AMHARA REGION, 3 April 2014- Tena (meaning health in Amharic) Esubalew, 25, and Eneayehu Beyene, 27, are the heroines of Delma kebele as they have become the health confidants of the community. Delma Kebele (sub district), which is located in Machakel woreda (district) in the Amhara Region in northwest Ethiopia. Delma is a community 10 kilo meter from an asphalt road with a population of 4,733. As part of the EU funded Africa Nutrition Security Project (ANSP), UNICEF launched a community health programme (2012-2015) in 20 districts across three regions of Ethiopia to help the Government boost the nutritional status of children under two in communities like Delma where child malnutrition has been alarmingly high.
Key to the programme’s success has been the role of community Health Extension Workers (HEWs). From Delma, Tena and Eneayehu have received intensive training with the support from UNICEF on nutrition so they can effectively carry out health extension duties.
“It is clear to us that three years ago no-one in this community could identify if a child was malnourished or not, this problem has been recently solved through the programme’s awareness strengthening on nutrition,” says Eneayehu
Eneayehu and Tena spend most of their days walking between households in Delma, visiting young mothers in the community and engaging them about the importance of child nutrition. They are trained to identify mild and moderate malnutrition and also growth faltering – based on which they provide age-tailored counselling. Additionally, they can diagnose if a child has Severe Acute Malnutrition (SAM) with or without complications. If a child is suffering from SAM with complications then the health extension workers will quickly have them referred to a health centre in the nearest town.
The health post where Tena and Eneayehu work is situated on top of a hill surrounded by open fields and grazing livestock. It is a busy hub frequented by the community’s young mothers, who are eager to learn about their children’s health status. The walls are plastered with graphs charting the health and development of the community’s under-five children. It is here that growth monitoring of all the community’s children under-two-years is conducted on a monthly basis and compared with World Health Organisation growth standards.
Yideneku Aynalem, 38, reaches up to a mud shelf in her hut and retrieves an illustrated booklet. “This is a very important document”, she says carefully opening the page to reveal a colourful chart. The HEWs have distributed the materials printed with the support of UNICEF throughout the community to enable lactating mothers to track their child’s weight. Yideneku points to a graph and traces with her finger a green upward curve signifying the trajectory of a healthy child’s development based on optimum height and weight measurements. She explains with a smile how her 10 month old child Barkelegn Walelign’s growth has started to correlate with the green line on the chart. “I have been given the knowledge and it is now my responsibility to keep putting this learning into action so that my child can remain strong and healthy”, she says. Yidenku’s child is one of 270 children under-two years of age that have benefited from the EU-UNICEF supported package of high impact interventions in Delma.
The community results are encouraging: the rate of underweight young children has reduced from six per cent to one per cent in two years. “At the start of the programme, six children in the village were diagnosed with Severe Acute Malnutrition (SAM) – this year only two children suffered this extreme health condition”, says, Tena.
TERGOL, AKOBO WOREDA (GAMBELLA REGION), 15 March, 2014- As the searing heat of the afternoon sun begins to ease, a group of women carrying jerry cans and plastic buckets start to descend into a small compound where they have access to clean water from two water points. The small compound is one of two sites where UNICEF has installed two emergency water treatment facilities (EMWAT kits) through its implementing partner, ZOA International, in Tergol town, in the Akobo district of the Gambella region, western Ethiopia.
Tergol is a small town by the Akobo River that marks the border between Ethiopia and South Sudan. Tergol has been under the spotlight since mid-December last year after thousands of South Sudanese asylum seekers crossed over into the town after being displaced by conflict in Africa’s youngest nation.
According to UNHCR, close to 66,000 asylum seekers crossed into Ethiopia by the beginning of March 2014. Akobo has received 34 per cent of this number, which is the second largest arrival rate after Pagak where 33,000 South Sudanese civilians displaced by conflict have entered. These asylum seekers are in a critical situation and need immediate humanitarian assistance including the provision of clean drinking water and sanitation services.
In Tergol, the host community has entirely depended on the Akobo River for its water needs as there has never been a facility to provide safe drinking water. However, this situation has been recently improved. With UNICEF’s support, EMWAT kits have been built and are now supplying clean drinking water to the Tergol community as well as to the thousands of South Sudanese asylum seekers. Water from the nearby river is purified and supplied by the first reservoir built by the emergency kit, the purified water is then transferred into a second reservoir where it is chemically treated before it is reticulated to the water access points. Each EMWAT kit has a capacity for providing 20,000 litres of clean water and the kits can be re-filled every two hours depending on the rate of demand.
