1. health and fitness

Child Health in Ethiopia
Background Document for the
National Child Survival Conference
April 22-24, 2004
Addis Ababa, Ethiopia
ACRONYMS
AIDS
ANC
CDC
C-IMCI
DHS
ENA
EPI
FDRE
FMOH
HEP
HIV
HMIS
HSDP
ICC
IEC
IMCI
IMR
IYCF
MCH
MDG
MMR
NIDs
NNM
PMTCT
PHCU
PPHC
RED
RHBs
SDPRP
SIAs
SNIDs
SNNPR
TBA
TT
Acquired Immune Deficiency Syndrome
Antenatal Care
Communicable Disease Control
Community Integrated Management of Childhood Illnesses
Demographic and Health Survey
Essential Nutrition Action
Expanded Program on Immunization
Federal Democratic Republic of Ethiopia
Federal Ministry of Health
Health Extension Package
Human Immunodeficiency Virus
Health Management Information System
Health Sector Development Program
Interagency Coordinating Committee
Information Education Communication
Integrated Management of Childhood Illnesses
Infant Mortality Rate
Infant and Young Child Feeding
Maternal and Child Health
Millennium Development Goal
Maternal Mortality Ratio
National Immunization Days
Neonatal Mortality Rate
Prevention of Mother to Child Transmission
Primary Health Care Unit
Primary Preventive Health Care
Reaching Every District
Regional Health Bureaus
Sustainable Development and Poverty Reduction Program
Supplementary Immunization Activities
Sub-National Immunization Days
Southern Nations and Nationalities and Peoples Region
Traditional Birth Attendant
Tetanus Toxoid
1
TABLE OF CONTENTS
Executive Summary ........................................................................................Page 3
Introduction.....................................................................................................Page 7
Child Mortality................................................................................................Page 9
Malnutrition ..................................................................................................Page 20
Vaccine-Preventable Diseases ......................................................................Page 26
Pneumonia, Diarrhea and Malaria ................................................................Page 29
Maternal and Newborn Health......................................................................Page 36
Community Health........................................................................................Page 41
Key Policies and Strategies...........................................................................Page 43
Child Health Programs..................................................................................Page 47
Organization of the Health System ...............................................................Page 51
Health Care Financing ..................................................................................Page 54
References.....................................................................................................Page 59
2
EXECUTIVE SUMMARY
Sixteen out of every 100 children born in Ethiopia will not live to see their fifth birthdays. Five
will not even live past their first month of life. For those fortunate enough to survive, one-half
will be stunted, a result of frequent illness and low food intake. Every year, approximately
472,000 children under five years of age die in Ethiopia, placing Ethiopia sixth in the world in
terms of absolute number of deaths. Many of these deaths could be avoided: effective,
affordable interventions exist, but have yet to reach the great majority of children who need
them.
In 2000, the Ethiopian Demographic and Health Survey (DHS) estimated the under-5 mortality
rate (U5MR) at 166 per 1000 live births. The Ethiopian Ministry of Health (MOH) estimates
that the U5MR for 2002-03 was 140. In 2000, the rate of 166 placed Ethiopia 21st in the world
for under-5 mortality. Ethiopia’s neonatal mortality rate is relatively even higher: at 49, it is
fifth-highest in the world.
From 1960 to 2000 there has been an average 1.2% annual decrease in under-5 mortality.
Decreases in under-5 mortality have been fairly proportional across all major age intervals.
Currently, among under-5 deaths, 29% die in the first 30 days of life, 29% from the first to the
11th month and 42% from one to four years of age. There are significant regional variations in
mortality, from a low of 114 in the capital, Addis Ababa, to a high of 229 in Afar region and 233
in Gambella region.
There are also significant variations in mortality by socioeconomic determinants, such as wealth,
education and urban-rural residence. The U5MR for the poorest 20% of the population is 32%
higher than that for the richest 20% (150 versus 114). The rate for those whose mothers have no
schooling is 121% higher than that for those whose mothers have at least a secondary education
(197 versus 89). And the U5MR for children who live in rural areas is 30% higher than that for
children who live in urban areas (193 versus 149).
What are children dying from? This report estimates that, based on data from DHS and MOH,
the following are the approximate cause-specific proportions for under-5 mortality: pneumonia
(28% of deaths), neonatal conditions (e.g., sepsis and asphyxia) (25%), malaria (20%), diarrhea
(20%), measles (4%) and AIDS (1%). Malnutrition is also a major underlying cause of death in
approximately 57%, and HIV/AIDS – in addition to directly causing a small percentage of deaths
– underlies 11% of other deaths, particularly those due to pneumonia. High maternal fertility,
especially early first pregnancy and short birth intervals, is also strongly associated with
increased under-5 mortality: children whose mothers were less than 20 years of age when they
gave birth have a 26% higher mortality rate than those whose mothers were in their 20’s (225
versus 179), and children born less than two years after their older siblings have an U5MR 183%
higher than those born four or more years later (272 versus 96).
The Millennium Development Goal (MDG) for child survival calls for a two-thirds reduction in
under-5 mortality by 2015 from the 1990 baseline. Assuming that in 1990 the U5MR in Ethiopia
was about 2001, the child survival MDG for Ethiopia is 67. Some progress has already been
1
The UNICEF estimate is 190; the DHS estimate is 217.
3
made: the U5MR has dropped by about 48 points since 1990. If the remaining 85 points are to
be achieved by 2015, however, from now until then the U5MR will have to drop by 7.7 points
per year, more than twice as quickly as it has until the present. Figure 1 shows the trend needed
to reach this goal.
Fig. 1: Current U5MR Trend versus Trend Needed to Reach MDG
250
200
150
Needed trend
i
Current trend
100
50
20
14
20
12
20
10
20
08
20
06
20
04
20
02
20
00
19
98
19
96
19
94
19
92
19
90
0
How will Ethiopia achieve this dramatic reduction? Only by focusing intensively on the key
child survival interventions that have been shown to effectively reduce mortality due to the major
causes of death in children under five. Figure 2 shows the current coverage rates for some of
these key interventions in Ethiopia. By scaling up coverage of these and a handful of other
interventions, Ethiopia can theoretically prevent the death of 319,000 children every year – 68%
of the total – which would meet the MDG for child survival. The challenge, however, is to
identify feasible strategies for delivering these interventions to the children who need them, with
a special focus on reaching those at greatest risk: the poor, the uneducated and those who live in
rural areas.
4
Fig. 2: Coverage of Key Child Survival Interventions
100%
80%
72%
56%
60%
51%
45%
43%
38%
40%
27%
34%
28%
24%
28%
19%
20%
9%
<1%
16%
12%
1%
Bi
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* FDRE MOH Health Indicators, 2002-03. ** Ethiopia DHS, 2000. *** Immunization Coverage Survey, 2001.
Currently, access to health facilities is limited, as is utilization of existing facilities: only about
61% of the population live within 10 km of a health facility, and the average number of
outpatient visits to public facilities is only 0.29/person/year. In addition to continuing efforts to
improve access and utilization, one alternative solution is to bring essential health services closer
to communities. To have maximum impact, these health services would have to target the
prevention and treatment of the major causes of under-5 death. In addition, they would have to
focus on the three regions – Oromia, Amhara and SNNPR – where more than 80% of child
deaths are occurring:
5
Fig. 3: Number of Under-5 Deaths by Region
180000
160000
140000
120000
100000
80000
60000
40000
20000
0
Tigray
Afar
Amhara
Oromia
Somali
BenGumuz
SNNPR Gambella
Harari
Addis
Ababa
Dire
Dawa
Derived from DHS 2000. Figures are approximate.
Ethiopia’s Health Sector Development Program II (HSDP II) has the potential to make a major
contribution to achieving the child survival MDG. In particular, through its development of a
new Health Extension Package (HEP), it proposes to scale up a number of key child survival
interventions. HEP is designed to take essential health services closer to the community by
building 10,000 new health posts and training 20,000 health workers to staff them. These new
staff will provide facility-based services and will perform outreach to villages in their catchment
areas (about 500-1000 households).
However, HEP and HSDP II must overcome several health systems constraints to improve child
health in Ethiopia. These include organization and management of the health sector at the
federal and regional levels; the production, distribution, retention and capacity of health
providers and managers; and functioning of the health information and drug management
systems. There also needs to be increased financial investments in child health, particularly in
the regions of greatest need.
The Child Survival Partnership can help. First, it can champion the cause of child health
domestically and internationally, and build on the strengths of all partners. And second, it can
assist the Government of Ethiopia to develop a national child health strategy, develop and fund a
national child health investment plan, and monitor and evaluate progress towards the MDG for
child survival.
6
INTRODUCTION
Nearly 11 million children under the age of five die each year, 90% of them in 42 countries and
50% of them in just six countries, including Ethiopia. Approximately six million of these deaths
could be averted through efforts directed towards a handful of preventable and treatable
disorders, including malnutrition, pneumonia, diarrhea, malaria, measles, neonatal conditions
and HIV/AIDS.
The Millennium Development Goal of reducing under-five mortality by two-thirds by 2015 from
1990 levels can not be achieved without a dramatic and sustained commitment of resources to
preventing and treating the most common causes of death in the countries where the greatest
proportion are occurring.
To this end, the Child Survival Partnership was formed in 2003 to mobilize increased resources,
effort and collaboration to take known, effective child survival interventions to scale in the 42
countries with the greatest burden of childhood disease. Members of the Partnership include
UNICEF, WHO, the World Bank, USAID, CIDA, the Bill & Melinda Gates Foundation and
representatives from developing countries, research institutions and international nongovernmental organizations.
In December 2003 a senior delegation representing the Child Survival Partnership came to
Ethiopia to work with the Government of Ethiopia to identify potential opportunities for formal
engagement. One outcome of that visit was the agreement to jointly sponsor a National Child
Survival Conference in April 2004, the purpose of which would be to reach consensus on the key
child survival interventions and delivery approaches needed for Ethiopia to reach the child
survival MDG, as well as the role of partners and the resources required in that endeavor.
The purpose of this Situation Analysis is to provide a backdrop for that meeting. It provides a
broad overview of the health status of children in Ethiopia and components of the health system
as they relate to child health and outlines the key constraints that currently limit progress towards
achieving the child survival MDG.
7
Background
Ethiopia is one of the poorest countries in the world. Per capita Gross National Income in 2002
was US $720 in purchasing power parity terms, not even one-half the average of US $1,620 for
sub-Saharan Africa. In 2000, 44.2% of the population was living in poverty.
Based on the 1994 Population and Housing Census and assuming an annual growth rate of 2.7%,
the current approximate population of Ethiopia is 69.1 million. Children constitute a very large
percentage of the population: 44.7% are under 15 years of age, 17.8% are under 5 years of age
and 3.6% are under 1 year of age. Nearly 85% of the population live in rural areas.
The overall health status of Ethiopia’s population is poor. The 2003 UN Human Development
Index ranks Ethiopia 169 out of 174 countries. Life expectancy at birth is 53 years for men and
55 years for women (MOH, 2002-03); multilateral agencies estimate it to be much lower – an
average of 44 years (UNICEF, 2001). Literacy rates are correspondingly low, an average of 40%
for men and 19% for women, and much lower in rural than in urban areas (33% vs. 80% for men
and 10% vs. 58% for women)2.
Children in Ethiopia fare especially poorly: each year an estimated 472,000 children under the
age of five die in Ethiopia3, placing Ethiopia sixth in the world in terms of absolute number of
under-5 deaths4.
2
Ethiopia Demographic and Health Survey (DHS), 2000. Literacy is defined as attendance through at least
secondary school or the ability to read a whole sentence.
