AMHARA REGION, Ethiopia, February 2016 – Moyanesh Almerew, a Health Extension Worker in Arara Kidanemeheret Kebele (sub-district) in Amhara Region can testify to how bad the current drought in Ethiopia is for children. She is one of thousands employed as part of the nationwide Health Extension Programme, a community-based programme bringing basic health services to the doorstep of Ethiopia’s large, rural population. According to Moyanesh, they have had seen many more cases of severe acute malnutrition among children this year as compared to previous years and the cases they are receiving are worse. Among them, six-month-old, Fikir, whom Moyanesh saw during a home visit, stands out.
“You would not believe how thin she was when we first found her,” recounts Moyanesh, “She had never been vaccinated so when we tried to give her the vaccines, it was not possible because she was only skin and bones,” explains Moyanesh. When she was first brought to the Arara Kidanemeheret Health Post, the child weighed just 4.5 kg and the measurement of her mid-upper arm circumference – the criteria for identifying severe malnutrition – was 10.5 cm. She was severely acutely malnourished.
Thankfully, after receiving treatment, Fikir has gained 2kg after treatment, which included medicine and therapeutic food for several weeks, and her mid-upper arm circumference grew to 11.8 cm, which puts her in the moderately acutely malnourished range. She continues to receive outpatient treatment at the health post.
Moderately acutely malnourished children are enrolled in the World Food Programme-supported Targeted Supplementary Feeding programme through which they receive fortified blended food and vegetable oil for six months to aid their nutritional recovery. Both this and the UNICEF-supported treatment for severe acute malnutrition are routine responses which are all the more critical in a crisis.
Seven-month-old Mastewal is another child who has been treated at the Arara Kidanemeheret Health Post. Her mother, Weynitu, says that the drought has taken quite a toll on her family, especially on Mastewal. The child was extremely emaciated before receiving treatment for severe acute malnutrition. Weynitu walks for more than two hours over steep hilly ground to get to the health post for Mastewal’s treatment but she says it is worth all the hardship since her daughter has shown a lot of progress in the last few of months.
To Moyanesh, it is a relief to see the wonders that therapeutic food treatment does for the children. “I doubt that some of these children would have survived if they didn’t receive this treatment,” she says.
Across the country, 458,000 children are expected to need treatment for severe acute malnutrition in 2016. More broadly, 10.2 million people, 6 million of them children, are in need of emergency food assistance due to the drought. UNICEF, the Nutrition sector lead agency, continues to coordinate the nutrition emergency response. With the support of donors, UNICEF provides supplies for the management of severe acute malnutrition and supports the treatment of malnourished children through the community-based management of acute malnutrition, along with training, quality assurance and monitoring of the nutrition emergency response. UNICEF is also supporting efforts to provide drought-affected communities with access to clean water and health services to address major causes of child illnesses and deaths that have been exacerbated by the drought.
To continue nutrition emergency response activities over the coming months, additional funds of US$5 million are needed, subject to needs-based revisions. A further US$ 42 million is needed over the next four years to strengthen nutrition services and build resilience to future shocks among communities that are worst-affected by the drought.
Editor’s note: UNICEF‘s Deputy Executive Director for Programmes, Ms. Geeta Rao Gupta, visited UNICEF-supported maternal and child health programmes in Ethiopia ahead of the Ministerial Conference on Immunization in Africa in Addis Ababa. At the conference, African leaders–including health and finance ministers –came together to commit to expanding access to vaccines for children across the continent.
My recent visit to a health post in Ethiopia’s Bassona Worena district allowed me to see routine immunization activities, community case management and child and newborn health care programmes in action. The visit also highlighted one crucial element that characterizes successful child health programmes: community engagement.
I spoke with several community health workers, including Ms. Demem Demeke, 29, who described the full range of services she provides in her one-room, neatly organized health post: “We provide promotive, preventive and basic curative health services including immunization, community case management of diarrhoea, malaria, pneumonia and sepsis, antenatal care, post-natal care and other services to our community.” With handwritten charts plastered across the walls, Ms. Demeke was able to tell me exactly which households in her area had children in need of immunization, and with folders organized by the day of the week, she knew which children were due for a vaccination on that day. I watched as she expertly vaccinated a baby boy and then comforted him and instructed his mother on his care – quality, personalized care provided right there in a remote village in rural Ethiopia.
