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23 years and counting: Ethiopians getting healthy and living longer lives

By Murad Ahmed
Tigrai Onlne - May 28, 2014

As we celebrate May 28(Ginbot 20), it is apt to count the achievements in several sectors. Accidentally, the World Health Organization (WHO) chose this month to report the state of Ethiopia's health services and situations. One of the major achievements was the rise in life expectancy.

The World Health Organization (WHO) report entitled "World Health Statistics 2014" stated that:

"At the national level, 24 countries gained more than 10 years in life expectancy (both sexes combined) between 1990 and 2012. Of these countries, 12 were in the WHO African Region and five in the WHO South-East Asia Region, along with Afghanistan, Cambodia, the Islamic Republic of Iran, the Lao People’s Democratic Republic, Lebanon, South Sudan and Turkey.

The top six individual gains recorded were in Liberia (19.7 years) followed by Ethiopia, Maldives, Cambodia, Timor-Leste and Rwanda. Among high-income countries, the average gain was 5.1 years, ranging from 0.2 years in the Russian Federation to 9.2 years in the Republic of Korea."

Life expectancy is important because it tells much more than the estimated length of life. It also summarizes the mortality pattern that prevails across all age groups in a given year – children and adolescents, adults and the elderly.

It is also important to note that during the 1990s life expectancy in Europe has showed stagnation, and in Africa it has even decreased. For Europe, the phenomenon is due mainly to adverse mortality trends in the former Soviet Union countries. The decrease in Africa has been caused by HIV/AIDS.

We recall that Ethiopia was among the best performers in reduction of under age 5 mortality rate last year.

The UN IGME - the UN Inter-agency Group for Child Mortality Estimation, reported last year:

"Many countries have made and are still making tremendous progress in lowering under-five mortality. Of the 61 high-mortality countries with at least 40 deaths per 1,000 live births in 2012, 25 have reduced their under-five mortality rate by at least half between 1990 and 2012.

Of them, Bangladesh (72 percent), Malawi (71 percent), Nepal (71 percent), Liberia (70 percent),Tanzania (68 percent), Timor-Leste (67 percent), and Ethiopia (67 percent) have already reduced the under-five mortality rate by two-thirds."

Similar gains have been registered in other areas from 1991 to 2014: Maternal mortality ratio (per 100 000 live births) declined from 1,400 to 420; the proportion of population without access to improved drinking-water sources declined from 13% to 52%; and proportion of population without access to improved sanitation rose from 2 to 24% and the figure of underweight children (aged < 5 year) decreased from 43.3% to 29.2%.

Take notice of the facts: In 1990, 204 children in every 1,000 in Ethiopia died before the age of five; only six countries had a higher rate. The latest data shows that by 2012 the rate had dropped to 68, a massive 67% fall in the under-five mortality rate.

While Ethiopians' life expectancy rose from 45 to 64 in the past 23 years, Adult mortality rate (probability of dying between 15 and 60 years of age per 1000 population) declined from 478 to 212.

All these in the last 23 years!!!

All these were not accidental achievements rather direct fruits of Ginbot 20.

Indeed, the Dergue regime had a health policy that gave emphasis to disease prevention and control, priority to rural areas in health service and promotion of self-reliance and community involvement.

But in practice the totalitarian political system lacked the commitment and leadership quality to address and maintain active popular participation in translating the formulated policy into action. In addition, the bulk of the national resources were committed to the pursuit of war throughout the life of the regime which left little for development activities in any sector. 

Therefore, in health as in most other sectors, in both of the previous regimes there was no meeting ground between declaration of intent and demonstrable performance.

Furthermore, the health administration apparatus contributed its own share to the perpetuation of backwardness in health development because, like the rest of the tightly centralized bureaucracy, it was unresponsive, self-serving and impervious to change.

It was in 1992, immediately after the establishment of a Transitional Government, that Ethiopia put in place a new scientific health policy.

The Health Policy of the Transitional Government was the result of a critical examination of the nature, magnitude and root causes of the prevailing health problems of the country and awareness of newly emerging health problems. It was founded on commitment to democracy and the rights and powers of the people that derive from it and to decentralization as the most appropriate system of government for the full exercise of these rights and powers in our pluralistic society.

It accorded appropriate emphasis to the needs of the less-privileged rural population which constitute the over-whelming majority of the population and the major productive force of the nation. It proposed realistic goals and the means for attaining them based on the fundamental principles that health, constituting physical, mental and social well-being, is a prerequisite for the enjoyment of life and for optimal productivity.