3
Black RE, Morris SS and Bryce J. “Where and why are 10 million children dying every year?” Lancet 2003; 361:
2226-34.
4
The first five countries are India, Nigeria, China, Pakistan and DR Congo.
8
CHILD MORTALITY
Childhood mortality rates
The 2000 Ethiopia Demographic and Health Survey estimates for under-5, infant and neonatal
mortality rates for the preceding five years were 166, 97 and 49 per 1000 live births,
respectively. The FDRE MOH estimate for under-5 mortality for 2002-03 is 140. Assuming
that between 2000 and 2004 the U5MR has continued to fall at the same rate as in the preceding
10 years (3.4 points per year), it is now approximately 152. In 2000, the figure of 166 ranked
Ethiopia 21st in the world by under-5 mortality rate.
Childhood Mortality Rates
Year or
period
Data source
2002-2003
FDRE MOH
1996-2000
1991-1995
1986-1990
DHS 2000
DHS 2000
DHS 2000
SS Africa
UNICEF
2004
Neonatal
Mortality1
Postneonata
l Mortality2
Infant
Mortality3
Child
Mortality4
97
49
68
63
48
62
70
97
130
133
106*
Under-5
Mortality5
140
77
94
96
166
211
217
174*
Sources: Ethiopia DHS, 2000; Federal Democratic Republic of Ethiopia (FDRE) Ministry of Health (MOH),
“Health and Health-Related Indicators,” EC 1995/GC 2002-03; UNICEF State of the World’s Children, 2004.
* Corresponding figures from UNICEF for Ethiopia for 2004 are 114 IMR and 171 U5MR.
1
Number of deaths per 1000 live births within the first month of life
2
Number of deaths per 1000 live births between the first month of life and the first birthday
3
Number of deaths per 1000 live births within the first year of life
4
Number of deaths per 1000 children surviving to age one, between ages one and five
5
Number of deaths per 1000 live births within the first five years of life
Childhood mortality trends
From 1960 to 2000 there has been an average 1.2% annual decrease in under-5 mortality, with
the suggestion of a steeper rate of decline in the period 1996-2000 than in the two five-year
periods preceding that.
9
Under-5 Mortality Trend
400
Deaths per 1000 live births
350
300
250
UNICEF
200
DHS
150
100
50
0
1960
1965
1970
1975
1980
1985
1990
1995
2000
Source: "Trends in child mortality in the developing world: 1960 to 1996" by Ken Hill, Rohini Pande, Mary Mahy,
and Gareth Jones, published by UNICEF in 1999. Model based on 1981 Ethiopia Demographic Survey and 1990
National Family and Fertility Survey.
Childhood Mortality Trends
250
200
150
NNMR
IMR
U5MR
100
50
0
1986-1990
1991-1995
1996-2000
Source: Ethiopia DHS, 2000.
The decrease in overall under-5 mortality has been achieved through fairly equivalent decreases
in the neonatal, postneonatal and child mortality rates.
10
Proportion of Under-5 Deaths by Age
100%
90%
80%
70%
60%
1-4 years
50%
1-11 months
40%
0-30 days
30%
20%
10%
0%
1986-1990
1991-1995
1996-2000
Source: Ethiopia DHS, 2000.
Proportional mortality
For the period 1996-2000, the age distribution of under-5 deaths was 29% in the first 30 days of
life, 29% from the first month to the 11th month of life, and 42% from the first year to the fourth
year. While the neonatal mortality rate is high in absolute terms (Ethiopia ranks fifth in the
world in neonatal mortality), the fact that deaths in the neonatal period account for a smaller
proportion of under-5 deaths than the average for the developing world (36%) underscores the
fact that children in Ethiopia are still dying in large numbers from preventable and treatable
conditions later in childhood. Still, it is sobering to realize that as many children are dying in the
first 30 days of life as in the ensuing 11 months of life.
When are Children Dying?
0-30 days, 29%
1-4 years, 42%
1-11 months,
29%
Source: Ethiopia DHS, 2000.
11
Regional variations
Ethiopia is a diverse country, composed of nine regions and two administrative states5 with a
broad geographic spectrum and over 40 distinct ethnic groups. It is therefore perhaps not
surprising that childhood mortality is not evenly distributed throughout the country. Under-5
mortality rates range from a low of 114 in the capital city of Addis Ababa to a high of 233 in
Gambella and 229 in Afar, two remote regions6. It is also interesting to note that in addition to
the variation in childhood mortality rates across regions, there is also significant variation in the
ratios of the rates to each other. Thus, for example, the ratio of neonatal mortality to infant
mortality in Tigray is 0.66, but in Afar the equivalent ratio is 0.35. This impressive discrepancy
could reflect methodological issues (e.g., age-heaping by respondents), but could also reflect true
differences in cultural practices or health services.
Childhood Mortality Rates by Region
Deaths per 1000 live births
250
200
150
1-4 years
1-11 months
0-30 days
100
50
N
at
io
na
l
D
aw
a
ire
Ab
ab
a
D
H
ar
ar
i
Ad
di
s
So
m
al
Be
i
nG
um
uz
SN
NP
R
G
am
be
lla
ar
Am
ha
ra
O
ro
m
ia
Af
Ti
g
ra
y
0
Source: Ethiopia DHS, 2000.
When referring to regional variations in health status – as this report does frequently – it is useful
to keep in mind the vast differences in population size among the regions. Oromia, with a
population of about 25 million, is about 137 times larger than Harari, with a population of
178,000. These differences are mirrored by differences in government administrative structure,
relative health systems capacity and a host of other important determinants of child health.
5
Tigray, Afar, Amhara, Oromia, Somali, Benishangul-Gumuz (Ben-Gumuz), Southern Nations, Nationalities and
Peoples Region (SNNPR), Gambella, and Harari, plus two Administrative States (Addis Ababa city administration
and Dire Dawa council).
6
These rates should be used for comparison to each other only, as they are based on the 10-year period preceding
the survey, rather than the 5-year period used for the national rate. As an illustration, while the national 5-year
under-5 mortality rate is 166, the 10-year rate is 188, underscoring the progress Ethiopia made from 1991-95.
12
Regional Population Sizes (000's)
24,395
25,000
20,000
17,669
13,686
15,000
10,000
5,000
4,006
4,002
1,301
2,725
580
228
357
178
0
Tigray
Afar
Amhara
Oromia
Somali
BenGumuz
SNNPR Gambella
Harari
Addis
Ababa
Dire
Dawa
Source: FDRE MOH, 2002-03.
The three largest regions – Oromia, Amhara and SNNPR – together account for 80% of
Ethiopia’s total population and more than 80% of under-5 deaths. Needless to say, progress
towards the child survival MDG in Ethiopia will not occur without progress in these three key
regions.
Causes of mortality
Population-based data on causes of under-5 mortality in Ethiopia do not exist. One recent global
analysis of childhood mortality published in the Lancet has suggested that Ethiopia falls into the
same “profile” as South Asia7. There are a number of reasons why this report considers this
classification incorrect.
First, the profile employed by the Lancet authors attributes virtually no mortality to malaria.
Despite the fact that the geography of Ethiopia is characterized by numerous highland regions,
approximately 70% of the country is considered malarious and there is little doubt that malaria is
an important cause of childhood morbidity and mortality.
WHO estimates that nearly 45 million people are “at risk” for developing malaria, through either
epidemics, seasonal transmission or year-round transmission. The FDRE MOH facility-based
surveillance system reports that in 2002-03 there were 689,849 cases of malaria and 2,409 deaths
due to malaria.
7
Black RE, et. al., 2003.
13
50
1,600,000
EXAM
POSITIVE
SPR
45
1,400,000
40
1,200,000
N
u
m
b
e
r
30
25
800,000
20
600,000
%
S
lid
eP
o
s
itiv
eR
a
te
35
1,000,000
15
400,000
10
200,000
5
0
0
1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
Year (Ethiopian Calendar)
Source: WHO, 2003.
At 18%, malaria is among the three most-common causes of hospital admission in infants, along
with diarrhea (19%) and pneumonia (20%) (FDRE MOH). According to facility records,
malaria is also the second-leading cause of death among infants, accounting for 21%, following
all types of pneumonia (40%), but exceeding diarrhea (7%). A 2001 RBM baseline survey
estimated that 28% of mortality in under-5 children is attributable to malaria. Even with this
limited data, it seems reasonable to attribute a much higher proportion of mortality to malaria.
In addition to the difference with respect to malaria, Ethiopia has a much higher prevalence of
HIV/AIDS than countries in the South Asia region. In 2001 UNAIDS estimated adult
prevalence at 6.4% (based on sentinel sites at prenatal care clinics), and the current estimate is
6.6%. The rate of mother-to-child transmission in sub-Saharan Africa is typically cited at 2040%, and in Ethiopia would be expected to be on the high end of that range due to extended
breastfeeding (median 25 months). If we assume (conservatively) that about one-third of
infected mothers transmit the virus to their newborns and that all of these infected infants will
eventually die, the suggestion is that about 2.2% of all children born – 22 out of 1000 live births
– will die from AIDS or complications related to AIDS. Without antiretroviral treatment or
prophylaxis or treatment for opportunistic infections, at least 90% of these deaths would be
expected to occur before age 5 (most by age 3), or about 20 per 1000 under-5 deaths (about 12%
of under-5 deaths). Of these deaths, only a small minority will be directly attributable to AIDS
itself. Facility-based studies have shown that 83-94% of deaths in HIV-infected children are due
to pneumonia, and most of the remainder are due to diarrhea and measles (but not malaria). This
report therefore proposes to attribute 1% of under-5 mortality to AIDS itself, and to include
HIV/AIDS as an underlying cause of death in 11%. Additionally, it proposes to increase the
proportion of deaths due to pneumonia to account for the effect of AIDS.
Measles too is probably more frequent in Ethiopia than in South Asia, in part due to the higher
prevalence of HIV/AIDS and to a lower measles immunization rate. A 2001 FDRE MOH
Immunization Coverage Survey estimated coverage at 51%, well below the current rate in India
(67%). Data from the MOH’s facility-based reportable disease surveillance system reported a
total of 3797 cases and 58 deaths due to measles in 2002-03. While this figure is quite low, it is
likely due to a successful measles SIA in 2002-03 that reached 90% of the target population (6
14
months to 14 years). Because such SIAs may not be sustainable in the long-term, it seems
reasonable to attribute a slightly larger proportion of mortality to measles in Ethiopia.
One final difference between Ethiopia and South Asia concerns mortality in the neonatal period.
Whereas in South Asia deaths due to neonatal complications account for about 34% of under-5
mortality, in Ethiopia we know from the 2000 DHS that about 29% of under-5 deaths occur in
the neonatal period. Since a small number of deaths in this period can be attributed to other
causes such as diarrhea or pneumonia, this report assumes that about 25% of under-5 deaths are
directly attributable to neonatal complications.
Based on this admittedly limited additional information, this report has placed Ethiopia in a
profile more similar to that of most of western and central Africa. As a result, the proportions of
attributable causes of under-5 mortality have been estimated as follows: pneumonia 28%,
neonatal complications 25%, malaria 20%, diarrhea 20%, measles 4%, AIDS 1% and other 2%.
Given these proportions of attributable causes of mortality and an estimated 472,000 under-5
deaths per year, it is estimated that each year about 132,160 children under five die from
pneumonia, 118,000 from neonatal complications, 94,400 from malaria, 94,400 from diarrhea,
18,880 from measles, 4,720 from AIDS and 9,440 from other causes.
What Are Children Dying From?