Safe water for mothers and children
While the women gather around the water points, they talk to each other as clean water fills their buckets and jerry cans. The women then help one another to balance the vessels on top of their heads.
When it is Nyathak Minyjang’s turn, a 25-year-old mother of four, she places her plastic bucket under the tap and holds the hose down to pour in the clean water. Prior to the response, Nyathak had lived on the South Sudan side of Akobo before coming to Tergol with her four children. Her only previous access to water was a river. She never imagined that she would have access to clean drinking water from a tap. “We used to drink water from a river. My children would regularly get sick and I would get sick too”, she says. “The quality of the water here is very nice.” Nyathak comes to the water point at least three times a day. She fetches water for cooking, bathing and drinking. Most importantly, she applies the lessons she learnt about personal hygiene from community hygiene promoters. She is also keen to keep her children clean.
Nyarout Gazwech, a 21-year-old mother of two boys, is also very happy about the supply of clean water. She came from the South Sudan city of Malakal a month and a half ago, leaving her two brothers and her mother behind when the conflict intensified. During her long trek to Tergol, she and her children had no option but to drink unsafe water. “My children were having diarrhoea after drinking the river water. Here we have clean water and my boys will not get diarrhoea again,” she says.
Comprehensive WASH approach
UNICEF in partnership with UNHCR, the Government Administration for Refugee and Returnee Affairs (ARRA), the Gambella Region Water Bureau, and its implementing partner ZOA supports the provision of safe water to the host community and asylum seekers in Tergol. UNICEF’s response has followed its Water Sanitation Hygiene (WASH) strategy by increasing equitable and sustainable access to safe water and basic sanitation services, as well as promoting improved hygiene in Tergol.
“We are providing clean water to the asylum seekers and to the host community. Furthermore, we teach them about safe hygiene practices such as the importance of hand washing and using latrines,” says Nigussie Yisma of ZOA who is coordinating the WASH interventions in Tergol.
Apart from Tergol, UNICEF also supports WASH interventions at the entry point in Pagag and in the Lietchor refugee camp. One EMWAT kit has been installed at the Pagag entry point and is providing clean drinking water to the asylum seekers and the host community. Similarly, five shallow water wells have been drilled in the Lietchor refugee camp to increase access to a sustainable source of clean water for the refugees. Moreover, water purification chemicals and emergency sanitation facilities are being distributed while hygiene promoters continue teaching the community and asylum seekers about safe personal and environmental hygiene practices.
Local capacity building
When the emergency response was launched in January 2014, community hygiene promoters were trained and they taught the community and asylum seekers about the benefits of safe hygiene practices. Furthermore, 40 communal latrines have been built in close proximity to the host community as well as where asylum seekers are staying.
“We have been taught about personal hygiene and the importance of hand washing before cooking and after using the toilet,” says Nyathak “They [hygiene promoters] also told us this can prevent our children from getting diarrhoea.”
In order to keep the facilities running smoothly, local water technicians have been trained on the management and maintenance of the water facilities to safeguard smooth operation. The water technicians are responsible for regularly monitoring the water levels and the quality of the drinking water.
Water purification chemicals and accessories are also readily available to the community.
Clean and safe drinking water is essential for life and is also bringing renewed hope for people like Nyathak and Nyarout after being displaced by the conflict in South Sudan.
HAROJILA FULASO, OROMIA REGION, 1 February 2014 – “The health extension worker told us to wash our hands with soap and if we don’t have soap, we can use ashes. So, when I have not been able to buy soap, this is what we use to disinfect our hands”.
Ms Shure Gore takes the can of ashes and hands it to United Nations Deputy Secretary-General Mr Jan Eliasson. He gently takes out some of the greyish substance and rubs it before rinsing it off with the water from the jerry can attached to the tree, next to the family’s’ latrine. “My hands are clean,” he exclaims while the family is observing his actions closely.
In Ethiopia’s Oromia region, the hygiene and environmental sanitation activities are the main focus for household and community level interventions. The woreda (district) latrine coverage is about 70 per cent. In Harojila Fulaso, however, 80 per cent of the households have reached the status of becoming a “model household.”
