Saving the innocent: Ethiopia is keeping the promise it made to its children

By: Dr KesetebirhaneAdmasu, Minister of Health, Federal Democratic Republic of Ethiopia; Co-Chair, A Promise Renewed and the African leadership for Child Survival Initiative

Dr Peter Salama, UNICEF Representative to Ethiopia

Health extension worker Bruktawit Mulu
Bruktawit Mulu, left, Health Extension worker, counsels Wagage Finte, 35, with her infant son Eshetu Belish at home in the Kerer Kebele, Machakel distict, West Gojjam zone, Amhara region of Ethiopia, 2 July 2013. ©UNICEF Ethiopia/2013/Ose

In 2000, the world made a promise to reduce deaths among children under-five by two thirds by 2015, compared to 1990, the benchmark year for the Millennium Development Goals (MDGs). With less than 460 days left until the deadline, great progress has been made in Ethiopia.

It is worth remembering that, just last year, Ethiopia achieved the child survival millennium development goal (MDG 4), three years ahead of time by cutting under-five mortality from 204per 1000 live births in 1990 to 68 per 1000 live births in 2012.

New UNICEF figures published last week in the Committing to Child Survival: A Promise Renewed report, show that Ethiopia continues to make progress in preventing deaths among children. Presentlythe number of under-five child deaths has fallen to 64per 1000 live births and more children are living to celebrate their fifth birthday.

Ethiopia’s experience and success can show world leaders some important lessons.

The first lesson is about leadership and country ownership. Governments need to lead and countries own the commitment. It may seem obvious but, despite much rhetoric, too often development priorities are still determined in Geneva or Washington rather than by the governments most concerned. By incorporating the MDGs into its national development plan, the Growth and Transformation Plan, and setting ambitious, national targets, the Government of Ethiopia has demonstrated strong leadership and country ownership, and consistently backed its decisions with high level commitment.

Second, evidence needs to determine policy choices. About 10 years ago, in order to address the increasing urban-rural gap in access to health services, the Government of Ethiopia launched the Health Extension Programme. The package of interventions wascarefully tailored to the major causes of mortality and morbidity, with epidemiology determining the priorities.

The early years were challenging, because delivering services to more than 80 million people in a vast and diverse country is not an easy task. However, year after year, the system has becomestronger and stronger, presently deploying over 38,000 government salaried rural and urban health extension workers. Starting from a focus on basic health promotion and disease prevention, incrementally high impact curative services have been integrated into the programme.

Side by side, multi-sectoral agendas have been incorporated to address root causes of childhood disease, such as food and nutrition security and water and sanitation. Community-based treatment of diarrhoea, pneumonia, malaria, severe acute malnutrition and, most recently, new-born sepsis and the inclusion of new vaccines are all now central components.

That leads us to the third lesson: that governments need to resource the plan and do so at scale. By putting the 38,000 mainly rural women on the government payroll, the government not only backed up its decision to bring health services to the doorstep of its rural people with real resources, but also sent a strong message that these health extension workers (HEWs) were here to stay. Sustainability was virtually guaranteed. The HEWs have since become a cornerstone of the health system. These young women represent the true heroes, or more precisely heroines, of this MDG story.

Members of the health development army-Kilte Awlalo District-Tigray Region
Members of the health development army who have come to discuss health service related issues with the Japanese Ambassador and UNICEF Representative to Ethiopia at a health post in Kilte Awlalo District, Tigray Region ©UNICEF Ethiopia/2012/Getachew

Prompted and encouraged by the success of the Health Extension Programme, Ethiopia has recently embarked on a new social mobilisation scheme which is referred to as Health Development Army (HDA).  HDA is a network of women volunteers organised to promote health, prevent disease through community participation and empowerment. The HDA has effectively facilitated the identification of local salient bottlenecks that hinder families from utilising key Maternal, Neonatal and Child Health Services and to come up with locally grown and acceptable strategies for addressing ongoing issues.  To date, the Government has been able to mobilise over three-million women to be part of an organized HDA.

