Helping health workers save Ethiopia’s youngest children

By Demissew Bizuwerk

Kejelo, Tiro AFETA, Oromia, 14 June 2018: Inside the small room of Kejelo health post, health extension worker Amelework Getachew carefully monitors her stock of medicines stacked on a small wooden shelf. She checks to make sure that an Oral Rehydration Salt (ORS), a fluid replacement used to prevent and treat diarrhoea, Amoxicillin Dispersible Tablet and Gentamicin injection, antibiotics used to treat children with pneumonia and serious bacterial infections, are available in good quantity. She cross checks the numbers on each bin card and the actual quantities on the shelf. “I can’t afford to run out of these medicines,” says Amelework, pointing towards a stock of sachets of ORS and packs of amoxicillin tablets and gentamicin injections. “They are lifesaving.”

After Amelework is done taking inventory, she collects her essential job-aids for home visits and attends to five-month-old Aziza in her home as part of her routine house-to-house visit. This way, Amelework makes sure that pregnant women and newborn babies get health follow-ups.

When Aziza was only 45 days old, she suffered from pneumonia, the common killer of infants in Ethiopia. “I was so worried when my child was sick,” says Rawda, Aziza’s mother. “She was struggling to breathe and had it not been for ‘doctor’, my child would not have survived.”

“I was so worried when my child was sick. She was struggling to breathe

Amelework, whose name also means “a golden character,” is a committed health worker. Her nine-year journey as a health extension worker started in a remote village of Kereyu Dodo when she was given the daunting task of changing people’s attitudes on a range of health-related misconceptions.  It wasn’t easy for her to convince people to dig toilets or use bed nets to keep them safe from malaria. “They used to call us names like the ‘toilet controllers’ or ‘bed net checkers,” she remembers.

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Amelework examines five months old Aziza. When Aziza was 45 days old, she suffered from Pneumonia. But now she is growing up healthy. ©UNICEF Ethiopia/2018/Demissew Bizuwerk

But Amelework is now dubbed ‘doctor’, a name bestowed to her out of love and respect by the village women.  She is key to the livelihoods of the community, saving mothers and newborns including little Aziza in the small village of Kejelo.

Although Ethiopia has managed to significantly reduce its under-five child mortality, newborn deaths have declined at a much slower pace.  Twenty-nine newborn babies die out of every 1,000 live births from preventable causes such as complications due to prematurity, birth asphyxia, and infections like sepsis, and pneumonia[1]. Newborn deaths also account for a greater and growing share of all deaths among children under 5; almost 44 per cent.

Supported by UNICEF, the Government of Ethiopia introduced the Community Based Newborn Care (CBNC) strategy in 2012. CBNC aims to empower health extension workers, such as Amelework, with skills to provide maternal and child health services during pregnancy, childbirth and postnatally. Heath extension workers are also trained to identify and treat newborns with severe bacterial infections or sepsis where referral is not possible. They provide treatment for sick children both at the health post and in houses during their regular visits.

“The treatment we are providing is free of charge,” says Amelework. “This is encouraging mothers to bring their children early when they are sick.  It is also helping us to save young children from serious illnesses like pneumonia.”

Amelework is trained to provide CBNC services by JSI Research & Training Institute, Inc/ The Last Ten Kilometers Project (JSI/L10K), which is implementing the programme with technical and financial support from UNICEF.  She also gets constant support and follow-up from the CBNC supervision team who regularly visit her health post to make sure that she is applying the standard operating procedures.

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Wosen Darge, the CBNC Regional Technical Officer from JSI/L10K supports Amelework with regular visits to her health post. ©UNICEF Ethiopia/2018/Demissew Bizuwerk

“We train and support Amelework to deliver her very important work by effectively identifying sick children in the village during her regular immunization outreach work and when she is providing house-to-house postnatal care,” says Wosen Darge, the CBNC Regional Technical Officer from JSI/L10K.  “We also monitor and evaluate her records to ensure key information is recorded and stored in the treatment book.”

Amelework is also provided with guidance and support on supply management. She keeps track of her medical supplies to avoid shortages of crical drugs that she needs for immediate use.

“Nothing is more fulfilling than seeing a mother’s happy face when her child is recovering from such illnesses”

UNICEF is supporting the scaling up of CBNC services with funds from the Margaret A. Cargill Foundation. Working in coordination with the Ministry of Health, it is expected that the positive experiences observed in villages like Kejelo will be expanded to pastoralist areas.

CNBC Jimma, Oromia
Amelework is the indispensable medical person for Kejelo village mothers and children. She is dubbed ‘doctor’ by the local women for saving their children. ©UNICEF Ethiopia/2018/Demissew Bizuwerk

A humble hard worker such as Amelework embodies Ethiopia’s hope to end preventable newborn and child deaths within this generation. “Nothing is more fulfilling than seeing a mother’s happy face when her child is recovering from such illnesses,” she says, “I am a mother myself and I know the feeling.”

Aziza is growing up healthy, her mother’s wish is to see her daughter becoming a ‘doctor’, like Amelework. “She [Amelework] saved my child’s life and I want my daughter to also do the same when she grows up,” says Rawda, with eyes full of hope to see a bright future for her baby daughter.