The model family is the approach adapted by the Health Extension Programme to improve household practices. After 96 hours of training and adopting 12 of the 16 packages, a family graduates to become a so-called model family. The health extension package is categorised under three major areas and one cross cutting area: namely Hygiene and environmental sanitation; family health services; disease prevention and control; and health education and communication.
The Lemma-Buchule family, in which Ms Shure Gore is the driving force, has a latrine with hand washing facilities and dry and liquid waste disposal pits. In addition, the household has adequate aeration and light and the animals are kept separate from the living area – to name a few requirements of becoming a model household.
The family lives a couple of minutes walk away from the health post. Ms Abebech Desalegn is one of the two health extension workers running the facility. The health post provides services to 736 households and 3,532 inhabitants – ensuring that health care is delivered at the doorstep. “I know Shure and her family very well,” says Ababech. “The family consists of 10 members, including eight children between the ages of 3 and 22 years old. They come here when they need vaccine, a new mosquito net or when they are ill.” She has assisted the household in reaching the status of “model household”. “They now inspire others to do just like them, they are an example to the community,” Ababech explains.
Health extension workers deliver health care at the doorstep
Ababech is a government salaried and trained health worker, under the Health Extension Programme, an innovative community based programme which started in 2003. To date, 38,000 health extension workers have been deployed in nearly all rural villages. The programme aims to create a healthy environment and healthy living by delivering essential health services to communities.
UNICEF supports the Health Extension Programme in different dimensions. Training of HEWs to improve their technical competencies in delivering health and nutrition services, procuring and distributing of vaccines, medicines and supplies, ensuring availability of job aids at health posts, have all led to increased coverage of health and nutrition services at community level.
In addition to prevention and health promotion services, health extension workers are also now involved in case management of pneumonia, diarrhoea and severe acute malnutrition in more than 90 percent of health posts.
The Deputy Secretary-General, Mr Jan Eliasson studies the charts on the wall of the small health post. “You are doing an excellent job here,” he says while impressed with the statistics and service delivery provided by this health extension post.
Abebech explains that she is required to split her time between the health post and the community. Community outreach activities include working with model families, community groups or households. “Every day I’m very busy she continues. When I’m at the health post I provide basic services such as: immunisation; health education; antenatal care; family planning; delivery and postnatal care; growth monitoring and community treatment of severe acute malnutrition; diagnosis and treatment of malaria, pneumonia and diarrhoea; treatment of eye infections; treatment of selected skin problems; Vitamin A supplementation; first aid and referral of difficult cases… just to name a few of my daily activities.”
In addition, this young health worker, who has worked at this health post for the last seven years, has done thirty deliveries and many more postnatal checks. “I’m happy UNICEF provided delivery beds, but I also need clean water. Every single day I walk to the nearest water point, because I need clean water for the latrine and health interventions.”
WASH interventions at Health Post level
To date, UNICEF has provided a total of 160 health posts with a complete WASH package. This includes: providing capacity in the design of WASH facilities, construction of water supply and sanitation facilities and hygiene promotion to health institutions through construction and disseminating information on hygiene and environmental sanitation. In addition, WASH interventions at the health post level include: the provision of a hand-washing stand; a septic tank; incinerator; placenta pits; general solid waste and sharp pits.
“I’m lucky having clean water nearby,” says Ababech. “But too many of my colleagues really struggle, especially those who work in remote and dry areas.”
Ethiopia has been an active participant in the Sanitation and Water for All Partnership. In 2013, the Ethiopian Government, with support from UNICEF, was able to establish a Sector-wide Approach termed the ONE WASH National Programme with a dedicated budget line for sanitation in the Government of Ethiopia’s treasury.
Although good progress is underway in the area of water, sanitation and hygiene, still some challenges remain. In 2010, out of a population of over 80 million, about 46 million were without access to improved water supply and sanitation and Ethiopia had the highest number of people (38 million) practicing open defecation among African countries. The lack of access to adequate clean drinking water and sanitation services has a dramatic impact on the lives of people, especially women and girls, and undermines efforts to improve health, nutrition and education outcomes.
Mr Jan Eliasson underlines the need for clean water and sanitation. “We really must act now. We have to talk about sanitation and improving access to toilets and clean water. We also must change attitudes and behaviours,” he emphasises with passion.
Ms Gore fully agrees. “Since I have a latrine and we wash our hands at critical times, I see less disease in my family. The children go to school and we work on the land – for this, we need to be healthy.”