But Ethiopia could not have done this alone. The fourth lesson is that international partners need to support the vision. In the concerted effort to save children’s lives, partners have played a key role. The bilateral government donors, the World Bank and UN agencies, NGOs and civil society, philanthropic foundations, and the private sector, have all played a key role through their funding, programmatic, operational and technical assistance, and their belief that Ethiopia could achieve its goals. Thanks to these coordinated efforts, Ethiopia has slashed child mortality rates. In 1990, 1 in 5 Ethiopian children could be expected to die before reaching the age of 5. Today, the figure is closer to 1 in 15. Well over 1 million children have been saved during this period.

While we deserve to celebrate our accomplishment, we also need to remind ourselves that we have a long way to go, because close to205,000 children under five years of age are still dying every year and nearly 43 per cent of these children are dying in their first 28 days of life. This means that more than 500 Ethiopian children die every day, mostly from preventable diseases. We also need to further address disparities in the delivery of services between rich and poor, urban and rural, pastoralist and agrarian areas, able and disabled and women and men. We also have to work hard to increase the quality of services rendered.

But Ethiopia has shown that a poor country, once only associated with famine and conflict, can become a leader for global health and development. The country is on a trajectory to bend the curve and achieve a major goal of “A Promise Renewed”, which is reducing the level of child death to 20 under-five deaths per 1000 live births by 2035.​  For Africa, there are no longer any excuses.

Health Extension Workers: Key to Reducing Malnutrition in Ethiopia

Eneayehu Beyene and Tena Esubalew, helth extention workers Amhara rigion of Ethiopia.
Eneayehu Beyene and Tena Esubalew, Health Extension Workers in Delma kebele of Machakel woreda Amhara region of Ethiopia. Preparing their monthly report on community based nutrition activities to submit to the health. ©UNICEF Ethiopia/2014/Tsegaye

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

Breast Feeding-Tena Esubalew Health Extension Worker coaches Etenesh Belay positioning of the child for effective breast feeding
Tena Esubalew Health Extension Worker coaches Etenesh Belay positioning of the child for effective breast feeding Amhara rigion of Ethiopia. ©UNICEF Ethiopia/2014/Tsegaye

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.

Breast Feeding-Yedeneku Aynalem 38 with her son Barkelegn 10 month
Yedeneku Aynalem 38 with her son Barkelegn 10 month, who is benefiting from community based nutrition Machakel woreda Amhara region. ©UNICEF Ethiopia/2014/Tsegaye

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.

Sudan and its partners learn how Ethiopia brings nutrition and health to doorstep of its people

By Sylvie Chamois

Team of visitors from Sudan getting a briefing on the Health & Nutrition programme
Salwa Abdelrahim Surkati Hassan, FMOH nutrition director, Nada Yahya Omer Hamza, WHO IMCI coordinator and Naglaa Osman Khidir Babikir, UNICEF nutrition officer visiting Tula health post in Babile woreda, East Hararghe zone of Oromia region ©UNICEF Ethiopia/2014/Gemeda

From the 24th to the 28th of March 2014, the Ethiopian Federal Ministry of Health (FMOH) and UNICEF Country Office had the pleasure to host a team from Khartoum composed of the Sudanese FMOH (planning, nutrition and IMCI[1] departments), WHO, WFP and UNICEF.

The objective of the visit was to learn how Nutrition has been integrated in the Health system and how the Government of Ethiopia managed to bring Health & Nutrition services to the doorstep of its people.

Following an opening meeting with the State Minister of Health, H. E. Dr Kedede Worku, the team proceeded directly to the domestic airport heading to East Hararghe zone of Oromia region. They were introduced to the programme by the Zonal Health Department’s head, Ato Ali Abdulai, before visiting Babile and Gursum woredas.

In the two districts, they were able to visit and discuss with the one-to-five network, a team of Health Development Women; female Health Extension Workers working in health posts; Health Workers in health centres and finally, nurses and doctors in Bessidimo hospital.

