Afar Region – Ethiopia Ms Leila Pakkala and Ms Valerie Guarnieri, UNICEF and WFP Regional Directors for Eastern and Central Africa, have visited the ongoing government-led drought response where UNICEF-WFP are closely collaborating. The drought is affecting six regions in Ethiopia, and 9.7 million people are in need of urgent food relief assistance including approximately 5.7 million children who are at risk from hunger, disease and lack of water as a result of the current El Niño driven drought.
In Afar Region, where an estimated 1.7 million people are affected by the drought, including 234,000 under-five children, the Regional Directors visited UNICEF/WFP/Government of Ethiopia supported programmes. These included the targeted supplementary feeding programme (TSFP) and an outreach site where one of Afar’s 20 Mobile Health and Nutrition Teams (MHNTs) provides preventive and curative health, nutrition and WASH services to a hard-to-reach community in Lubakda kebele.
The Mobile Health and Nutrition Team provides Outpatient Therapeutic Programme (OTP) and targeted supplementary feeding programme (TSFP) services to remote communities. The TSFP is integrated with MHNT services that address under five children and pregnant and lactating women with moderate acute malnutrition, and link them to TSFP when they are discharged from OTP. This solves the challenge in addressing the SAM–MAM continuum of care and preventing moderate acute malnourished children deteriorating into severe acute malnutrition.
The Directors also visited a multi-village water scheme for Afar pastoralist communities in Musle Kebele, Kore Woreda (district) which suffers from chronic water insecurity.
“Valerie and I are hugely impressed by the work of the WFP and UNICEF teams in Afar,” said UNICEF’s Pakkala. “The quality of the work being done in such difficult circumstances – from the mobile health and nutrition teams, to WASH, protection, education and advocacy – is remarkable. We were also immensely impressed with the national level partnership between UNICEF and WFP, and our credibility with government and donors. The relationship and collaboration is a model for other countries to learn from and emulate.”
“Ethiopia is showing us that drought does not have to equal disaster,” said Valerie Guarnieri of WFP. “We can clearly see the evidence here that a robust, government-led humanitarian response – supported by the international community – can and does save lives in a time of crisis.”
UNICEF and WFP continue to support the Government in responding to the current drought with a focus on the most vulnerable and hard to reach communities by using proven context specific solutions and approaches.
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.
17 February 2015, Semera, Afar Region: A delegation led by Her Royal Highness Crown Princess Mary of Denmark paid a one day visit to the Afar Region of Ethiopia to observe first-hand the implementation of the Joint Programme on eliminating female genital mutilation/ cutting (FGM/C) supported by UNFPA, United Nations Population Fund, and UNICEF, United Nations Children’s Fund as well as a programme on the prevention of child marriage. She was able to see efforts undertaken by community members regarding the abandonment of the two harmful practices and institutional responses at mitigating complications. Crown Princess Mary was accompanied by the Danish Minister for Trade and Development Cooperation, Mr. Mogens Jensen.
The Joint Programme addresses the issue of FGM/C not only because of its harmful impact on the reproductive and sexual health of women, but also because it violates women’s and girls’ fundamental human rights. This harmful practice has both immediate and long term consequences to the health and well-being of girls and women, negatively impacting maternal and neonatal health outcomes, and also increasing the risk of HIV/AIDS transmission. The practice often leaves girls with severe pain and trauma, shock, hemorrhage, sepsis, urine retention, ulceration of the genital region, and urinary infection, among other complications. Girls’ and women’s health, their empowerment, and the realization of their rights are negatively affected by FGM as well as the achievement of the Millennium Development Goals related to reducing child mortality, improving maternal health and combating HIV/AIDS.
In the Afar Region girls and women are subjected to the worst form of the practice – infibulation – usually at the ages of seven to nine. In some districts in Afar, this harmful traditional practice is even exercised within some days after the birth of the child. The rights-based approach affirms that well–being, bodily integrity and health are influenced by the way a human being is valued.