DAASANACH, Southern Nations, Nationalities, and People’s Region (SNNPR), 18 December 2013 – Omorate village in South Omo Zone of the SNNPR is a semi-arid area where the Daasanach tribes live. Their houses are dome-shaped made from a frame of branches, covered with hides and patch works. These houses are scattered along the site where the Omo River delta enters Lake Turkana of Kenya. Most tribes in South Omo are pastoralists. In Omorate too, the people’s lives are bound to the fate of their herds of cattle, sheep and goats that they raise.
Children play a critical role in the pastoralist lifestyle. Boys as young as 6 years old start to herd their family’s sheep and goats, while girls marry very young so parents get additional livestock through dowry. Therefore, parents do not send their children to school. In the Daasanach tribe, education is considered as a luxury. For teachers of Alkatekach Primary School this is their biggest challenge. They use the Alternative Basic Education (ABE) system to cater for the need of the children. The Alternative Basic Education system responds to the urgent need for an education that suits the special needs and constraints of pastoral life. It provides flexible school hours, allowing pastoral children fulfil their household responsibilities of herding cattle to find water and pastures while still finding time for school.
Meseret Chanyalew, Director of the school, explains there is an increase in the number of children from last year because of the continuous effort to enroll and retain students. “We enroll students throughout the year to encourage children to come to school. We also discuss with the community to create awareness on education by going house to house to convince parents to send their children to school.”
Located five kilometers from Omorate town of Kuraz district, the Alkatekach Primary school has only 79 registered students for the 2013/2014 academic year and the highest grade these students can reach is fourth grade. This is because there are no classes set up above the fourth grade.
The Lucky ones in the family go to school
14 years old Temesegen Koshme is a third grade student in Alkatekach Primary School. He is sitting in a class exercising the conversion formula for different measurements. His favorite subjects are mathematics and social science. Unlike Temesgen, children his age are taking care of family cattle or are married off. “I prefer coming to school than looking after my parents’ cattle. Alkatekach is where I grasp knowledge,” says Temesgen, “When I go to school in the morning my brother and sister look after the cattle. After school, I go straight to the field to take over”.
Temesgen’s parents told him that his younger sister is waiting to be married off, “I tried to explain that she has to come to school, but they did not listen to me” says Temesgen concerned about his sister’s future. Temesgen is one of the lucky ones to be enrolled this year. For him school is his happiest place.
Agure Amite, a father of twelve, living in Omorate village, sends two of his children to Alkatekach Primary School. When asked why the others do not go to school he says, “Some of them have to look after my cattle and others are not ready for school because they are below 10 years old.” Some parents in the Daasanach tribe send their children to school when they reach age 10. However, nationally children start school at age 7.
Alternative Basic Education (ABE) accommodates the pastoral children
The 2012 study on situation of out of school children in Ethiopia shows that SNNPR has 46.5% of out of school children making it the third highest region after Oromia (49.2%) and Amhara (48.7%).
With the support of UNICEF and the generous donation of US$240, 000 received from ING the Daasanach tribe now has ABE centers close to in their area. In addition to the construction of ABE centers, ING’s support also helped to provide furniture, training for ABE facilitators and education materials to pastoralist and economically disadvantaged children. For Meseret and her colleagues at the Alkatekach Primary School, this means increasing the schools capacity up to sixth grade means that children like Temesgen will be able to receive education within their community for the next two years.
DERA DISTRICT: AMHARA REGION, 30 October, 2013 – It is early Thursday morning and Gibtsawit Health Post, found in a rural village of Gibtsawit Mariam located 42 kilometres from Bahirdar, is busy with patients. The small room is crowded with mothers who are there to check their babies’ growth; pregnant women having their antenatal care and men and women of the community who are receiving malaria treatment. Today is a special day, because the health extension workers of the health post are welcoming Mr Paul Rochon, Deputy Minister of International Development, Foreign Affairs, Trade and Development Canada (DFATD) and Dr Peter Salama, UNICEF Representative to Ethiopia.
Misa Wondimagegn, a 25 year old health extension worker, supports the community in Gibtsawit village of Dera district with curative and preventative health and nutrition services. Misa and her colleagues Meseret and Hagere are supported by the health development army (a network of one volunteer to five Households) attend the 13,366 population of the kebele.
Misa has been working at Gibtsawit Health Post for seven years. “It was just when I finished tenth grade that I had the opportunity to join the training for health extension workers. It was hard convincing people to allow me to monitor the growth of their baby and take my advice about what to feed their children,” she says. “We travelled long distances to reach as many households in the village as possible. In each of our visit we tried to improve the health seeking behaviour of the community and eventually encouraged them to go to the health post.”