The Government therefore accords health a prominent place in its order of priorities and is committed to the attainment of these goals utilizing all accessible internal and external resources.  In particular the Government fully appreciates the decisive role of popular participation and the development of self-reliance in these endeavors and is therefore determined to create the requisite social and political conditions conducive to their realization.

The government of Ethiopia issued its health policy in 1993, which emphasized the importance of achieving access to a basic package of quality primary health care services by all segments of the population, using the decentralized state of governance. The health policy stipulates that the health services should include preventive, preemptive and curative components.

In order to achieve the goals of the health policy, a twenty-year health sector development strategy has been formulated, which is being implemented through a series of five-year plans.

The implementation of the first health sector development program (HSDP) was launched in 1997, and now the second HSDP is under way. The main trust of the HSDP implementation is based on sector-wide approach, encompassing the following eight components: Service delivery and quality of care; Health facility rehabilitation and expansion; Human resource development; Pharmaceutical services; Information, education and communication; Health sector management and management of information systems; Monitoring and evaluation and Health care financing.

The HSDP introduced a four-tier health service system which comprises: a primary health care unit, (a network of a health center and five health posts), the hospital, regional hospital and specialized referral hospital.

A health post is now being staffed by two health extension workers. These new cadres are trained for one year and their training emphasizes disease prevention measures with focus on the following programs:

A health center is at the highest level of a primary health care unit. It includes services such as in-patient and out-patient services including surgery, and with laboratory services.

A health station used to give services that a health center does, but at a smaller scale.  Health Station is now being phased out. According to the new health sector development program (HSDP), a primary health care unit comprises of 5 health posts and a health center serving as a referral point.  Therefore, when the HSDP is fully implemented, a health center will serve 25,000 people.

The aspect of health management and support within the health system is operated in accordance with the decentralized administrative structures. At present, the decentralization process has expanded to district level and has devolved primary responsibility for service delivery and management from regional health bureaus to district health offices, enabling them to management and coordination primary health care delivery in the their respective areas.

Supportive and educational supervision is undertaken at all levels, from the Federal Ministry of Health to district health offices. In addition, responsibility for logistical support is shared among the Federal Ministry of Health, the regional health bureaus, and district health offices.

This achievement would have been simply a fairy tale, had it not been for a sustained high level political commitment, a strong leadership in the health sector, effective alignment and harmonization of stakeholders and  a sincere and massive community participation.

Indeed, the achievement attests the quality of leadership and policies applied both in the health sector and the nation in general.

The facts speak for themselves:

  • Over the last three years alone, the government have trained and deployed more than 4,500 midwives. This number is expected to reach more than 13,000 by the end of 2015.
  • The number of public medical schools increased from 3 to 25 over the past five years. The enrollment capacity has grown from 600 to 3200.
  • The construction of 15,000 health posts more than 3000 primary health centers and more than 300 primary hospitals across the country is expected to bring about equitable and quality health services to all segments of the population.

The government's commitment is demonstrated nowhere better than in the most challenging part of the health sector policy. That is; the financing aspect.

As public treasury data indicate:

"The increased share of government financing is the result of a sustained effort to increase the share of health sector expenditure in the total national budget:

Between 1989 and 1996, health expenditures rose from 2.8 percent to 6.2 percent of the total budget.

Between 1991 and 1996, the Government health budget has increased from about 1 percent of GDP to about 2.7 percent of GDP.

During this period, the real value of the health budget has increased by 35 percent."

Since 1992 there have been several major changes in the structure of the government budget to the health sector.

  • First, the proportion of salaries in the recurrent budget has declined to 53 percent in 1996 as a large share of the recent increases in health spending has gone to drugs and other non-salary items.
  • Second, there has been a reallocation of resources away from facilities in Addis Ababa and to primary care facilities. Since 1994, capital expenditure on health centers and health stations has risen from 17 to 40 percent of the capital budget.
  • Third, support for public health services has increased with more than half of total regional recurrent expenditures focused on Primary Health Care-related services.
  • Fourth, control over health expenditure has shifted to the regions, which have, since 1994, controlled between 83 and 88 percent of the health expenditure and which in 1996 controlled 83 percent of the recurrent budget and 95 percent of the capital budget.

The progresses made in the past 23 years have been attested by several renowned institutions and personalities.

Gabriel Jaramillo, General Manager of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said last year: 

“From the day when Ethiopia was the first to set the goal of universal coverage, our partners here have shown tremendous courage and vision.