[1] EDHS 2016

Surviving hard times through therapeutic foods

Story – Bethlehem Kiros

Photos – Meklit Mersha 

SOUTHERN NATIONS, NATIONALITIES AND PEOPLE’S REGION (SNNPR), November 2016- Poverty and drought have left people in many parts of Ethiopia to grapple with food shortage; SNNPR is no different. Children are most affected, as evidenced by a high number of severe acute malnutrition (SAM) cases. Fortunately, the Government of Ethiopia implements the Community-Based Management of Acute Malnutrition (CMAM) programme, supported by UNICEF with generous contribution from European Commission’s humanitarian aid department (ECHO). The programme enables children affected by malnutrition to receive life-saving services at stabilization centres (SC) and health posts, such as 32-year-old Bogalech Boreda’s twin infants.

Bogalech Boreda, 32, has 6 children. Her youngest 10-months-old twins Tegegn and Kibru Elias have both become severely malnourished because she could not nurse them sufficiently.
Bogalech’s 10-month-old twins Kibru and Tegegn have been in the Outpatient Therapeutic Feeding Programme (OTP) for SAM more than once. Since Bogalech has three more children at home, she says feeding the twins has not been easy.

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She gets help from her older children when they return from school, such as Caleb, 12, pictured here holding one of the twins.  Still, taking care of the infants occupies most of Bogalech’s day, making it impossible for her to work. Her husband is unemployed with an additional two children from another wife, his earnings from a small plot of farm land are not enough to provide for them.

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The health extension workers (HEWs) of Morancho Kutela health post have arranged for Bogalech to receive targeted supplementary food multiple times since the twins were born. “I normally had enough milk to nurse my children in the past,” explains Bogalech, “but now, there are two of them and I also do not eat enough at home, so they have been suffering since they were born.”

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Three weeks before the picture was taken, Tegegn suffered from diarrhoea and was referred to the Stabilization Centre (SC) at the kebele’s (sub-district) health centre. After a few days of antibiotics and therapeutic milk treatment, he was referred to the health post for OTP to continue his treatment as an outpatient. Since his brother’s situation was not much better, both were enrolled to receive the RUTF.

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In the two weeks since the boys’ treatment began, Bogalech says she has seen progress on her babies’ health and appearance. “They love the [RUTF], they just cannot get enough of it. And the thought of having something to give them when they are hungry gives me such relief,” she adds. Since she is nursing them and providing additional food in her home, she hopes they will grow strong and healthy.

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Their middle-upper arm circumference (MUAC) and weight is measured every week until they reach their target weight for discharge. Currently at 6.2 kg, Tegegn’s target weight for discharge is 6.9 kg, which is still about 2 kg underweight for an average 10-month-old boy according to World Health Organization guidelines. His MUAC was 10.9 cm when he was first enrolled for treatment and has now reached 11.25 cm.

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Bogalech dreams of starting an avocado and corn flour business in the market to support herself and her children.

Saving a child too thin to be vaccinated

By Bethlehem Kiros

Fatima Yesuf, 25, brings her 8 months old daughter to the Metiya health center for checkup and to receive the Plumpynuts food supplementsAMHARA 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.

Weynitu Demissie, 34, has a 7 months old daughter who is recovering from acute malnutrition
Weynitu Demissie (far left) walks a long distance to get to Arara Kidanemeheret Health Post where she receives therapeutic food for her seven-month-old malnourished daughter, Mastewal. ©UNICEF Ethiopia/2016/Nahom Tesfaye

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.

Children need communities

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.

A group of women in front of houses.
UNICEF/UN010923/TesfayeMs. Geeta Rao Gupta, accompanied by women in the community on her visit to model household in Bassona Worena District, North Shewa Zone, Amhara Region, Ethiopia.

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 UNICEFs Deputy Executive Director for Programmes.

Ethiopia’s model families hailed as agents of social transformation

Ethiopia is boosting its healthcare statistics by enouraging rural households to adopt and disseminate a range of good habits

by The Guardian

Wudinesh Demisse, right, and her model family, part of the Ethiopia’s so-called health development army. Photograph: Lauren McKown/Pathfinder International

Wudinesh Demisse raises her hand above her head, showing off the matchstick-sized birth-control implant embedded just beneath the skin of her upper arm.

Wudinesh, 28, is a farmer in rural West Arsi, in Ethiopia’s central Oromia region. With three children already, Wudinesh says it is time to stop. “For me, three is enough,” she says, through a translator. “If they are too many, they are too expensive.”

Wudinesh, who lives in a small village 200km south of the capital, Addis Ababa, is one of millions of Ethiopian women who have gained access to modern forms of birth control over the past decade. Today, her local health post stocks a range of products, from condoms and pills to longer-acting injections and implants.

Ethiopia is increasingly touted as a family planning success story. The government, which has made maternal and child health national priorities, is proud of its statistics – the country’s contraceptive prevalence rate, for example, jumped from 15% in 2005 to 29% in 2011 – and says efforts to reach remote, rural areas lie at the heart of its success.

Along with trained, salaried health extension workers – all of whom are female, a step to make families more comfortable with door-to-door visits – thousands of volunteers have been enlisted nationwide in the government’s “health development army”. Read more