In the first leg of her visit, Crown Princess Mary met different community members at a locality in the Afambo District and observed community dialogues involving different sectors of the community on the abandonment of FGM/C and child marriage. In addition, she observed a discussion of adolescent girls’ club and interacted with the participants. This intervention which aims at integrating efforts at the abandonment of FGM/C and child marriage is under implementation for the past two years in seven localities in the Afambo District and is coordinated by the Bureau of Women, Children and Youth Affairs of the Afar Region. Woizero Zahara Humed, Head of the Bureau of Women, Children and Youth Affairs, provided the visitors with an overall briefing regarding the programme. Crown Princess Mary interacted with community members, especially women and girls, and appreciated the efforts being undertaken to abandon the harmful practices and empower girls and women.
The Ethiopian Demographic and Health Survey of 2011puts the median age at first marriage for the Afar Region as the third lowest in the country at age 16.5. Moreover, despite the progresses made in recent years, the prevalence of FGM/C remains very high in the Region. According to the 2011 Welfare Monitoring Survey the prevalence of FGM/C is highest in the Region at 60 per cent. But six districts in the Region in which the UNFPA-UNICEF Joint Programme on Accelerated Abandonment of FGM/C is being implemented have publicly declare abandonment of the practice since the initiative was launched in 2008.
For the second leg of her visit, Crown Princess Mary was taken to the Barbara May Maternity Hospital in Mille District, where she observed services being provided by the hospital at tackling complications resulting from FGM/C and child marriage, such as teenage pregnancy and childbirth. She was given a tour of the facilities of the hospital by Valerie Browning – Head of the Afar Pastoralist Development Association which is running the hospital – and the medical staff of the hospital. It was indicated during the visit that the hospital which has been operational since 2011 is providing life-saving delivery services and treating obstetric complications created by FGM/C. Crown Princess Mary also got the chance to interact with patients during her visit to the hospital.
Crown Princess Mary admired the commitment of the Afar Region in tackling FGM and child marriage when she met Awel Arba, Vice President of the Afar Region, later in the day. She appreciated the support being provided by UNFPA and UNICEF. The Vice President assured the Crown Princess that his Region was keen in continuing efforts at improving the lives of girls and women and remarked that his Region looked forward to support from Denmark.
During the Girl’s Summit held in London in June 2014, the Government of Ethiopia has committed to eliminate both FGM/C and child marriage by 2025.
The visit was jointly organized by the Embassy of Denmark, UNFPA, and UNICEF.
Butajira, 2 April 2014: Around fifteen journalists from eleven media houses visited Butajira hospital and health center to witness firsthand the facilities for mothers and new-borns there.
The media visit was organized by the Federal Ministry of Health, European Union and UNICEF to show the commendable services provided by Butajira hospital and health centre ahead of the high level launch of the ‘Enhancing Skilled Delivery in Ethiopia’ (ESDE) which was made possible with EU’s generous €40.2 million grant.
New mother Aster Kebede’s face is filled with grace holding her new baby girl already named Etenesh Gobeza. After an hour of delivery, she has immediately started breast-feeding her child sitting comfortably on the hospital bed. It took her a day to come to the hospital from the neighboring Mareko woreda (district) with her mother Fichage Arega. Now, both of them are proudly sitting close to each other admiring the newly born child and grandchild in relief.
“I am highly content with the service provided here at the hospital. The staff were really kind to me and I had a smooth delivery. I am also grateful that such service is offered for free.” said Aster.
In Ethiopia the most critical period of care for maternal and neonatal mortality reduction (skilled birth attendance) has remained stagnant for the past two decades with only 29 per cent of mothers accessing this essential care. In addition, despite the improvements in reducing under 5 mortality rates, neonatal mortality rate has also remained stagnant showing no significant reduction from 39 in the 2005 to 37 in 2011.
“Both the quality and quantity of services have increased in the hospital due to the commitment and motivation of the hospital management and its staff to prevent any death of mothers and new-borns” said Andualem Mengistu, Manager of the hospital.
According to Andualem, the range of mothers who deliver at the hospital has increased from 10-15 up to 80-90 mothers per week at present. This significant increase is due to the introduction of free service for mothers who deliver at the hospital, increase in the number of midwives on duty programme and early referral system from the Health Center. In addition, the hospital implements Maternal Death Surveillance and Response (MDSR) and uses volunteers from Voluntary Services Organization (VSO) to fill the staffing and skill gap.