Other, 2%
Measles, 4%
AIDS, 1%
Neonatal, 25%
Diarrhea, 20%
Malnutrition
57%
HIV/AIDS
11%
Malaria, 20%
Pneumonia,
28%
Preventable mortality
How many of these deaths can be prevented? Another set of authors from the Lancet estimate
that with 99% coverage of interventions currently available and for which there is sufficient
evidence for effect in prevention or treatment, 65% of deaths due to pneumonia can be averted,
38% of deaths due to neonatal complications, 89% of deaths due to malaria, 88% of those from
15
diarrhea, 100% of those resulting from measles and 48% of those due to AIDS8. It can therefore
be estimated that a total of about 319,000 under-5 deaths can be prevented each year in Ethiopia,
85,904 due to pneumonia, 44,840 due to neonatal complications, 84,016 due to malaria, 83,072
due to diarrhea, 18,880 due to measles and 2,266 due to AIDS. 319,000 avertable deaths per
year translates to 68% of the total, much higher than the average of 57% for the 42 countries
with 90% of worldwide child deaths.
Annual Preventable Under-5 Deaths
Condition
Attributable mortality Attributable deaths
Pneumonia
Neonatal conditions
Malaria
Diarrhea
Measles
AIDS
Other
Total
Preventable
proportion
Preventable deaths
28%
25%
20%
20%
4%
1%
2%
132,160
118,000
94,400
94,400
18,880
4,720
9,440
65%
38%
89%
88%
100%
48%
0%
85,904
44,840
84,016
83,072
18,880
2,266
0
100%
472,000
68%
318,978
How Many Lives Can be Saved Each Year?
140,000
120,000
100,000
80,000
Attributable deaths
Preventable deaths
60,000
40,000
TOTAL
319,000
20,000
0
Neonatal
Malaria
Pneumonia
Diarrhea
AIDS
Measles
Not explicitly included in the above calculations is the mortality contribution of malnutrition.
Malnutrition is thought to underlie about 57% of all under-5 deaths, and perhaps more due to the
high prevalence of malnutrition among HIV-infected children. However, other than in times of
famine it is not typically a direct, attributable cause of death. Instead, it exerts its influence
8
Jones GJ, et. al. “How many child deaths can we prevent this year?” Lancet 2003; 362: 65-71.
16
primarily through the exacerbation of other causes, such as diarrhea or pneumonia. Thus,
interventions such as breastfeeding and complementary feeding, which are included in the list of
interventions effective against diarrhea and pneumonia, wield much of their influence through
the reduction of underlying malnutrition. However, it is reasonable to expect that the wide-scale
implementation of interventions dedicated towards the reduction of malnutrition would reduce
(but not eliminate) the risk of mortality for about 274,000 under-5 children each year.
Maternal and neonatal mortality
As with under-5 mortality, there are no population-based data on the causes of maternal and
neonatal mortality. What limited information is available comes from facilities through the
routine health information system. For newborns it is reported that 32% of deaths are due to
infection, 29% to birth asphyxia, 24% prematurity and 15% other. Included in the “other”
category is neonatal tetanus. There are an estimated 17,900 neonatal tetanus cases every year, of
which 13,400 die, making Ethiopia number four in the world for neonatal tetanus deaths.
13,4000 deaths translates to approximately 10% of deaths in the neonatal period.
In the community, it might be expected that asphyxia, infection and tetanus account for even
larger proportions of death, as these are conditions which lead rapidly to death in the newborn
and for which there is typically little effective recourse in the community (whereas they are
largely preventable or treatable in the facility setting). On the other hand, since these data are
based on the 5% of deliveries which take place in facilities – a self-selected sample of bettereducated, wealthier, more urban mothers who tend to have more antenatal care visits, better
nutritional status and a lower rate of prematurity – one might also anticipate that in the
community the percentage of deaths due to prematurity would be higher. Needless to say, there
is need for additional information in this area.
Causes of Neonatal Mortality
Other, 15%
Infections, 32%
Prematurity,
24%
Birth asphyxia,
29%
Facility-based deaths. Source: FDRE MOH, 2002-03.
17
The 2000 DHS estimated the maternal mortality ratio in Ethiopia to be 871 (uncertainty range of
500-1200), compared to an average of 910 for sub-Saharan Africa (WHO). As with neonatal
mortality, the only estimates for attributable causes of maternal mortality come from facilities
and are subject to the same self-selection bias. With that caveat, the MOH reports that maternal
deaths due to complications resulting from abortion account for 32% of all deaths, obstructed
labor 22%, sepsis 12%, hemorrhage 10% and hypertension 9%.
Causes of Maternal Mortality
Other, 15%
Haemorrhage
, 10%
Sepsis, 12%
Abortion,
32%
Hypertension,
9%
Obstructed
labor, 22%
Source: FDRE MOH, 2002-03. Facility-based deaths.
Determinants of childhood mortality
Childhood mortality varies not just by region, but by a host of socioeconomic factors as well.
This effect is especially strong for wealth status, maternal educational status and urban-rural
residence. Whereas the under-5 mortality rate among the wealthiest 20% of the population is
114, among the poorest 20% it is 150, 32% higher (for the 2nd poorest 20% the rate is 189, 66%
higher). For children of mothers with at least secondary school education it is 89, but for
children of mothers with no schooling it is 197, 121% greater. Likewise, for children who live in
urban areas the mortality rate is 149, whereas the rate for rural children is 193, 30% higher.
18
Socioeconomic Determinants of Under-5 Mortality
250
200
150
100
50
la
am
be
l
Ad
di
s
G
Ab
ab
a
R
ur
al
U
rb
an
sc
ho
ol
o
N
Se
co
nd
ar
y
R
ic
he
st
20
%
Po
or
es
t2
0%
sc
ho
ol
0
Source: Ethiopia DHS, 2000. Period 1991-2000.
Maternal fertility characteristics are another potent set of determinants of childhood mortality.
The under-5 mortality rate for children whose mothers were less than 20 years of age when they
gave birth is 225, versus 179 for children whose mothers were in their twenties. Children whose
birth order is seven or higher have a mortality rate of 196 versus 177 for those born second or
third (first-born children have the highest rate, 225). In 2000, 66% of women 30-34 years of age
had had their first child when they were less than 20 years old, and 18% had had seven or more
children.
Children for whom the preceding birth interval was less than two years had a mortality rate of
272, versus a mortality rate of 96 for whom the interval was four or more years. While the effect
may be less robust after controlling for other socioeconomic determinants (e.g., education) and
death of the preceding child, it is likely that birth intervals play an important role in determining
childhood mortality in Ethiopia. In 2000, the median birth interval was 34 months, and 20% of
all preceding birth intervals were less than two years.
Preceding Birth Interval and Under-5
Mortality
300
250
200
150
100
50
0
<2 years
2 years
3 years
4+ years
Period 1991-2000. Source: Ethiopia DHS, 2000.
19
MALNUTRITION
The famine of 2002-03 is said to have affected upwards of 14 million individuals, most of them
children. As terrible as that event was, it was an exacerbation of a problem that has existed for
years. About half of all children under five are stunted (about six million children total), and
about one-quarter are severely stunted. Eleven percent are wasted and 1% (a small proportion,
but representing about 125,000 children) are severely wasted. As expected, rural children fare
much worse than urban children (for severe stunting, 27% versus 19%) as do children of
uneducated versus well-educated mothers (28% versus 11%).
Percentage of children classified as malnourished
Height-for-age
-3 SD
-2 SD
Weight-for-height
-3 SD
-2 SD
Weight-for-age
-3 SD
-2 SD
Urban
Rural
19
27
42
53
<1
2
6
11
8
17
34
49
Secondary +
No education
11
28
33
53
<1
2
7
11
4
17
28
50
Total
26
52
1
11
16
47
Source: Ethiopia DHS, 2000.
Nutritional status also varies greatly by region, with the highest rates found in Tigray, Amhara
and SNNP regions, and the lowest rates found in the two urban regions, Addis Ababa and Dire
Dawa. Rural children are consistently more stunted and wasted than their urban counterparts,
but visual inspection of the regional data suggests that stunting and wasting do not appear to be
consistently predictive of each other. That is, acute malnutrition is not necessarily a predictor of
chronic malnutrition and vice versa. Thus, Amhara region, which has the highest proportion of
stunted children, also has one of the lowest proportions of wasted children. Likewise, Gambella
region, which has the highest level of wasting also has one of the lowest levels of stunting. The
famine of 2002-03 is reported to have resulted in the resettlement of a large number of families
to less drought-prone areas, but the effect on malnutrition rates is not currently known.
20
Malnutrition Rates by Region and Residence (-2 SD)
80%
70%
60%
Stunted
50%
Wasted
40%
30%
20%
10%
To
ta
l
R
ur
al
U
rb
an
So
m
Be
al
i
nG
um
uz
SN
N
P
G
am
be
la
H
ar
Ad
ar
di
i
s
Ab
ab
a
D
ire
D
aw
a
Af
fa
r
Am
ha
ra
O
ro
m
iy
a
Ti
gr
ay
0%
Source: Ethiopia DHS, 2000.
When does malnutrition begin? Almost immediately. Despite the fact that virtually all mothers
breastfeed their newborns (see below), 11% of infants less than six months of age are already
stunted. Malnutrition rates continue to rise to 12-23 months of age, resulting in stunting in
nearly 60% of children and wasting in about 20%. From that period onwards about 60% of
children remain stunted and about 10% of children remain wasted.
Malnutrition Rates by Age (-2 SD)
80%
60%
Stunted
40%
Wasted
20%
0%
<6
6-11
12-23
24-35
36-47
48-59
Age in months
Source: Ethiopia DHS, 2000.
21
Breastfeeding
Breastfeeding is nearly universal in Ethiopia. Ninety-six percent of children, both urban and
rural, have been breastfed during at least one period in their lives. In addition, the percentage of
children ever-breastfed varies minimally across regions, from 95-98%. Women also continue to
breastfeed for an extended period: at 24 months of age 72% are still breastfeeding and at 36
months 31% are still breastfeeding.
However, breastfeeding is not optimal. Prelacteal feeding is common. A baseline survey in
preparation for a community IMCI program in one district showed 73% of children were given
butter as a first feed before initiating breastfeeding and only 10% of children were not given any
feeding other than breast. Nationally, only 52% of newborns are put to breast within one hour of
birth and only 75% are breastfed the first day of birth. Regional variations are significant: in
Amhara region only 32% and 51% of newborns are breastfed within one hour and one day of
birth, respectively, versus 62% and 94% in SNNPR.
Initiation of Breastfeeding
100%
90%
80%
70%
60%
Within 1 day of birth *
50%
Within 1 hour of birth
40%
30%
20%
10%
at
io
na
l
N
H
ar
Ad
ar
i
di
s
Ab
ab
a
D
ire
D
aw
a
Af
ar
Am
ha
ra
O
ro
m
ia
So
m
al
Be
i
nG
um
uz
SN
N
PR
G
am
be
lla
Ti
gr
ay
0%
* Includes children who started breastfeeding within one hour of birth
Source: Ethiopia DHS, 2000.
The median duration of exclusive breastfeeding is only 2.5 months, varying from 1.8 months in
urban children to 2.6 months among rural children. Even in infants less than two months of age
less than 80% of children are exclusively breastfed. This proportion drops rapidly over the
ensuing months and by six months of age only about one-quarter of infants are still exclusively
breastfed. About 8% of infants 8-9 months of age are still being exclusively breastfed.
22
Complementary feeding
Complementary feeding occurs too early in about 14% of infants and too late in about 68%. At
6-7 months of age only about 34% of children are receiving complementary foods and this figure
rises to a high of only 84% at 16-19 months.