I also visited the home of Ms. Etenesh Deksiosa, a leader in the Health Development Army, a band of community members who support the work of the community health workers by educating neighbours and encouraging them to use maternal, newborn and child health services. Demonstrating the various tools she uses to educate her neighbours, she proudly told me: “I am always inspired to teach communities about the importance of vaccination and other child health-related issues.”
I was very impressed by professionalism and strong sense of responsibility of the community health workers. By engaging the communities they serve and working in partnership with the leaders in the Health Development Army they create a high level of ownership and a conducive environment to address traditional practices, cultural beliefs and social norms that contribute to hesitancy or even resistance to vaccination. The trust they build also helps to identify and reach children who are the most vulnerable — children who might otherwise never benefit from health services.
Ethiopia’s 38,000 health workers are mainly women selected from local communities who are paid by the government as part of the country’s flagship health extension programme. With the help of these committed women Ethiopia has expanded access to and demand for essential health services like immunization, making significant gains in reducing child mortality in less than a generation. By leveraging community engagement for child health Ethiopia reduced under-five mortality by two-thirds between 1990 and 2012 meeting Millennium Development Goal (MDG) 4 ahead of schedule.
Community involvement is a common success factor among countries that are reducing the prevalence of childhood diseases, particularly those that can be prevented with vaccines. Engaging and involving communities directly through community health workers and champions within communities is among the most effective means of promoting immunization in rural or marginalized populations and contributing to broader health goals.
At UNICEF, we have learned that lesson well over the years, most recently through our efforts to eradicate polio in Africa and elsewhere. Involvement and engagement of community leaders by community health extension workers transformed those efforts leading to increased success in reaching vulnerable children previously missed in polio vaccination campaigns.
Despite this experience and evidence, in far too many African countries today, consistent, nation-wide investments in community health programmes are still the exception – not the rule.
To maximize the return on investment in immunization programmes and to strengthen overall health systems, Ministries of Health should allocate adequate resources to support community-based health workers working hand-in-hand with community networks. By educating communities and generating demand, community health workers are key to expanding coverage and sustaining demand. And when community health workers involve community members in planning and monitoring the quality of services, it boosts community ownership, acceptance and accountability – cornerstones of effective health programmes.
During my visit to the health post in Bassona Worena, I was privileged to personally witness what the power of a partnership between a government health system and communities can achieve. With communities by their side, governments can succeed in reducing child mortality through quality and equitable health programmes, allowing children everywhere to reach their full potential. Community health programmes characterized by the full engagement and involvement of communities must become the norm across the African continent. UNICEF stands ready to assist. It is one of the most effective ways to make the right to health a reality for all children.
Geeta Rao Gupta is UNICEF‘s Deputy Executive Director for Programmes.
Moges dashes across the grass with a herding whip in hand. At three years old he can’t make it crack like his father or the other men in Romey Kebele (sub-district), a pastoralist area a few hours outside Addis Ababa where his family lives. But he smiles proudly as he loops it in wide circles around his head.
Muluemebet Balcha, one of the Health Extension Workers (HEW) that helped save Moges’ life, remembers how distraught his mother was. Ms. Muluemebet had contacted her to offer postnatal care for Moges through the Ethiopian government’s Health Extension Programme (HEP). “She was desperate. She thought the child would have died,” she said.
“I gave him treatment and on the second day he got well. I was very happy to see him survive,” she remembers.
Prior to becoming this kebele’s first HEW, Ms. Muluemebet says not all new-borns in the area were as lucky as Moges. “Before that training was given so many children who encountered the same problem died,” she said. The HEP has done wonders for families in hard-to-reach rural areas like Moges’ ever since it was established in 2003.
With help from UN agencies like UNICEF, it continues to grow. As of 2015 there were more than 38,000 HEWs like Ms. Muluemebet working in over 16,000 health posts across the country. Each health post serves around 5,000 people, meaning the vast majority of Ethiopia’s population of 99 million are within reach of free, basic health care.