Growth Monitoring and Promotion is the cornerstone in the Community Based Nutrition Programme. It creates a platform for the health extension workers to contact the caregivers and check the nutritional status of children, detect growth faltering at early stage and provide counselling on Infant and Young Child Feeding practices (IYCF).
“Now, the situation has changed a lot: we have mothers who bring their children for check-up and pregnant women who come for antenatal care. The support we get from UNICEF and the Canadian Government has increased the variety of treatments we provide for the community. We have outpatient treatment for children diagnosed with severe acute malnutrition and for pregnant women we give antenatal care and supply iron –folate. We promote good Hygiene and sanitation and we also give treatment for common childhood illnesses like pneumonia malaria and diarrhoea for the community,” Misa explains with smile on her face.
Support in Action
Since 2007, the Canadian Government has been supporting UNICEF Ethiopia’s interventions in Child Survival with Vitamin A and Zinc Supplementation and Integrated Health System Strengthening as well as routine immunization. Dera is one of the 100 UNICEF supported districts implementing the preventive and curative nutrition interventions. It is implementing Community Based Nutrition (CBN), integrated with other Community Maternal New-born and Child Health Interventions (CMNCH) to prevent child malnutrition, focusing on the first 1000 days: the time between conception and when a child turns two years of age.
In August 2013, 1,247 children attended the monthly Growth Monitoring and Promotion session in Dera enabling Misa and the other 78 health extension workers in the district to identify nutritional status of the children, detect early growth faltering, help the caregivers visualize the status and counsel them on appropriate age specific feeding messages using the Family Health Card as a counselling aid and refer children for further care in a timely manner whenever needed.
Haimanot Andarge, a 20 year old mother of baby girl Azeb, is one of the many mothers in the district who got follow ups from Misa and her colleagues during their pregnancy. “Misa used to come to my house regularly ever since she knew I was pregnant. She gave me vaccines and other supplements which was important for my baby. And when my labour began my husband took me to the health post. Misa encouraged me to deliver at Hamusit Health Centre which referred me to Bahirdar Hospital in time as my delivery was complicated. My baby was delivered safely because the health post was in our village to identify my condition,” Haimanot remembered. Her eyes reflect her fear of what might have happened. “ Azeb, is going to be two this year and Misa still follows up on her regularly and gives me advice on what to feed her,” adds Haimanot.
Integrating approaches to combat malnutrition
One of the challenges to the health extension workers was what kind of advice to give to families with low income, regarding additional food for their children. “Health Extension Workers usually explain to families to use variety of cereals, animal protein and vegetables. Those who have money would buy and others barter with what they have produced,” explains Ato Worku Endale, Head of the Dera District Health Office. “Recently we have been integrating the health extension programme with the agriculture extension programme to support farmers on what to produce and how they can support their children and family with variety of food items. In addition, the safety net programme that has been implemented in this particular community allows families with low income to be involved in the income generating activities.”
With the integrated multisectoral approach of the government of Ethiopia and the support of UNICEF and partners such as DFATD, the hard work of health extension workers like Misa and colleagues is paying off.
Revolutionizing treatment of Severe Acute Malnutrition (SAM)
The support from UNICEF and the Canada Government that started the preventive nutrition programme of Community Based Nutrition linked with provision of WASH facilities has helped reduce the number of children who are malnourished. According to Dr. Peter Salama, the collaborative work of all stake holders, the availability of treating health posts within the community have made saving a child easier than ever before.
At the end of the visit the team eagerly waits to hear from Misa and her colleagues on their response to the fundamental question of how many children were lost to malnutrition recently. “There were 27 children diagnosed with Severe Acute malnutrition in July 2012- August 2013. They were treated with the Out-patient Therapeutic Programme (OTP) and 20 have been cured and seven are still on follow up with good prognosis but we have not lost a single child,” Misa explained boastfully.
“It was not easy to change the attitude of the community. When we started, there was no one before us working with the community reaching every household door to door. We started from nothing. But with the support of donors like UNICEF and the Canadian Government, I cannot even remember the last time a child died in the community for the last four years,” Misa reminisces.
“It makes me realise that it was not for nothing that I worked so hard at the beginning. I have brought change in my community.” Misa concludes.