Breastfeeding Status by Age (months)
100%
90%
80%
70%
Exclusive breastfeeding
60%
Complementary foods
50%
Any breastfeeding
40%
30%
20%
10%
0%
<2
2-3
4-5
6-7
8-9
10-11 12-13 14-15 16-17 18-19 20-21 22-23
Source: Ethiopia DHS, 2000.
Vitamin A
A national survey of school children in 1998 found that 1% had Bitot’s spots. Nationwide, 56%
of children received vitamin A supplementation in the six months preceding the 2000 DHS. This
coverage varied by urban-rural residence, but even more profoundly by region: while more than
80% of children in Addis Ababa and Dire Dawa consumed vitamin A, only about one quarter of
children in Afar did so. Supplementation did not necessarily correspond to apparent need; that
is, children who did not consume vitamin A-rich foods within the week preceding the survey
were not more likely to receive vitamin A supplementation. In Afar, where the apparent need
was greatest, supplementation was also lowest. In Addis Ababa, where consumption of vitamin
A-rich foods was the second-highest, supplementation was also one of the highest.
23
Vitamin A Food Consumption and Supplementation
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Consumed Vitamin A-rich foods
N
at
io
na
l
R
ur
al
U
rb
an
Ab
ab
a
D
ire
D
aw
a
H
ar
ar
i
Ad
di
s
Ti
gr
ay
Af
ar
Am
ha
ra
O
ro
m
ia
So
m
al
Be
i
nG
um
uz
SN
N
PR
G
am
be
lla
0%
Received Vitamin A supplementation
Source: Ethiopia DHS, 2000.
In addition to the regional variation in vitamin A supplementation, there also has been significant
discontinuity over time. In fact, the 2000 DHS appears to have been conducted around the time
that the MOH launched its most successful supplementation campaign ever, during which it
reached a coverage rate of nearly 85% (according to population estimates at the time). However,
there have been significant coverage gaps in the intervening time, with only three campaigns
over the past five years. In 2002, due to problems with inappropriate capsule administration
practices among volunteers, distribution became facility-based, supported by a simultaneous
community mobilization campaign. At the same time, the schedule was changed to once a year,
a frequency which will not meet the needs of vitamin A-deficient children.
Vitamin A Supplementation Campaigns
D
ec
19
97
Ju
ne
19
98
D
ec
19
98
M
ay
19
99
D
ec
19
99
M
ay
20
00
D
ec
20
00
Ju
ne
20
01
D
ec
20
01
M
ay
20
02
D
ec
20
02
Ye
ar
20
03
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: FDRE MOH, 2002-03.
24
Iodine
Overall, only about 28% of households use salt with an iodine concentration of at least 25ppm.
This varies from a low of 12% in Tigray region to a high of only 49% in Gambella region.
Iodized Salt Consumption
100%
80%
60%
40%
20%
l
N
at
io
na
ur
al
R
rb
an
U
H
ar
Ad
ar
i
di
s
Ab
ab
a
D
ire
D
aw
a
Af
ar
Am
ha
ra
O
ro
m
ia
So
m
al
Be
i
nG
um
uz
SN
N
PR
G
am
be
lla
Ti
gr
ay
0%
Percentage of households whose cooking salt contained at least 25 ppm. 15 ppm is considered adequate, but test kits
were marked at 25 ppm intervals. Source: Ethiopia DHS, 2000.
Nutrition activities have been incorporated into a number of initiatives, including IMCI,
community IMCI and the Health Extension Package, but a formal nutrition policy remains to be
adopted. A PROFILES study was run recently and one result has been the adoption of Essential
Nutrition Actions, an initiative which stresses the scaling-up of key nutrition interventions at the
policy, program and provider levels.
25
VACCINE-PREVENTABLE DISEASES
Based on information from the facility-based routine surveillance system, in 2002-03 there were
a total of 3797 cases of measles and 58 deaths, and 17,900 cases of neonatal tetanus and 13,400
deaths. Tetanus is reviewed in the maternal and newborn section.
The 2000 DHS reported very low coverage levels for most antigens9. A FDRE MOH
Immunization Coverage Survey conducted in 2001 found much higher coverage rates, but still
well below desired levels. Of particular note for child mortality, only about one-half of children
are immunized against measles by age one. Thirty-two percent of children under 23 months of
age were fully immunized at the time of the survey, and 28% were fully immunized by one year,
indicating that when children have good access to immunization services they typically complete
the set within the recommended time.
Immunization Coverage Rates by Antigen
yr
1
by
Fu
lly
Fu
lly
M
ea
sl
es
3
O
PV
2
O
PV
1
O
PV
PT
3
D
PT
2
D
PT
1
D
BC
G
100
90
80
70
60
50
40
30
20
10
0
Source: FDRE MOH, Immunization Coverage Survey, 2001.
As with most other health services, immunization coverage varies dramatically by region. While
over 80% of children in Addis Ababa are fully immunized by age one, less than 5% of children
in Afar, Somali and Benishangul-Gumuz are. Immunization coverage rates in the three most
populous regions – Oromia, Amahara and SNNPR – are also low and can be seen to drive the
national average.
9
Vaccination coverage among children 12-23 months of age by 12 months of age, based on health card and
mother’s report: BCG 41%, DPT1 40%, DPT2 28%, DPT3 18%, OPV0 12%, OPV1 74%, OPV2 55%, OPV3+
30%, Measles 21%, All 12%, None 25%.
26
Immunization Coverage Rates by Region
100
90
80
70
60
Fully by 1 yr
50
Measles
40
30
20
10
N
at
io
na
l
a
D
aw
ire
D
Ab
ab
a
H
ar
ar
i
Ad
di
s
am
be
lla
PR
G
SN
N
i
um
uz
Be
nG
So
m
al
O
ro
m
ia
Am
ha
ra
Af
ar
Ti
gr
ay
0
Source: FDRE MOH, Immunization Coverage Survey, 2001.
DPT3 Coverage
Source: FDRE MOH, 2002-03.
Nationwide, DPT3 immunization rates fell in 2002-03 from the previous year, due primarily to
decreases in Oromia and Amhara regions. Tigray region has continued to build on its earlier
successes and now reaches nearly 90% of children. On the other hand, Somali region has
consistently performed poorly and Afar region has only in this past year managed to increase its
coverage rate. Perhaps most concerning was the drop in coverage in Oromia region, from 53 to
27
41%. This decrease may have been in part due to population dislocations resulting from the
famine there at the time.
Immunization Coverage Trends (DPT3)
100
90
80
70
60
50
40
30
20
10
2001-02
at
io
na
l
N
a
D
aw
ire
D
Ab
ab
a
H
ar
ar
i
Ad
di
s
be
lla
am
SN
N
PR
2000-01
G
i
Be
nG
um
uz
1998-99
So
m
al
a
O
ro
m
ia
Am
ha
r
Af
ar
Ti
gr
ay
0
2002-03
Source: FDRE MOH, 1998-2003
A health facility survey of child health services conducted in SNNPR10 in 2001 found that 79%
of facilities had all the necessary EPI equipment and supplies and of the 88% of facilities with a
functioning refrigerator, only 59% reported safe vaccine temperatures (2-80 C). All vaccines
were present in 89% of facilities and 6-month stock-outs were as follows: BCG 16%, OPV 7%,
DPT 14%, Measles 9%, TT 5%. Outreach was conducted by 98% of facilities, for an average of
7.6 times/month to 8.4 communities.
In addition to the routine EPI system, Ethiopia has continued to employ National Immunization
Days (NIDs), sub-NIDs (SNIDs) and supplemental immunization activities (SIAs) for tetanus,
and measles. Polio eradication efforts have been ongoing and the country has been polio-free for
the past three years. GAVI has been working at the national level for nearly ten years, but
recently Immunization Coordination Committees (ICCs) have been established at the regional
level. Even more recently, Ethiopia has adopted the Reaching Every District (RED) initiative,
which by report has succeeded in bringing together administrators, managers and providers at the
regional level to jointly budget and plan immunization activities.
10
“Health Facility Survey of Child Health Services: SNNPR”; ESHE Project, March 2002.
28
PNEUMONIA, DIARRHEA AND MALARIA
Pneumonia
Within the two weeks preceding the 2000 DHS, 24% of children experienced symptoms of
cough and short, rapid breathing. Of those children, only 16% were taken to a health facility or
trained provider11 for care. As expected, urban children were taken more frequently than rural
children (41% versus 14%). The percentage of children taken for care varied little by age of the
child: 16% of those under six months of age, 20% of those 6-11 months and 19% of those 12-23
months.
Percentage of Children with Symptoms of
ARI in Preceding 2 Weeks
30%
25%
20%
Not taken to trained provider*
15%
Taken to trained provider
10%
5%
0%
Urban
Rural
Total
* Trained provider excludes pharmacy, shop and traditional practitioner.
Source: Ethiopia DHS, 2000.
Current MOH policy does not permit antibiotic treatment of pneumonia by community-based
health workers.
Diarrhea
The incidence and treatment figures for diarrhea were similar: 24% of children in the preceding
two weeks experienced diarrhea, and of those only 13% were taken to a health facility or trained
provider. Incidence varied significantly with age: while 15% of infants under six months
experienced diarrhea, 39% of those 6-11 months and 37% of those 12-23 months experienced
diarrhea. However, there was little variation by age regarding whether or not a child with
diarrhea was taken for care
As with pneumonia, rural children experienced a higher rate of diarrhea and a lower rate of care
from a trained provider compared to urban children.
11
Excludes pharmacy, shop and traditional provider.
29
Percentage of Children with Diarrhea in Preceding 2
Weeks
30%
25%
20%
Not taken to trained provider*
15%
Taken to trained provider
10%
5%
0%
Urban
Rural
Total
* Trained provider excludes pharmacy, shop and traditional practitioner.
Source: Ethiopia DHS, 2000.
Among children with diarrhea, 13% received oral rehydration solution (ORS), 19% received
either ORS or recommended home fluids (RHF), 45% received Oral Rehydration Therapy (ORT,
consisting of ORS, RHF or increased fluids) and 39% received no treatment at all. Urban
children were much more likely to receive ORT than rural children (69% versus 43%).
Recommended Treatment for Diarrhea
100%
90%
80%
70%
60%
Received ORS
i
50%
Received ORS or RHF
ReceivedORT
40%
30%
20%
10%
0%
Urban
Rural
Total
* ORS = Oral Rehydration Solution (ORS) and RHF = Recommended Home Fluids.
Source: Ethiopia DHS, 2000.
Of those children with diarrhea, 35% were offered more liquids during their illness, 17% were
offered the same amount and 48% were offered less. Eighty-seven percent were offered less
food during their illness. It is not known what percentage of children were offered more food
following their illness.
30
Seventy-two percent of households use an unprotected water source for their drinking water, and
rural households are more than three times more likely to use an unprotected source than urban
households (80% versus 24%). Access to sanitation facilities is even more limited: 88% of
households do not have access to any type of sanitation facility (toilet or any type of latrine).
Ninety-six percent of rural households lack access, but even 50% of urban households do not
have access to adequate sanitation. In one community IMCI baseline study, 78% of individuals
were found to never use soap when washing their hands.
Drinking Water Source and Sanitation Facilities
100%
80%
Urban
60%
Rural
40%
Total
20%
0%
Unprotected water source*
No sanitation facility**
* Unprotected drinking water source includes water from river, pond and uncovered well or spring
** No sanitation facility includes no facility and bush
Source: FDRE MOH, 2002-03.