Team of visitors from Sudan getting a briefing on the Health & Nutrition programme
Team of visitors from Sudan getting a briefing on the Health & Nutrition programme in Babile health centre, Babile woreda, East Hararghe zone of Oromia region on March 25, 2014
©UNICEF Ethiopia/2014/Gemeda

In Harare, Frehiwot Mesfin presented a project managed by Haromaya University, with the support of UNICEF and FAO, to produce complementary food for children under two years of age using exclusively locally available ingredients.

Back in Addis Ababa, the team had the opportunity to visit the local producing factory for Ready-to-Use Therapeutic Food[2], Hilina PLC.

On the last day, during the debriefing meeting at the FMOH with Ato Birara Melese, head of the Nutrition unit, the visitors appreciated having been able to see all levels of the Health system, from the Federal Ministry down to the households with the one-to-five network. They said that they were impressed by the very well organised and functional system and confident that they can adapt the Ethiopian experience to integrate child and maternal Health & Nutrition to the lowest level. Sudan is working hard to accelerate the achievement of the Millennium Development Goal 4 – to halve child mortality by 2015.

38,000 health extension workers bring health services to the doorstep of rural Ethiopians

By Sacha Westerbeek

Ethiopia, 2012. A young girl in the arms of her caregiver – interacting with UNICEF’s Sacha Westerbeek and Health Extension worker in Romey Village, North Shoa Zone, Amhara Region. Photo credit: UNICEF Ethiopia/2012/Getachew

Even before I joined UNICEF Ethiopia in June 2011, I had heard about its impressive health extension programme: health care is decentralised and over 30,000 health workers are deployed throughout the country and on Government payroll. A great story to tell!

By now, I’ve visited many health posts, run by these amazing women, generally in their early twenties from rural communities, dynamic and dedicated. Being educated and given the opportunity to work in their community, you can really see how this transforms their lives and status within the society in addition to the gains made in terms of health care. When one speaks about health in Ethiopia, I think about the health extension workers. To me, these young women represent the true heroes, or more precisely heroines, and one of the reasons why Ethiopia is doing so well in terms of its health indicators.

“Ethiopia Achieves the Child Survival Millennium Development Goal (MDG), three years ahead of time.” If you don’t follow global health debates closely, you may have missed this news, which broke the news in September 2013 and seriously hit the roofs in this nick of the woods.

Ethiopia, 2012. Health Extension Worker Haimanot Hailu and her partner walk through Romey Kebele (sub-district) North Shoa Zone, Amhara Region, for home visits carrying vaccine carriers. ©UNICEF Ethiopia/2012/Getachew

How did this happen in terms of policy choices? Around ten years ago, in order to address the increasing urban-rural gap in access to health services, the Government of Ethiopia launched the Health Extension Programme (HEP). This package of interventions was carefully tailored to the major causes of childhood mortality and morbidity – the epidemiology determined the priorities. The early years were not easy and, at several junctures, the system almost collapsed under the weight of expectations and the urgent imperative of delivering services to more than 80 million people in a vast and diverse country. And yet, every year, starting from a focus on basic prevention (insecticide treated nets, vaccination), the system has become stronger and stronger. Incrementally, best practice in curative-oriented, primary health care from around the world has been integrated into the HEP. So too has a multi-sectoral agenda that attempts to address root causes of childhood disease, such as food and nutrition security and water and sanitation. Community-based treatment of diarrhoea, pneumonia, malaria, severe acute malnutrition and, most recently, new-born sepsis and the inclusion of new vaccines, are all now central components.

Today, 38,000 health extension workers are deployed bringing health services to the doorstep of its rural people with real resources – becoming the cornerstone of the health system. Through my visits throughout this enormous country, I can see that the programme is sustainable and that the bilateral government donors, the World Bank and UN agencies, NGOs and civil society, philanthropic foundations, and the private sector, have all played a key role through their funding, their programmatic, operational and technical assistance, and their belief that Ethiopia could achieve the goals. Ethiopia could not have done this alone.

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