Teshome Alemu, Moges’ father, says he owes his child’s life to the HEWs. “To go to [the nearest hospital] you may not even afford the transportation cost,” he said. “If you don’t have money, you can suffer a lot. The children will also suffer.”
“The provision of this service in our Kebele is very beneficial,” he added.
In September 2013 Ethiopia turned heads around the world by announcing it had achieved Millennium Development Goal 4, which pushed for a reduction of child mortality rates by 67 percent, three years ahead of its 2015 deadline. What started as 205 deaths for every 1,000 children in 1990 tapered off to 59 deaths per 1,000 in 2015. While developments in technology and new levels of political support are partially responsible for this drop, the HEP was a key driver in making this improvement a reality.
Meeting MDG 4 was a milestone in the country’s history, but HEWs aren’t claiming “mission accomplished” quite yet.
“The size of kebeles and their population means they cannot be covered by one HEW. I am the only health worker serving this community so it is very tough to reach all the households,” says Ms. Muluemebet, outlining challenges she and the program at large still faces.
Because she balances so many patients, she’s not always able to put in the time to make sure health education sticks. “Given the awareness of the community, it takes a long time to implement some of the activities. Families are getting the education needed, but sometimes it takes them a while to put it into practice,” she says.
Moges’ mother, Kokeb Nigusse, admits that while the community is grateful for the free services they provide, not everyone follows their advice to the fullest.
“They give the children medicinal drops, injections and syrup when they are sick,” she said. “They check up on the children. They also follow up and give injections to pregnant women. More significantly they advise us to deliver in health institutions and not at home.” Despite this last suggestion, she says, house deliveries still occur.
With more support from Ethiopia and UNICEF, that is beginning to change. “Before I started work, most mothers delivered at home. But now, if you take this year’s data, out of 171 pregnant mothers only 20 delivered at home,” said Ms. Muluemebet. The rest delivered at the local HEP health centre.
There have also been gains in building confidence in mothers like Ms. Kokeb, who are reluctant to vaccinate their children. “Vaccination of children was very low previously but now almost all children get vaccinated,” says Ms. Muluemebet. “I informed her that if the child gets sick he should get treatment even before baptism, because the community believes they shouldn’t get anything before baptism.”
Pneumonia, diarrhoea and malaria are three of the five most common life-threatening conditions that new-borns face in Ethiopia. These threats have curtailed with the debut of the integrated community case-based management of common childhood illnesses (ICCM) regime. So far, more than 28,000 HEWs like have been trained in ICCM.
With help from the financial support of its donors, UNICEF has guided development of the ICCM and HEP programs, given technical assistance to Ethiopia’s Ministry of Health, and delivered 10,000 health kits to HEP health posts throughout the country. Ms. Muluemebet says the change from this support has been enormous.
“I am a witness to seeing mothers die while giving birth,” she says. “But with the HEP we can easily detect mothers who need help, or who need to get service at health centres, and if it is beyond their capacity they call the ambulance and they take the mother to health centre and they can be easily saved.”
Moges and Ms Kokeb were saved from having to travel great lengths to get basic care. Today they walk hand-in-hand across the bright green plains that surround their vast plot of land, happy, at ease and part of a complete family. As the HEP continues to grow, success stories like theirs will become a shared experience for millions more Ethiopians.
DHANDAMANE, SOMALI REGION, ETHIOPIA, 23rd October 2013 – As we drive through the Valley of Marvels between JigJiga, the Somali Regional capital, and Babille, which straddles the neighbouring Oromia Region, the emerald glow of vibrant plant life sits in stark contrast to the florescent copper shimmer of the soil below. The road is smooth tarmac and carves a winding path through the sparse moonscape.
This western tip of what is classified as one of Ethiopia’s four developing regional states is currently blessed with more precipitation than its eastern extremities, but drought, regular disease outbreaks, flooding and limited access to healthcare have blighted the majority of the region for a number of years.
Adawe Warsame is a Health & Nutrition Officer with UNICEF. Having grown up in the nearby city of Dire Dawa and a Somali himself, he is well aware of the historic complications of the region.