Malaria
Plasmodium falciparum and Plasmodium vivax are the two dominant malaria parasite species
and the main vector is Anopheles arabiensis. The major transmission season is September –
December, following the June – September rains, and the minor season is April – May, following
the February – March rains. The major transmission season occurs in nearly all areas of the
country, and approximately 70% of the country is considered malarious. The absolute number of
cases per year varies greatly by region, as does the number of cases relative to the region’s
population. As would be expected, the four most populous regions have the greatest number of
cases, but Benishangul-Gumuz and Gambella have by far the greatest burden of disease.
31
Malaria Cases and Cases per 1 Million People
180000
160000
140000
120000
100000
Cases
Cases/million
80000
60000
40000
20000
D
aw
a
ar
ar
i
H
Ab
ab
a
ire
D
G
Ad
di
s
be
lla
am
NP
R
SN
Be
nG
um
uz
So
m
al
i
O
ro
m
ia
Am
ha
ra
ar
Af
Ti
g
ra
y
0
Facility-based routine surveillance system.
Source: FDRE MOH, 2002-03.
Nationwide, 28% of children were ill with fever in the two weeks preceding the 2000 DHS, and
of these 19% were taken to a trained provider. According to the 2001 RBM Baseline Survey,
only 7% of children receive early diagnosis and treatment. As expected, there was substantial
regional variation in the two-week incidence and treatment of fever. When interpreting these
data it is important to note that malaria incidence varies significantly by time of year and not all
regions were surveyed simultaneously. The effect of resettlement of families following the
2002-03 famine to more fertile but lower-lying and more malarious areas is not yet known.
Percentage of Children with Fever in Preceding 2 Weeks
50%
45%
40%
35%
30%
Not taken to trained provider*
25%
Taken to trained provider**
20%
15%
10%
5%
N
at
io
na
l
ur
al
rb
an
R
U
a
Am r
ha
r
O a
ro
m
ia
S
Be om
n- ali
G
um
SN uz
NP
R
G
am
be
lla
A d Ha
r
ar
di
i
s
Ab
a
D
ire ba
D
aw
a
Af
Ti
g
ra
y
0%
* Includes not taken to any provider, and taken to a pharmacy, shop or traditional practitioner
** Trained provider includes private doctor or clinic, any government facility and NGO facility
Source: Ethiopia DHS, 2000.
32
The RBM survey found that only 31% of cases of fever seen in health facilities received
appropriate management and that the case fatality rate was 5.2%. Intermittent presumptive
therapy for pregnant women is currently not a part of MOH policy and current coverage is zero.
At the time the DHS was conducted, bednets were essentially unavailable in Ethiopia: only 1%
of households used a bednet and of those only 18% were impregnated with insecticide. Since the
time of that survey it is reported that a large number of bednets have been distributed,
particularly in Oromia and Amhara districts, but current coverage rates are unknown. Bednets
are still taxed and tariffed.
Drug availability
The 2002 SNNPR Health Facility Survey surveyed 46 health centers and health stations and
found that a substantial proportion were out of stock for a number of drugs essential for proper
management of pneumonia, diarrhea and malaria. By report, there are numerous problems with
the drug management system at all levels – procurement, distribution and storage – and stockouts are frequent and unpredictable, often dictating the types of drugs prescribed.
Percentage of Facilities with Specific Drugs in SNNPR
100%
80%
60%
40%
20%
O
R
C
S
ot
rim
ox
C
ad
ot
ul
rim
t
ox
pe
C
ot
di
rim
at
ric
ox
az
ol
e
sy
ru
p
Am
ox
ta
bl
et
Am
ox
sy
ru
Su
p
lfa
-P
yr
Vi
im
ta
et
m
h
in
A
10
0,
Vi
00
ta
0
m
in
A
50
,0
00
N
al
id
ix
C
ic
hl
or
ac
am
id
ph
en
ic
Q
ol
ui
,i
ni
nj
ne
,i
nj
ec
ta
bl
e
0%
Health center
Health station
Source: ESHE Health Facility Survey, 2003.
The distribution of drug outlets varies greatly by region. Afar, Oromia and Benishangul-Gumuz
have no public or NGO outlets, and both Tigray and Somali have extremely high population to
outlet ratios (2 million and 4 million to one, respectively). On the other hand, Gambella, Harari,
Addis Ababa and Dire Dawa have far lower ratios – about 200,000 to one or lower.
33
Average Population per Public/NGO Drug Outlet
N
at
io
na
l
aw
a
D
Ab
ab
a
D
ire
H
ar
ri
Ad
di
s
Af
ar
*
Am
ha
ra
O
ro
m
ia
*
So
m
al
Be
i*
nG
um
uz
*
SN
N
PR
G
am
be
lla
Ti
gr
ay
*
2,000,000
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
* Tigray 2.003 million, Afar no outlets, Oromia no outlets, Somali 4.002 million, Benishangul-Gumuz no outlets
Source: FDRE MOH, 2002-03.
Ratios of population to private drug outlet are about one factor lower, but significant variation
still exists across regions. In both analyses, Somali stands out as having especially poor access
to drug outlets.
Average Population per Private Drug Outlet
N
at
io
na
l
D
aw
a
D
ire
Ab
ab
a
H
ar
ri
Ad
di
s
be
lla
am
uz
PR
G
SN
N
i
um
Be
nG
So
m
al
O
ro
m
ia
Am
ha
ra
Af
ar
Ti
gr
ay
100,000
90,000
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
Source: FDRE MOH, 2002-03.
There are also significant regional discrepancies in human resources, particularly when it comes
to program managers and health providers. In Oromia, for example, a region larger than most
countries in Africa, staffing for program management is extraordinarily limited: there is only
one staff for nutrition, one for IMCI, one for maternal health, one for family planning, two for
HIV/AIDS, 3 for EPI and a team of about 10 for malaria. The staffing pattern for each region is
34
different, but no region has the staff it needs to scale up interventions to anything approaching
universal coverage.
Health provider staffing is also extremely limited and highly variable. Overall, there is about
one nurse per 4,882 population (the WHO “standard” is 1:5000), but recruitment and retention –
particularly in the more remote and larger regions – is consistently difficult.
Nurses and Health Assistants per 100,000 Population
160
148
140
120
100
86
80
53
60
57
51
40
21
19
16
20
44
30
20
11
N
at
io
na
l
aw
a
D
ire
D
Ad
di
s
Ab
ab
a
H
ar
ar
i
be
lla
am
G
So
m
al
Be
i
nG
um
uz
SN
NP
R
ro
m
ia
O
Am
ha
ra
Af
ar
Ti
gr
ay
0
Source: FDRE MOH, 2002-03.
The number of pediatricians is even more limited. Overall, there are a total of 1,280 physicians
in the country, but only about 82 pediatricians. Most of these pediatricians are in the urban
centers, leaving only a handful for the remainder of the country. Harari, even though it has one
of the country’s highest ratios, has only one pediatrician for its population of 178,000. The three
largest regions (accounting for about 56 million people, or 80% of the country) together have
only 10 pediatricians.
Pediatricians per 1 million Population
10
8
5.6
6
5.6
3.3
4
2
0.7
0.0
0.1
0.2
0.7
0.0
0.2
0.4
0.0
N
at
io
na
l
D
aw
a
ire
D
Ab
ab
a
H
ar
ar
i
Ad
di
s
be
lla
am
G
So
m
al
i
Be
nG
um
uz
SN
NP
R
O
ro
m
ia
ar
Am
ha
ra
Af
Ti
g
ra
y
0
Source: FDRE MOH, 2002-03.
35
MATERNAL AND NEONATAL HEALTH
Ethiopia’s neonatal mortality rate of 49 is one of the highest in the world, behind only Liberia
(68), Mozambique (54), Mali (50) and Nepal (50). Community-based data on cause-specific
mortality are not available, but the three top causes are infection, asphyxia and complications of
prematurity, as they are elsewhere in the world. Ethiopia also has an extremely high number of
deaths due to neonatal tetanus, thought to account for an additional 10% of neonatal deaths.
Opportunities for the prevention and management of these causes are directly related to
interventions directed towards the mother; namely, fertility control and maternal health.
Fertility
According to the 2000 DHS, the under-5 mortality rate for children whose mothers were less
than 20 years of age when they gave birth was 225, versus 179 for children whose mothers were
in their twenties. Children whose birth order is seven or higher had a mortality rate of 196
versus 177 for those born second or third (first-born children had the highest rate, 225). In 2000,
66% of women 30-34 years of age had had their first child when they were less than 20 years
old, and 18% had had seven or more children.
Twenty percent of children are born within two years of the previous birth and 43% are born
three or more years following the previous birth. In Ethiopia a preceding birth interval of less
than two years is associated with a 2.8 times greater risk of death compared to intervals of four
years and greater (272 versus 96).
Distribution of Preceding Birth Interval (Months)
45%
40%
35%
30%
Urban
25%
Rural
20%
Total
15%
10%
5%
0%
7-23
24-35
36-47
48+
Source: Ethiopia DHS, 2000.
The total fertility rate (TFR) in Ethiopia is 5.9 (DHS 2000). There is significant variation by
residence (3.3 in urban areas, versus 6.4 for rural areas) and education (3.1 among those with at
least secondary schooling, versus 6.2 among those with no schooling). Between the National
36
Family and Fertility Survey in 1990 and the DHS in 2000 there has been a decrease of about 0.5
children per woman (from 6.4 to 5.9).
In addition to actual decreases in fertility over time, a generational effect can be seen in the ideal
number of children desired by women: among all women of reproductive age the desired
number of children is 5.3, but among women 15-19 years of age it is 4.2.
Ideal Number of Children
6
5
4
Women 15-19 years old
3
All women
2
1
0
Urban
Rural
Total
Source: Ethiopia DHS, 2000.
According to MOH statistics, the contraceptive prevalence rate (CPR) in 2002-03 was 22%, a
substantial increase from 8% in 1998-99. In 2000 the total unmet need for family planning was
36% (22% for spacing and 14% for limiting). In rural areas, where the CPR is much lower,
unmet need is correspondingly higher (37% versus 25%).
Unmet Need for Family Planning
40%
35%
30%
25%
For spacing
20%
For limiting
Total
15%
10%
5%
0%
Urban
Rural
Total
Source: Ethiopia DHS, 2000.
37
Motherhood
In 2002-03 the FDRE MOH estimated that only 27% of pregnant women had one or more
antenatal care visits, and that of these only 10% had four or more. Current TT2 coverage is
estimated at 28% of pregnant women, and the 2001 Immunization Coverage Survey found that
only 25% of newborns are protected from tetanus at birth. The 2000 DHS obtained roughly
equivalent results, with much higher (but still sub-optimal) coverage in urban areas. A series of
three SIAs for tetanus toxoid conducted from 1999-2003 targeted all women of reproductive age
in 17 high-risk zones and achieved TT3 coverage of 66% (FDRE MOH).
Tetanus Toxoid Coverage During Pregnancy
100
90
Coverage rate
80
70
60
None
50
1 dose
40
2+ doses
30
20
10
0
Urban
Rural
Total
Source: Ethiopia DHS, 2000.
In 2000 the DHS found that only about 5% of deliveries took place in a health facility. In rural
areas 98% of deliveries are in the home, but even in urban areas 68% of women give birth at
home. Only 10% of births receive any type of postnatal care in the month following delivery,
and only 8% receive it within two days, implying that only 3% receive this care outside a health
facility (since all facility births – 5% of the total – would be expected to provide this type of
care). The MOH estimates that only about 9% of deliveries are attended by a skilled provider.
