a plan um they are very proactive
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and getting all the donors around the
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table this is a government that knows
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exactly what it wants to do it's
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ambitious and bold and they are not
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afraid of uh helping direct and form
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what donor are doing and to say no to uh
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programs and and activities that they
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don't want and we I really appreciate
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that I think that's uh that's the way it
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ought to
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be just over two decades ago the
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situation in Ethiopia seemed hopeless
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Ethiopia for example in the 1980s
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Ethiopia was a disaster we had the
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pictures of death and suffering brought
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into our television screens every day
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they have achieved a huge amount with
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the health extension program with people
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with basic skills uh now spread out over
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the entire country and they're making
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major inroads into maternal and child
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health into sanitation into the
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management of basic infectious
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diseases Ethiopia may still have a long
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way to go yet many things have
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undeniably improved while there are
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rightfully doubters and critics of what
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the the government has achieved um and
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the Ministry of Health but there's no
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denying that have been these huge Health
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outcomes over the last 25
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years the interesting thing to watch out
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for going forward is how the government
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is still going to maintain this balance
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of control over where it wants the
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country to go but still not stifle um
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the freedoms and the voices of those
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that doubt what it's doing and maybe
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criticize it a little and it's striking
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this balance that um I think will be
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important to look at in the
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future the Ethiopian experience shows
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that taking the community as a potential
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producer of Health rather than as a
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potential consumer of medicines and
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Curative Services is a way forward to
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achieve better outcomes in health we
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open our mind see for alternative
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options but there is always a way if
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you're really committed to look look for
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Alternatives and that's what is the
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guiding principle of our uh government
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to do anything to have Equitable
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Services and have Innovative practices
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at the Grassroots
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