“Giving birth should be a time of happiness and celebration for mothers and not a time of sorrow. And newborns are not predestined to die” said Dr. Asheber Gaym, Health Specialist at UNICEF. “We need to make all our efforts to stop the unnecessary death of mothers and new-born in the country by closely working with the Government and partners” he added.
Ali Abdella, deputy head of the woreda health unit indicates that, their main objective is to create demand so that mothers deliver at a health facility and not at home. The maternal mortality rate in the city used to be 67 deaths per 10,000 in 2010 and now it has gone down to 6 deaths per 10,000 which is a significant achievement.
According to Ethiopian Demographic and Health Survey (EDHS) 2011, Ethiopia has one of the highest maternal mortality ratios in the world estimated at 676 maternal deaths per 100,000 live births far from the MDG target of 267.
“We are now aiming at quality service and HDF (Home Delivery Free) community.” he stresses.
Translation of paragraphs from stories by journalists that took part in the media visit are posted here: [With a link to the Amharic story]
Hospitals can solve Maternal health and newborn deaths when they have the necessary equipments and sustainable supply. To equip new and old hospitals with the necessary equipments to sustain the supply, the European Union has donated 40 million Euros through a project implemented by Ministry of Health and UNICEF. All health sectors will benefit from this three year project Read more.
“Many newborn and maternal lives were saved because of this hospital” says Fetiya “The service is for free, so all mothers should come to the hospital and save the life of their children and themselves” Fetiya conveys her message. Read more
SEBETA DISTRICT, 1 February 2014 – “Wash your hands before you eat; wash your hands after visiting the toilet; wash your body… clean your environment ….” The song in the Oromiffa language continues with further messages on hygiene.
When the UN Deputy Secretary-General, Mr Jan Eliasson walks toward the latrines at DimaPrimary School in Sebeta, Oromia Region, he is welcomed by students from the Hygiene and Sanitation club, singing proudly about personal and environmental hygiene.
Hayat Hachallu, is 13 years old and a member of the Dima Primary school Hygiene and Sanitation Club. This 7th grader is certainly not shy. She takes the DSG by the hand and shows him the school latrine, hand washing facilities and the water point.
“Here are the latrines for girls,” she explains to the special visitor, while opening the door carefully. “For us, girls, it is very important to have private facilities. A place where we feel safe and have the privacy we need. The toilets here are not great: they are too dark, the doors don’t close very well and it really smells badly,” she says. “Now, let me show you our newly built latrines,” and she pulls Mr. Eliasson away from the rickety iron sheet structure toward a stone construction.
There are 30,634 primary schools in Ethiopia, of which 5,000 are directly supported by UNICEF. Primary schools are encouraged to address key Water, Sanitation and Hygiene (WASH) issues such as installation of water supply, construction of gender-segregated toilets and hand-washing facilities. Hayat and the other girls are benefiting from UNICEF funding for the newly built girls latrine.
“Look Mister look”, Hayat points proudly. “Look, here are our new toilets. They are much better don’t you think,” she asks cheekily. Hayat clarifies that the school Hygiene and Sanitation activities are managed by the Environmental Protection and Sanitation Club which is composed of 105 students of which 57 are girls and 5 are teachers.
Mr Mesfin Tessema, the school director further elaborates: “The sanitation club is established to engage children in various hygiene and sanitation activities as part of learning and behavioural change.”
When Mr Jan Eliasson asks about the clubs activities, Hayat goes into detail: We are involved in the clearing and cleaning of the school compound; cleaning of the latrines; we encourage students to wash their hands after they use latrines; we conduct environmental sanitation campaigns in the school and within the community; and we have established relationships with the nearby Health Post for the promotion of hygiene activities. And we are also involved with the beautification and environmental protection of the school compound with tree planting.”
Children are agents of change
By focusing on school aged children and providing them with the necessary tools and knowledge to change behaviours at school and home, children play a crucial role in sharing information and knowledge with their parents and family members to achieve better health, environmental, sanitation and hygiene practices.