While there is a fair amount of regional variation in the percentage of women receiving skilled
attendance at birth, the variation for unskilled attendance is huge. In Somali, for instance, 80%
of deliveries are attended by an untrained traditional birth attendant (TBA), while in Gambella
only 10% are. Ethiopia has recently adopted and piloted the Making Pregnancy Safer initiative
to improve care-seeking, transport and care for high-risk deliveries and is in the process of
reviewing the results.
38
Percentage of Deliveries in Health Facilities
100%
80%
67%
60%
40%
31%
20%
4%
4%
4%
3%
6%
8%
32%
25%
23%
4%
5%
2%
N
at
io
na
l
R
ur
al
U
rb
an
D
aw
a
D
ire
H
ar
ar
i
Ab
ab
a
Ad
di
s
Af
ar
Am
ha
ra
O
ro
m
ia
So
m
al
Be
i
nG
um
uz
SN
N
PR
G
am
be
lla
Ti
gr
ay
0%
Source: Ethiopia DHS, 2000.
Assistance During Delivery
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Health professional
Trained TBA*
D
N
at
io
na
l
R
ur
al
U
rb
an
a
D
aw
ire
H
ar
ar
i
Ab
ab
a
Ad
di
s
So
m
al
Be
i
nG
um
uz
SN
N
PR
G
am
be
lla
O
ro
m
ia
ar
ha
ra
Am
Af
Ti
gr
ay
0%
Untrained TBA
No assistance**
* TBA = Traditional Birth Attendant. ** No assistance includes assistance by relative, other and no one.
Source: Ethiopia DHS, 2000.
The number of nurse midwives relative to population varies significantly by region, and is an
especially acute problem for the three largest regions – Oromia, Amhara and SNNPR – due to
reported difficulties with recruiting, training and retaining appropriate staff. However, it is
39
important to note that the correlation between midwives per population and the rate of facilitybased delivery or skilled attendance is poor. Addis Ababa, for example has only about three
midwives/100,000 but a 69% skilled attendance rate, whereas Harari with proportionally four
times as many midwives has only a 26% skilled attendance rate.
Nurse Midwives per 100,000 Population
14
12.4
12
10
7.5
8
6
4.7
4
4.5
3.0
2.2
2
1.0
0.9
0.9
1.7
1.7
1.5
N
at
io
na
l
a
D
aw
ire
D
Ab
ab
a
H
ar
ar
i
Ad
di
s
So
m
al
Be
i
nG
um
uz
SN
N
PR
G
am
be
lla
O
ro
m
ia
Am
ha
ra
Af
ar
Ti
gr
ay
0
Source: Ethiopia DHS, 2000.
Pediatric HIV/AIDS
Nearly all cases of pediatric HIV/AIDS are thought to result from mother to child transmission.
Based on results from 34 surveillance sites (antenatal care clinics), current estimates are that
about 6.6% of pregnant women are infected with HIV. Although about 20-40% of these women
would be expected to pass the virus on to their newborns, there is currently no data on the
prevalence of HIV infection in children. However, effective prevention of mother to child
transmission would be expected to result in a substantial drop not only in the number of deaths
directly attributable to AIDS, but also to deaths attributable to pneumonia, diarrhea and measles,
for which AIDS is an important underlying risk factor. Ethiopia currently has pilot PMTCT
programs in four urban hospitals and is in the process of expanding the initiative throughout the
country. The current strategy is to eventually take PMTCT down to the health center level.
40
COMMUNITY HEALTH
Since 1980(9), Community Health Agents (CHAs) and Traditional Birth Attendants (TBAs) have
been trained to act as a link between the community and health facilities as part of a communitybased Primary Health Care (PHC) strategy. There was a unit responsible for coordinating this
endeavor in the structure of the MOH at all levels. Standardized criteria for recruitment and
training curricula for CHAs and TBAs were prepared by the central MOH. A training time of 90
days for CHAs and 15 days for TBAs was prescribed. For each PA/Kebele, one CHA and two
TBAs were recruited. By 1982 a total of 12,605 CHAs and 14,445 TBAs were recruited and
trained(10).
The duties of CHAs were as follows(11):
• Stimulate members of the community to participate actively in improving the health of
their families and community
• Provide health education relevant to local health problems
• Implement a variety of methods of controlling communicable diseases
• Provide MCH services
• Provide curative services for minor illnesses and injuries and refer those requiring
complex examination and treatment
• Collect health information and statistics
And for TBAs(12):
• Give appropriate information and advice to expectant mothers in the community
• Manage normal deliveries and refer pregnancies with complications to health facilities
• Encourage and assist women in the post-partum period through home visits
• Advise parents on the benefits of birth spacing
• Report to the clinic the number of births and deaths of infants attended
In 1983 a study showed that in one area only 62% of CHAs trained at the beginning of the
program were still working. Of the remaining 38%, just under half never even became active.
Reasons given for dropping out were lack of support in terms of drug supplies and supervision
from the health system and lack of continuing education. For those who never started, the
primary problem cited was lack of support from the community. Similar problems were found to
affect programs in other countries as well,(13,14) and there was evidence from elsewhere that
voluntary community-based health workers had minimal impact on health status.(14)
Criticism was also aimed at the training process: the trainers themselves were hospital-based,
and had no real concept of the needs of a community-based system. In 1988 the following
reasons were given for the failure of the CHS in Ethiopia:
• Lack of community involvement
• Lack of intersectoral collaboration
• Poor program management
• Poor human resources management
• Inadequate refresher training and supervision
• Lack of surveillance for hygiene and environmental health
41
At the moment there are several community-based health services still being provided:
• 12,000 TBAs still attend more than 90% of deliveries
• 14,000 community based reproductive health agents (CBRHAs) are actively providing
family planning education, as well as the provision of different kinds of family planning
contraceptives
• In big regions like Oromia and Amhara, malaria cases are being treated empirically at the
community level by community based malaria workers who are recruited by the
community on a voluntary basis
• In SNNPR a Community Health Promoter's Initiative (CHPI) launched by the USAID
ESHE Project and the Regional Health Bureau in February 2003 with the goal of creating
a human bridge between the health facilities and the rural communities they serve (15).
CHPI uses community volunteers to communicate health messages and mobilize their
communities for health-related activities; this initiative is tapping into the natural
networks within villages and beginning to bring about change in behavior.
• Idir is a centuries-old voluntary community network that provides emergency financial
assistance when a member dies. A membership fee is regularly collected and used to pay
for funeral expenses. A feasibility study showed that the network could also be used to
assist members when they become ill. Several Idir networks are now being used to help
orphans and people living with HIV/AIDS.
Behavior change and communications
The only population-based data available relate to exposure to mass media, and do not include
counseling or community-level activities. However, the figures are telling: only 14% of women
and 27% of men watch television, listen to the radio or read the newspaper at least once a week.
In rural areas, 94% of women and 80% of men have no exposure to mass media. The
implication is that health education in the community can not rely on mass media to effect
behavior change.
Exposure to Mass Media
100%
80%
60%
Women
Men
40%
20%
0%
Urban
Rural
Total
Exposure = at least once a week. Mass media includes television, radio and newspaper.
Source: Ethiopia DHS, 2000.
42
KEY POLICIES AND STRATEGIES RELATED TO CHILD HEALTH
Ethiopia has two major efforts aimed at achieving its health MDGs, and all are interrelated. The
first effort is a national Health Sector Development Program (HSDP II) initiated in 2002/03, a
follow-on project to HSDP I which began in 1997. The second effort is Ethiopia’s poverty
reduction program, as outlined in its Sustainable Development and Poverty Reduction Program
(SDPRP). SDPRP focuses on reduction in poverty and reduction in the health problems that
either result in poverty or are the result of poverty. Child health is the major focus of both HSDP
II and SDPRP. In fact, HSDP II is incorporated de facto as the health component of SDPRP.
HSDP I
HSDP I was an $800 million effort launched in 1997-98 that translated the Ethiopian
government’s health policy statement into action. The program covered the period 1997/98 –
2001/02. It put disease prevention at the center of its reorganization of the health service
delivery system. It had eight components that were to result in a fully integrated delivery system
at the local level. One of HSDP’s priorities was to expand and rehabilitate the network of
primary health care units (PHCU), to upgrade and expand district hospital facilities and to
promote equity by focusing on rural parts of the country.
HSDP I had support from the highest Government levels, and all major donors were involved, as
were all Regional Health Bureaus. Its objectives were to:
• Increase access to health care (and thus utilization) from 40% to 50-55%
• Improve service quality through training and an improved supply of necessary inputs
• Strengthen the management of health services at federal and regional levels
• Encourage participation of the private sector and the NGO sector by creating an enabling
environment for participation, coordination and mobilization of funds
Although there was no explicit child survival strategy, HSDP I did in fact focus on the need for
improved primary care and addressed all primary child survival interventions.
Implementation was primarily PHCU based. HSDP I identified a minimum package of health
services, including preventive services like EPI, micronutrients, school health, IEC, and AIDS
prevention as well as curative services like IMCI, safe motherhood, TB, leprosy and STI
treatment. Major causes of mortality and morbidity in children were to be addressed, including
malnutrition, promotion and the use of ORT, continued feeding during diarrhea episodes,
standardized case management for childhood illnesses, vitamin A supplementation for under 5
children, growth monitoring for children under 3 years of age. Outreach activities were to be the
foundation of much of this work.
The mid term review of HSDP I conducted in February, 2001, along with three consecutive
Annual Reviews (ARMS) and other World Bank reports, identified a number of generic and
operational problems:
• There was an enormous increase in the number of health posts and expansion of health
centers. Utilization of these services, however, did not mach this expansion.
43
Deleted: included
Deleted: , having been developed and
coordinated out of the Prime Minister’s
Office.
Deleted: A
•
•
•
•
•
•
•
•
•
•
•
While outpatient use rates did not increase, some services showed an increase such as
contraceptive use.
Immunization rates except polio declined.
There was no budget line item for immunizations in the regional budget, with full
reliance on budget subsidies from donors.
HSDP had limited impact on the delivery of basic maternal and child health care and
made slow progress in implementing child health activities.
Regions were unable to address malnutrition in part because of lack of an effective focal
point in Regional Health Bureaus for nutrition.
Overall lack of staff capacity in terms of numbers and skills levels meant that many new
facilities were under-staffed and quality of care suffered.
Significant disparities in human resources needs among regions resulted in low coverage
of health workers and facilities in some areas.
Some key staff were not deployed because there were not enough to go around and
production of these types of manpower (midwives and junior nurses) is too low. The
review estimated that acceptable staffing levels may not be achieved within 25 years.
The preference for curative services by professionals, the public and decision makers at
all levels meant that little attention was given to disease prevention and health promotion.
There was frequently a lack of essential medical equipment and essential drugs in
facilities, contributing to low demand and perceived low quality of care.
Slow budget approval, disbursement procedures and inadequate budget at health facility
level had been a problem. In general funds allocated for health were inadequate to meet
program objectives or decision makers expectations.
A joint review mission looking at progress on implementation of Ethiopia’s Health Sector
Development Program (HSDP I) made several recommendations including:
• Address the problem of persisting high levels of child malnutrition by focusing on
maternal nutrition and nutrition in children under two years of age through the
introduction of a basic minimum nutrition package and improved caring practices.
• Establish control mechanisms for vitamin A deficiency in children under five through
regular supplementation at EPI sites and with NIDs, dietary diversification and food
fortification.
• Control iodine deficiency disorders by introducing legislation for importing and
marketing iodized salt.
• Control iron folate deficiency through supplementation during antenatal care visits, food
fortification and dietary diversification.
• Improve household food security through community-based initiatives.
