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.
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.
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 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.
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, 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.
Ethiopia is boosting its healthcare statistics by enouraging rural households to adopt and disseminate a range of good habits
by The Guardian
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
Poor countries are starting to realize something that richer ones sometimes forget: Basic, inexpensive measures can have dramatic impacts on the health of a country. And they can save thousands of lives.
Take, for instance, the situation in Ethiopia.
The country used to have one of the highest rates of child mortality in the world.
“If you were a kid born in 1990 [in Ethiopia], you had a 1 in 5 chance of not surviving to your fifth birthday,” says Peter Salama, who directs UNICEF’s efforts in Ethiopia.
Since then, the country has improved that survival rate by about 60 percent. “So [Ethiopia has made] a tremendous achievement in the space of two decades,” Salama says.
This progress isn’t a result of expensive international aid or the recruitment of foreign doctors into Ethiopia. Instead, the country has invested in simple, bare-bone clinics scattered around the country, which are run by minimally-educated community health workers.
Foos Muhumed Gudaal is one of 35,000 rural health extension workers in Ethiopia. She practices at a post in the village of Walgo Yar in the eastern part of the country. The clinic is a simple, cement building with only two rooms: one for Gudaal to live in and one that serves as a consultation room. There is no electricity. There are no lights.
Gudaal’s role at the post is a bit like the old image of a small-town pediatrician. But she isn’t even a nurse. Instead, Gudaal, along with all the other health extension workers, has gone through a special, one-year training program.
Her salary also isn’t anywhere near that of a pediatrician. She earns roughly $35 each month.
But Gudaal can still treat the diseases that often cut a child’s life short in Ethiopia. And she can make sure kids in the village are up to date on their vaccines.
One of the main conditions Gudaal deals with is malaria. The parasite kills about 600 million people worldwide each year, and the vast majority of those deaths occur in children under age 5. Gudaal can diagnose and treat most malaria cases at her health post.
She can also easily treat diarrhea and respiratory infections, two other major killers of children in the developing world.
Because there is no electricity at the clinic, Gudaal has to rely on a kerosene-fired refrigerator to keep her vaccines cold. The aging fridge sits in a small shed next to the consultation room.
Gudaal lifts several vaccine vials out of the fridge. She not only administers immunizations, but she also keeps records for who in the village needs shots and boosters.
Since being launched a decade ago, this health extension program in Ethiopia has had a huge effect in the country, Salama says.
Quite simply, it has saved lives. “Children are now treated right across the country on a scale that was previously unheard of around the world,” he says.
“Take acute severe malnutrition, for which Ethiopia was famous in the ’70s and ’80s,” Salama says. “Today, successfully, these same lady health workers treat 300,000 children [each year] for severe malnutrition.” Previously, these children would have most invariably died, he says.
Despite these improvements, Ethiopia still has a long way to go when it comes to children’s health. Malnutrition is still the leading cause of death for children under age 5 in the country. Nearly 20 percent of Ethiopian babies are born underweight, weighing less than 5 1/2 pounds. And about 40 percent of kids don’t reach a normal height because of malnutrition.
But, Salama says, the beauty of Ethiopia’s health extension program is that it’s sustainable. It’s run by the government, not a foreign foundation or agency. So as long as there’s the political will, it’s able to reach kids across the country.
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.