It is phenomenal how much they have achieved, and how much more they are now aiming for. Ethiopia is widely recognized for its achievements in the health field in recent years.

HIV-related deaths dropped from 99,000 in 2005 to 44,000 in 2011, a direct result of expanded treatment with anti-retroviral drugs.

There has also been a 50 per cent decline in death rates for children under the age of five, from 2000 to 2011."

Simon Bland, Chair of the Board of the Global Fund, called Ethiopia's progress “astonishing”.

Stephen O’Brien, the United Kingdom’s Parliamentary Undersecretary of State for International Development, said that Ethiopia’s use of an army of volunteer women to improve maternal health reinforced efforts. He also noted:

“Putting women and girls front and center is really happening here. “[Ethiopia] is a role model we recognize and cite to other programs.”

The renowned Bill Gates, who is CEO of Bill & Melinda Gates Foundation, took time to visit Ethiopia's health services and put his observations in detail. Mr. Bill Gates said that:

"I’ve made many trips to Africa, but my recent visit to Ethiopia was definitely one of the most exciting. With effective governance and coordinated support from our foundation and other donors, the advances I saw in health and agriculture may be the key to unleashing Ethiopia’s potential and that of other African countries.

Ethiopia is one of the poorest countries in the world and has faced enormous challenges feeding its people and providing critical health services to mothers and their children. Yet, I returned from a recent visit excited about advances the country is making in agriculture and health.

If these innovations—which are a top priority for our foundation—succeed, they can be replicated in other African countries that also face big challenges in health and agriculture.

One factor in Ethiopia’s progress is Prime Minister Meles Zenawi and his leadership team, who have played a key role in reinventing the country’s agricultural and health systems. Making changes to either would be a big challenge in any country, so it’s even more impressive in Ethiopia, which has the second largest population of any country in Africa but a limited economic infrastructure.

What Ethiopia is doing in health is really a model system because it reaches everyone in the country. I visited the Germana Gale Health Post, where I talked to several of the more than 30,000 health extension workers who have been trained in recent years to deliver basic health education, prevention, and treatment. Most of the health workers are women, and those I met were energetic and well-trained."

Similarly, the UK Department for International Development announced that:

"Ethiopia's 85 million inhabitants mainly live in small rural communities spread across mountains, making access to healthcare a challenge. However, in the last decade the Ethiopian government has built or upgraded 15,000 health facilities across the country. The results are remarkable, at present more than 92% of the population lives within 10km of a public health clinic.

The TB project is now delivering additional training to HEWs to provide TB detection and management services to their communities. Many TB sufferers are often too ill to make the short journey to their local health centre and women face cultural and geographical barriers. With their new skills, the HEWs can now collect saliva swabs directly from individuals during their door-to-door community visits and send them to laboratories.

The results are positive, TB diagnostic and treatment services have become more accessible to the poor, specifically women, elderly and children. Notification rates have doubled and a significant improvement in treatment outcomes can be seen, in 2011 the success rate reached 90%.

The TB REACH project has now been expanded to 4 additional zones and further scale-up is being planned by the national TB program."

The testimony of Mrs. Milinda reiterates the facts. She said that:

"Ethiopia’s health extension program is reaching people in every corner of the country."

Dr Peter Salama, Unicef country representative for Ethiopia, noted that:

"The government has set some very bold and extremely ambitious targets. It has then backed them up with real resources and real commitment sustained over the last 10 years,"

"...the fact that the health extension programme has been government-owned rather than donor-led has contributed to its success, and means the gains made are sustainable in the longer term."

It should not be forgotten that Ethiopia has still a long way to go. But the achievements made in the past 23 years indicate that the future is brighter and brighter.

As Bill Gates said:

Prime Minister Meles Zenawi and his leadership team have played a key role in reinventing the country’s agricultural and health systems. Making changes to either would be a big challenge in any country, so it’s even more impressive in Ethiopia, which has the second largest population of any country in Africa but a limited economic infrastructure.

Still, we should not be complacent. As Mr Gates noted:

"Ethiopia still faces some big problems. But the people I met and what I saw re-energized me and increased my optimism that....the people of Ethiopia and can serve as model activities in other African countries.

Improving agricultural productivity and the quality of life through better health services is the key to unleashing the potential of Ethiopia and other poor countries and getting them on the road to self-sufficiency."

Eternal honor to the martyrs!!!

23 years and counting: Ethiopians getting healthy and living longer lives

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