44
Health Sector Development Program II
HSDP II is an extension of HSDP I, with a sharper focus on prevention and control of
communicable diseases. The overall goal of HSDP II is to improve the health status of
Ethiopians but with a re-focus on poverty related diseases. It expects to achieve this goal
through development and implementation of a Health Extension Package (HEP) aimed at
effective prevention and control of communicable diseases with active community participation.
HSDP II does not have an explicit under-5 mortality objective nor does it directly address the
child mortality MDG since its time horizon is so short (three years). It does, however, have a
number of interim targets that, if reached, should lower under-five mortality. The main child
survival related targets of HSDP II for the coming period (2002/03-2004/05) are:
• Increase health care coverage from 52% to 65%
• Slow construction of health facilities and instead focus on improving the quality of care
and availability of essential supplies and other inputs
• Implement a Health Extension Package on a pilot basis using existing PHC workers
• Train, deploy and motivate an adequate number of technical and managerial health
workers
• Strengthen management of health services at the woreda, regional and national level
• Create an enabling environment for private and NGO partners in service delivery, and
coordinate and mobilize health resources.
• Reduce infant mortality from 97 to 85 per 1000 live births
• Increase EPI (DPT3) coverage from 50% to 70%
• Reduce maternal mortality from 500-700/100,000 live births to 400-450/100,000 live
births
• Increase contraceptive prevalence rate from 18.7% to 24%
• Expand IMCI implementation to 80% of health facilities
The Health Extension Package (HEP)
HEP is a package of services designed to improve access in an equitable fashion to essential
preventive health interventions through community/kebele based health services, with a strong
focus on sustained preventive health actions and increased health awareness. A new cadre of
health workers, most of them women, will be trained for one year and deployed up to two to each
kebele and they will be accountable to health centers of their areas. Currently HEP is being
piloted in 100 districts.
Components of the Health Extension Package include the following:
1. Hygiene and Environmental Sanitation
a. Proper and safe excreta disposal
b. Proper solid and liquid waste disposal
c. Water supply safety measures
d. Food hygiene and safety measures
e. Healthy home environment
f. Arthropods and rodent control
45
g. Personal hygiene
2. Disease Prevention and Control
a. HIV/AIDS prevention and control
b. TB prevention and control
c. Malaria prevention and control
d. First Aid
3. Family Health Services
a. Maternal and child health
b. Family planning
c. Immunization
d. Adolescent Reproductive Health
e. Nutrition
4. Health Education and Communication
Other government programs and strategies
The Federal Government has a population policy that calls for a reduction of the TFR to 4% by
2015, an increase in the CPR to 44% by 2015 and a reduction in maternal, infant, and child
morbidity and mortality rates. Ethiopia’s HIV/AIDS policy, approved in 1998, outlines the
impact of HIV/AIDS on health and economic development. The Ministry of Health’s Health
Care Financing Strategy calls for waivers for the poor, exemptions for certain services (child
survival services included) and the retention of user fee revenue to improve quality of services.
Ethiopia’s Sustainable Development and Poverty Reduction Program (SDPRP), which focuses
on rapid economic growth while maintaining macroeconomic stability, has a health component
which essentially is HSDP II, even though some of the health indicators and targets differ. The
SDPRP also focuses on HEP. The health focus of SDPRP can be considered “child survival
friendly” since prevention is its priority and many of the known, effective child survival
programs are mentioned. Unlike HSDP II, SDPRP has specific indicators such as under-5
mortality, infant mortality and DPT3 coverage that will be monitored.
46
CHILD HEALTH PROGRAMS
Nutrition
From 1976-1994 the former Ethiopian Nutrition Institute (ENI) was the responsible body for
nutrition activities in the country. In 1994, restructuring of the Federal MOH resulted in the
merging of ENI with two other institutions to form the Ethiopian Health and Nutrition Research
Institute, which worked exclusively on research. In 1996, Ethiopia launched the National
Micronutrient Deficiency Control Program, which has two components – vitamin A deficiency
and iodine deficiency disorders. This program was started in the Family Health Department
(FHD) under the Maternal and Child Heath Team. One expert was assigned to lead the program.
In 2001, the FHD was restructured and a Nutrition Team was established. The objective was to
carry out other broad nutrition activities in addition to Micronutrients.
Major challenges:
• At federal and regional levels, inadequate staff designated to nutrition and where
assigned not trained or motivated to work in nutrition
• Supply and logistics constraints
• Inadequate financial input from the government
• Inadequate understanding of and collaboration with NGOs and other sectors in food
security at the federal and regional level
• No indicators, information collection, supervision guideline and strategy/program defined
• Nutrition policy is not yet finalized
• Absence of a national Code of Marketing of Breast Milk substitute
Deleted: i
Deleted: Strategy for IYCF and vitamin
A supplementation guideline finalized but
not disseminated¶
Deleted: c
Expanded Program on Immunization (EPI)
Deleted: m
EPI is one of the major child survival and development interventions planned and implemented
during HSDP I. In 1980, the Government established the EPI program, which was tasked with
increasing vaccination coverage against the six childhood killer diseases by 10% each year to
reach 100% coverage in 1990. This program goal was never realized. The period 1988-1990
saw a rapid acceleration of coverage under the Universal Childhood Immunization (UCI)
initiative. Unfortunately, due to internal conflicts and dwindling resource inputs, a drastic
decline in coverage was observed during the program.
Major challenges identified during the HSDP I final evaluation:
• Inadequate program management at all levels
• Lack of regular supervision at all levels
• Lack of human resources, especially at the operational level
• Lack of training at lower level
• High turnover of staff
• Weak vaccine and cold chains management at all levels
• High vaccine wastage
• Under-utilization of five existing regional cold rooms
47
Deleted: b
Deleted: m
•
•
•
•
•
Lack of cold chain maintenance equipment
Poor injection safety practices
Low participation of private sector in immunization programs
Lack of health education and community mobilization materials at service delivery levels
No budget allocation by regions
Integrated Management of Childhood Illnesses (IMCI)
The first and second international consultant training on IMCI were conducted in Addis Ababa in
November 1995 and May 1996 respectively, using semi-adapted IMCI training materials for
Ethiopia. The Ministry of Health of Ethiopia endorsed IMCI as a key strategy to reduce
childhood mortality and morbidity and to promote child health and development in 1996. This
was followed by a national orientation workshop in February 1996, during which an IMCI
National Task Force was formed.
The FMOH selected three regions for initial implementation: Tigray, SNNPR and Addis Ababa.
Activities in the selected regions started in 1998 with orientation workshops. The Amhara
Region started IMCI implementation in December 2000 before the expansion phase was
officially launched. A central and regional five-year strategic IMCI plan was developed in May
2000. The first and second national IMCI review and re-planning workshops were conducted in
March 2001 and 2004 respectively.
All regions have included IMCI in their annual health plan of action and are actively
implementing IMCI. Of the 569 districts in the country, 109 (19.16%) are actively implementing
IMCI. Out of 604 public hospitals and health centers, 198 (32.78%) have IMCI trained health
workers managing under-five children. Out of a total of 10,318 target health workers, 2,803
(27.2%) have been trained on Case Management, both in pre-service and in-service training
courses. Twenty key family and community practices were adapted and a three-year strategic
plan for C-IMCI implementation was developed. C-IMCI was initiated in two pilot regions,
Amhara and Tigray.
Major challenges:
• Under-staffing of the family health team at all levels including the Maternal and Child
Health team at the Federal MOH
• Delay in the finalization of the HIV sign validation study in collaboration with Addis
Ababa University has forced postponement of the finalization of HIV/AIDS adaptation
into the IMCI algorithm
• Integration of IMCI follow-up with the routine supervision where routine supervision is
weak
• Harmonization of IMCI Classifications with HMIS codes of diseases
• Coordination and collaboration with other child health related programs and/or line
ministries at various levels, especially for the implementation of C-IMCI
48
Deleted:
Deleted: ¶
Malaria Control
The control of malaria in Ethiopia has a history of more than four decades, which initially began
as pilot control projects in the 1950’s and then became a national eradication campaign in the
1960’s followed by a control strategy in the 1970’s. In 1976 the vertical organization known as
the National Organization for the Control of Malaria and Other Vector-borne Diseases
(NOCMVD) evolved from the Malaria Eradication Service (MES). Some of the many
contributions attributable to this program’s activities include reduced prevalence and level of
transmission in many areas and the opening up of fertile arable lowland areas and major river
valleys for expanded agriculture and settlement. Since June 1993, under the general policy of
decentralization and federalism in Ethiopia, malaria control became the responsibility of the
regional health offices. The central level is now responsible for formulation of policies,
provision of technical guidelines to regions, assistance in training, conducting operational
research and support in anti-malarial drugs, insecticides and equipment.
Efforts to introduce Roll Back Malaria (RBM) in Ethiopia were first started in 1998. By
December 1999, Ethiopia had completed estimates and mobilization of supplies for impending
epidemics. A national conference on RBM was held in February 2000. An RBM baseline
survey was conducted in 2001. Plans of action in the context of the national malaria control
strategic plan were developed for the period 2001-2005.
Major challenges:
• High population size coupled with low health service coverage & utilization
• Low coverage of community based services
• Shortage of resources (human resource, funds, materials)
• High cost of ITNs and extreme poverty of the target population
• Lack of appropriate and systematic data collection and communication
Prevention of Mother to Child Transmission (PMTCT)
A relatively new program in Ethiopia, the prevention of mother-to-child transmission of HIV is
critical to improving child survival. In August 1998, the National HIV/AIDS policy was
endorsed, which promotes multi-sectoral approach to prevent AIDS. A national situation
assessment for PMTCT program implementation was conducted in collaboration with UNICEF
in 1998. In March of 2000, a National Workshop on Strategies for Prevention of Mother to
Child Transmission of HIV was conducted. Based on the consensus reached at this workshop,
MOH selected four initial sites for PMTCT services: Gondar, Jimma, Dire Dawa and Dilla. The
Strategic Framework for the National Response to HIV/AIDS for 2001-2005 was issued in June
2001. The PMTCT technical working group was established in 2001, providing technical
guidance and assistance to decision-makers and implementing partners, and reporting to the HIV
Task Force. National Guidelines on PMTCT were developed in November 2001 with technical
and financial support from UNICEF and WHO.
In June 2003, services began at the 4 selected UNICEF-sponsored sites. Through January 2004,
2407 clients had been pre-test counseled, 1487 clients agreed to be tested and 172 were found to
49
be HIV-infected. The seroprevalence ranged from 9.7% in Dilla to 13.2% in Jimma, with an
average of 11.9%. Of these, the number of mother-infant pairs who have taken NVP is 34 (of 39
HIV positive). The Nigat Project is conducted with the Department of Paediatrics and Child
Health (Addis Ababa University) in collaboration with Johns Hopkins University School of
Public Health. It is a clinical trial for the prevention of mother to child transmission of HIV
(PMTCT) which was started in February 2001. The Hareg Project is a USAID and CDC
program and involves 6 regions. Services have recently started in February and March, 2003.
Major challenges:
• Low uptake of services
• Lack of coordination and integration
• Shortage of drugs and supplies
• Manpower shortages
• New service added to already overtaxed system
Maternal Health
Maternal and newborn health are identified as a priority area in the 1993 health policy. Priority
was given to the provision of Safe Motherhood services to cater for normal pregnancies,
deliveries and referral centers for high-risk pregnancies, appropriate maternal and child
nutritional education, provision of family planning services, post abortion care, addressing the
sexual and Reproductive Health needs of adolescents, encouraging paternal involvement and
discouraging harmful traditional practices.