“The issues the people face in the Somali Region are multi-layered,” he explains. “In one part of the region there is a flood, which is followed by a disease outbreak; in another, severe drought. This has a huge impact on both the health and nutrition of the people here, as well as the ability of the government to provide adequate services.
“Most regions are underdeveloped in terms of health facilities, human resources and education. It is difficult to provide even the most basic of services in many areas.”
Accessing Hard to Reach Areas
The next morning we continue along the same road through Babille towards Dire Dawa, entering the Oromia Region, before leaving the asphalt and turning back on ourselves towards the Koro kebele – a more direct access road does not currently exist.
Our driver first has to remove branches from the road, which have been placed there by the neighbouring Oromia village. After a brief exchange, in which they question why the support is being provided solely to the Somali people, they help to clear the path for us. With regional governmental offices only responsible for their own kebeles, this is a common occurrence. By working closely with the Ethiopian government, UNICEF are able to mitigate such issues and access areas that others cannot.
“UNICEF is a little privileged in terms of movement compared to other NGOs,” Adawe assures us. ” As we work closely with the Regional Health Bureau, the vehicles have special plate numbers and the staff are also from the government side.”
The MHNT helps to train Health Extension Workers (HEWs) through a 16 package programme, which includes disease prevention and control, family health services, hygiene and environmental sanitation, health education and Harmful Traditional Practices (HTPs). They also provide immunisations, deliver medicine and supplies, support Traditional Birthing Assistants (TBAs) and treat severe malnutrition. UNICEF currently supports 24 MHNTs in the Somali region. There used to be others operated by different NGOs, but due to financing restrictions these have now ceased to be operational.
As we arrive in the village, we are met by Mohamed Almur Musu, the kebele leader, who informs us that he is responsible for protecting both the people and the animals in his community. Adawe briefly explains the purpose of our visit before we begin to make our way through the village.
“We are on the border between the Somali and Oromia regions, and so have been a little neglected,” Mohamed explains at the entrance to one of the village houses. “Nowadays, we have better support and a new health facility, which makes us feel more secure. The problems we face here are many, but slowly things are improving.”
The Plight of Harmful Traditional Practices
One of the biggest and often most sensitive issues in the region is HTPs, such as early childhood marriage and female genital mutilation (FGM). According to the 2011 Welfare Monitoring Survey (WMS) report, the region has the third highest rate of FGM (in 0-14 year olds) in Ethiopia (31%), after Afar (60%) and Amhara (47%).
“Prior to the government intervention, religious leaders were advising us not to practice these things,” Mohamed informs us, a nervous smile directed at those around him indicating that the issue is still one he is not altogether comfortable with. “The change wasn’t really monitored though and people were still doing it.”
Beyond the obvious initial pain of the procedure, the long term physiological, sexual and psychological effects of FGM are well documented. The consequences can even include death as a result of shock, haemorrhage or septicaemia. Long-term complications include loss of libido, genital malformation, delayed menarche, chronic pelvic complications and recurrent urinary retention and infection. Girls who have undergone FGM or also prone to various complications during birth and are more at risk of contracting HIV.
“We now have a very strong community stance against it. I can confidently say that it is no longer a part of our lives here,” Mohamed exclaims proudly.
At the first Girl Summit – held on July 22, 2014, in London, and joint hosted by UNICEF – Ethiopia’s deputy Prime Minister (DPM) Demeke Mekonnen announced a package to eradicate both FGM and early childhood marriage by 2025. This is the most recent step in a decade’s long struggle, but statistics are now starting to indicate that real progress is being made and this new target is a realistic one.
Women at the Centre of the Progress
The house we are borrowing shade from is that of Marayama Abdiwahad, a confidant woman who plays a central role in the kebele’s women’s group. She has a 13-year-old daughter, Bisharo, and is clearly driven by a desire to improve the quality of life for all children in her community.
“Progress began with just a few simple steps,” she says, directing us to look around at the village as she talks. “The mobile team have taught us how to collect rubbish, to gather it somewhere and to burn it. Before, we didn’t wash our children, and our dishes and utensils were not clean, now we are also doing this.”