In collaboration with its major partners in reproductive health (UNICEF, WHO and UNFPA),
the federal MOH launched Making Pregnancy Safer in four zones of the four big regions
(Oromia, Amhara, SNNPR, and Tigray) in June 2001. The national goal for MPS is to
strengthen the capacity of selected facilities to provide basic and emergency obstetric care
through ensuring a functional referral loop between zonal hospitals and the four health centers
that refer to it, as well as health posts/clinics and communities, for the reduction of maternal and
perinatal mortality. MPS has two components: facility based MPS where the referral linkage is
between the health centers, and community based MPS, where the referral linkage is between the
community (TBAs) and the health centers. Though its impact has not yet been evaluated, the
facility based MPS is underway in the four selected zones (Arsi, South Wollo, Gedio and W.
Zone), but the community component is at a preparatory stage (needs assessment is underway).
Major challenges as noted by the HSDP I evaluation:
• Reproductive Health issues lack adequate political commitment
• Inadequate facilities providing basic and comprehensive EOC, with no effective referral
system
• Weak information system resulting in underreporting
• Serious shortage of appropriate skilled human resources at all levels
• Limited and irregular availability of family planning commodities
• Lack of adequate clinical practice during pre-service training and absence of in-service
training
50
Deleted: of this year
Information, Education and Communication (IEC)
IEC was articulated as an important component of HSDP I, which recognized it as a vital tool in
the development and successful implementation of health and health related programs. Strategic
health communication is an integral part of quality health services, an important means of
creating demand for use of services and for motivating positive attitudes and practices to ensure
health promoting behaviors
Major challenge identified during the final evaluation of HSDP I:
• Lack of health communication specialists
• High turnover of experienced staff
• The production of material at the federal level has not necessarily been in response to the
needs of the regions
• Inadequate budgetary allocation to IEC especially at regional and lower levels and delay
in project finance liquidation
• Lack of coordination of many players, both within the government and NGOs in IEC, has
resulted in duplication, unfocused efforts and resources on priority areas in health
• While the role and importance of IEC seems to be recognized, its translation into a
vehicle or tool through which the behavior change can be effected has not been fully
realized
• Planned supportive supervisions to regions and review meetings were undertaken
irregularly
• None of the region had undertaken operational research or audience based research
mostly due to lack of technical capacity.
• No comprehensive communication interventions had been undertaken in the regions
mainly due to lack of proper direction, leadership and technical knowledge
51
ORGANIZATION OF THE HEALTH SYSTEM
The health policy of Ethiopia emphasizes the importance of achieving access for all segments of
the population to a basic package of quality primary health care services, via a decentralized state
system of governance. This service package includes preventive, promotive and basic curative
services. In order to attain this goal, HSDP I introduced a four-tier system for health service
delivery. This is characterized by a primary health care unit (PHCU), comprising one health
center and five satellite health posts, and the district hospital, zonal hospital and specialized
referral hospital. A PHCU unit has been planned to serve 25,000 people, while district and zonal
hospitals are each expected to serve 250,000 and 1,000,000 people respectively.
The growing size and scope of the private health sector, both for-profit and not-for-profit, offers
an opportunity to enhance health service coverage, and HSDP has explicitly recognized the
complementarity between the two sub-sectors with the articulation of a strategy to promote
private sector involvement.
Management and support
Health services are managed in accordance with the decentralized structures of the country as a
whole. Overall responsibility for health policy and regulation is the responsibility of the Federal
Ministry of Health in Addis Ababa, while responsibility for management of health service
delivery falls to the respective Regional Health Bureaus (RHBs). As a result, management of
health facilities, personnel and health training institutions within the regions is undertaken by the
RHBs. They are supported in this function by zonal health departments in some regions, and
increasingly through the establishment and staffing of woreda health offices.
Supervision takes place at all levels, from FMOH departments through to zones. Responsibility
for logistical support is again shared between FMOH and the RHB. A Health Management
Information System (HMIS) has been established for routine reporting of activities and health
service utilization, and structures are in place for periodic monitoring of and evaluation of the
health system as a whole.
Health care utilization and coverage
Access is improving, but continues to be poor. In 2002-03 the MOH estimated that public health
services coverage reached 61.3% of the population. In 2001-02, coverage was estimated at
51.8%, but the following year was revised upwards to 61.0%. Access is defined as residence less
than 10km from a health facility, but is not actually measured. It is calculated based on
theoretical catchment areas (e.g., 25,000 catchment area per health center and 5,000 per health
post) and there may be instances of double-counting in the PHC Units.
52
Deleted: then
Deleted: has
Average Population per Health Post
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
N
at
io
na
l
aw
a
D
D
ire
Ab
ab
a
H
ar
ar
i
Ad
di
s
N
PR
be
lla
G
am
SN
i
um
uz
So
m
al
Be
nG
ro
m
ia
O
Am
ha
ra
Af
ar
Ti
gr
ay
0
Source: FDRE MOH, 2002-03.
Pastoralist communities, which represent about 10% of the population and are mobile and
seasonally change their residence, are especially difficult to reach with traditional facility-based
health services.
Estimated health service coverage and utilization by region (2000-2001)
Region
Population
Tigray
Afar
Amhara
Oromia
Somali
Ben-Gumuz
SNNPR
Gambella
Harari
Addis Ababa
Dire Dawa
3,797,000
1,243,000
16,748,000
23,023,000
3,797,000
551,000
12,903,000
216,000
166,000
1,570,000
330,000
Potential health
service coverage (%)
66.24
52.70
43.50
46.91
30.55
86.21
55.06
87.96
114.46
93.39
51.52
National
65,344,000
51.24
Outpatient visits per
capita per year
0.80
0.23
0.15
0.28
0.04
0.76
0.20
0.80
0.79
0.55
0.28
0.27
Source: FMOH (1993 EC), Health and Health- Related Indicators.
53
Potential Health Service Coverage
114%
120%
100%
80%
93%
88%
86%
66%
53%
60%
55%
47%
44%
52%
51%
31%
40%
20%
re
l
ti o
Di
Na
Da
ab
Ab
s
Ad
di
G
na
wa
a
ri
ra
Ha
ll a
am
be
NP
R
uz
um
G
Be
n-
SN
al
i
m
So
O
Am
ro
ha
m
ia
ra
ar
Af
Ti
gr
ay
0%
Source: FDRE MOH, 2000-01.
Annual Outpatient Visits per Capita
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0.84
0.74
0.54
0.53
0.49
0.33
0.16
l
Na
t io
na
wa
Da
a
re
ab
Ab
s
di
Ad
Di
re
Ha
ll a
be
am
G
NP
R
um
G
nBe
SN
uz
al
i
m
So
ro
m
ia
ra
O
Am
ha
ar
Af
ay
gr
ri
0.1
0.09
Ti
0.29
0.26
0.24
Source: FDRE MOH, 2002-03.
54
HEALTH CARE FINANCING
Health services in Ethiopia are financed by four main sources: 1) government (both federal and
regional), 2) bilateral and multilateral donors (both grants and loans), 3) non-governmental
organizations, and 4) private contributions, both from out of pocket payments and through
private sector investment in health services.
Total Health Expenditures
According to the second NHA conducted using 1992 EFY data, the total health expenditure in
EFY 1992 was estimated to be ETB 2.9 billion (355.5 million USD). The first NHA conducted
using EFY 1988 data estimated the total health expenditures at ETB 1.45 billion or 230 million
USD. The total nominal health expenditures double if one looks at domestic currency, and
showed an increment of about 55 percent in USD. The per capita health expenditure has
increased by about one dollar from 4.5 USD to 5.6 USD per person per year between the two
time periods.
Total and per capita health expenditure by major source classifications (EFY 1992)
Per
capita USD
Percent
118,731,993
1.87
33%
471,443,092
57,178,404
0.90
16%
1,057,826,612
128,297,219
2.02
36%
NGOs (local
and intl)
290,082,327
35,182,285
0.55
10%
Private
132,849,569
16,112,499
0.25
5%
2,931,161,723
355,502,340
5.60
100%
Source
Amount in Birr
Government
978,960,122
Bilaterals &
Multilaterals
Households
Total
Amount in
USD
Source: Ethiopia’s second NHA draft report, 2003.
55
Health Care Expenditures
Private , 5%
,
NGOs, 10%
Government ,
33%
Household ,
36%
External
donors, 16%
Source: Ethiopia’s second NHA draft report, 2003.
The major source of funding for health remains the same as in the first round in that households
are still the lead financing source, accounting for 36% of total health expenditures, but their role
significantly declined from about 53% in the first round. Government financing from taxes,
general revenue and loans stands next, covering 33% of total health expenditures. The rest of the
world through bilateral and multilateral assistance comes third with 16%. Since financing from
the rest of the world mostly comes through the government, the second round shows that about
50% of health expenditures are financed from public sources. The share of NGOs has also
increased to about 10% from the previous 7%. If one looks at per capita expenditures,
households spend $2.02, government $1.87, the rest of the world $0.9, NGOs $0.55 and the
private sector $.25 USD per person per year.
Functional distribution of expenditures
Ethiopian health expenditures are dominated by expenditures on curative care. Expenditures on
pharmaceuticals (including vaccines) consumed about 39% of total health expenditures.
Curative care as a service took about 19% of total expenditures. If we exclude vaccines from
pharmaceutical expenditures and consider the rest as curative treatment, then the share of
curative care increases to about 57% of total expenditures. Overall, expenditure on primary care
accounted for about 16% and if we include vaccines, sanitation, and environmental health
functions that are categorized under health related, it increases to 18%. The share of health
administration stands at a reasonable level of 8%.
56
Functional breakdown of expenditures
Function
Amount in Birr
Per
Amount in USD Capita USD Proportion
Curative care
549,681,727.06 66,667,482.55
Pharmaceuticals (excluding
vaccine)
1,123,670,832.92 136,283,056.10
1.05
19%
2.15
38%
Vaccine
39,955,530.85
4,845,958.17
0.08
1%
PPHC
460,386,264.69
55,837,390.54
0.88
16%
Health administration
221,213,385.29
26,829,597.52
0.42
8%
Capital formation
440,756,737.45
53,456,647.10
0.84
15%
Training
57,455,171.64
6,968,380.91
0.11
2%
R&D
21,498,331.34
2,607,399.08
0.04
1%
Sanitation &envt health
16,543,741.54
2,006,487.66
0.03
1%
2,931,161,722.78 355,502,399.63
5.60
100%
Total
Source: Ethiopia’s second NHC, draft Report, 2003.
Government Health Expenditures
Training, 2%
Curative care ,
19%
Drugs, 38%
,
Environmental
health, 1%
Capital, 15%
Administration,
8%
Vaccine, 1%
PPHC, 16%
R&D, 1%
Source: Ethiopia’s second NHC, draft Report, 2003.
57
Outpatient and inpatient services, without pharmaceuticals, consume as much as PPHC. In EFY
1992, the expenditure for outpatient and inpatient services (including rehabilitative care)
amounted to ETB 549.7 million or about 22% of total health expenditures on service delivery.
The major source of financing for these treatments comes from household out of pocket
expenditures. In contrast, Birr 517 million or about 21% of total health expenditures on health
service delivery was used for primary health care activities. If one looks at the detailed
compositions of PPHC, about 41% was spent on mother and child health while 29% was used for
expansion of primary health care and 12% for controlling communicable diseases. Other
services like IEC, non-communicable disease control, sanitation and environmental health
together consume 18% of resources.
Breakdown of PPHC Expenditures
Others
18%
MCH
41%
Expansion
29%
CDC
12%
Source: Ethiopia’s second NHC, draft Report, 2003.
Deleted: ¶
¶
¶
¶
¶
¶
58
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59