Although, this seems straightforward, the impact it has had on the community has been huge,
“Our children always used to get diarrhoea,” she continues. “Now, they are healthy and energetic. If anyone does get sick, we also now have the necessary facilities here to treat them.”
In addition to the hygiene aspect of the 16 package programme provided to the community, Marayama also discusses the role the women’s group has played in eradicating FGM.
“We used to perform FGM, but after receiving the 16 package we have committed ourselves to not performing it,” she says proudly. “We have discussed together the health problems it brings and have vowed to eradicate it from our community.”
When questioned about her own daughter, Marayama is defiant.
“If you yourselves are not ashamed, I will happily show you my daughter,” she insists, with a knowing smile. “I will never allow anyone to perform FGM on her.”
Abdullah Abiid, 22, is the kebele’s only HEW. He has been working in his role for a year now. When we meet him, he is discussing HTPs with the kebele’s women’s group.
“FGM no longer happens here,” he informs us proudly. “There is still early marriage, but now the girls are going to school and learning about this too.” At times, the progress has not been easy, but Abdullah is committed to achieving his objectives and improving life for all in his community.
“Some listen and accept what I am saying straight away, others laugh at me,” he says. “When they laugh, I don’t stop what I am doing because I know they will see what the other women are doing and follow their lead.
“They used to be ashamed to use a latrine even. When I explained that their own hygiene and the cleanliness of the home are important for maintaining the health of their children, they started to make the change.”
Part of a Bigger Picture
The progress in the level of hygiene and the eradication of HTPs is part of a bigger picture, whereby both the health and quality of life of all those in the community is improving – especially for girls.
The training and provision of clean delivery kits to TBAs has had a profound impact on the quality of birthing services, and this has been supported further by Tetanus Toxoid injections, which massively reduces the neo-natal tetanus mortality rate. The presence of the Health Post (HP) and MHNT for emergency situations also enables pregnant women to have more confidence should complications occur.
In the neighbouring Helobiyo Kebele, Ruman Ibrahim Osman, 28, is a prime example of the impact this has had. We are invited into her home where she is sat holding her 1-week old baby girl, Farhiyo. She had previously lost two children during complicated deliveries.
“During the delivery of my previous child, the baby was in a difficult position and then got stuck,” she bravely informs us. “I was suffering for around 24 hours. The community tried to help, but finally, after a prolonged issue, the baby died.”
She had also lost another child in similar circumstances just 12 months earlier. With Farhiyo, however, the delivery was much more straight forward and she received support throughout her pregnancy.
“Initially, I met with the MHNT when they came to our village,” she recalls. “They told the pregnant mothers to come and gave us advice, vaccinations and linked us to the birth assistant. Then I got support from the birth assistant and gave birth with her help here at home.”
She is also now receiving continued support from the TBA and HEW.
” I have been told to breastfeed within the first few hours and I don’t give any additional food or water,” she says confidently. ” The mobile team are vaccinating us and our children, and treating diseases like malaria. The situation here is now much better.”
Although there is still some way to go to completely eradicate HTPs from the Somali region and to improve the health and nutrition of all, positive progress is clearly being made. For those working with UNICEF in the region, this is something that they are proud to be a part of.
“As someone with an educational background in public health, it brings me great pleasure to see these poorer communities now learning such important lessons,” Adawe exclaims gleefully back at UNICEF’s Somali regional office in JigJiga. “The people here do not deliberately want to hurt or damage their children.
“Driven by the services of our mobile teams, we are empowering them to protect both themselves and their future.”
Not so very long ago Ethiopia had one of the worst child mortality rates in Africa but it’s managed to slash the death toll by two-thirds, three years ahead of the Millennium Development Goal’s (MDG’s).
On a recent interview with CCTV, UNICEF Representative to Ethiopia, Ms. Gillian Mellsop, said “The key heroes in reducing child mortality by two third in Ethiopia are the 38,000, mainly women government salaried, health extension workers in addition to the political commitment and the vision of the government and sustainable funding.”
See the full programme which was aired on CCTV below:
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
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.
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.