Ethiopia has been an active participant in the Sanitation and Water for All Partnership. In 2013, the Ethiopian Government, with support from UNICEF, was able to establish a Sector-wide Approach termed the ONE WASH National Programme with a dedicated budget line for sanitation in the Government of Ethiopia’s treasury for sanitation.
Since 1990, the country has made substantial progress in improving access to water supply and sanitation coverage. However, millions of people still remain without access to safe water and sanitation services. In 2010, out of a population of over 80 million, about 46 million were without access to improved water supply and sanitation and Ethiopia had the highest number of people (38 million) practicing open defecation among African countries. The lack of access to adequate clean drinking water and sanitation services has a dramatic impact on the lives of people, especially women and girls, and undermines efforts to improve health, nutrition and education outcomes.
Although good progress is underway, still some challenges remain. Nationally, only around 31 per cent of school have water supply facilities in their premises and 33 per cent have improved latrine facilities. On average, the toilet/student ratio is 1:120. In Oromia Region, where the Dima Primary School is situated, only 52 per cent of its total population has access to safe drinking water and the sanitation and hygiene coverage is also 52 per cent.
It is up to ALL of us
The Deputy Secretary-General talks with the school children to hear about their experiences. While they explain the importance of the school club in educating the community on hygiene practices, and the challenges they are facing, the DSG appeals to each and every one of them. “It is up to ALL of us,” he underlines while speaking to the students and the bystanders. With passion and conviction he adds: “Nobody can do everything, but everybody can do something”.
Hayat and her peers nod in agreement. Although they had never previously heard of the DSG’s Call to Action on Sanitation, they know the importance of sanitation. They know their individual and club efforts will bring change. They know its up to them to make their school and community a better place. In the end, this is also their call to action.
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.
HAROJILA FULASO, OROMIA REGION, 1 February 2014 – “The health extension worker told us to wash our hands with soap and if we don’t have soap, we can use ashes. So, when I have not been able to buy soap, this is what we use to disinfect our hands”.
Ms Shure Gore takes the can of ashes and hands it to United Nations Deputy Secretary-General Mr Jan Eliasson. He gently takes out some of the greyish substance and rubs it before rinsing it off with the water from the jerry can attached to the tree, next to the family’s’ latrine. “My hands are clean,” he exclaims while the family is observing his actions closely.
In Ethiopia’s Oromia region, the hygiene and environmental sanitation activities are the main focus for household and community level interventions. The woreda (district) latrine coverage is about 70 per cent. In Harojila Fulaso, however, 80 per cent of the households have reached the status of becoming a “model household.”
The model family is the approach adapted by the Health Extension Programme to improve household practices. After 96 hours of training and adopting 12 of the 16 packages, a family graduates to become a so-called model family. The health extension package is categorised under three major areas and one cross cutting area: namely Hygiene and environmental sanitation; family health services; disease prevention and control; and health education and communication.
The Lemma-Buchule family, in which Ms Shure Gore is the driving force, has a latrine with hand washing facilities and dry and liquid waste disposal pits. In addition, the household has adequate aeration and light and the animals are kept separate from the living area – to name a few requirements of becoming a model household.
The family lives a couple of minutes walk away from the health post. Ms Abebech Desalegn is one of the two health extension workers running the facility. The health post provides services to 736 households and 3,532 inhabitants – ensuring that health care is delivered at the doorstep. “I know Shure and her family very well,” says Ababech. “The family consists of 10 members, including eight children between the ages of 3 and 22 years old. They come here when they need vaccine, a new mosquito net or when they are ill.” She has assisted the household in reaching the status of “model household”. “They now inspire others to do just like them, they are an example to the community,” Ababech explains.
Health extension workers deliver health care at the doorstep
Ababech is a government salaried and trained health worker, under the Health Extension Programme, an innovative community based programme which started in 2003. To date, 38,000 health extension workers have been deployed in nearly all rural villages. The programme aims to create a healthy environment and healthy living by delivering essential health services to communities.
UNICEF supports the Health Extension Programme in different dimensions. Training of HEWs to improve their technical competencies in delivering health and nutrition services, procuring and distributing of vaccines, medicines and supplies, ensuring availability of job aids at health posts, have all led to increased coverage of health and nutrition services at community level.
In addition to prevention and health promotion services, health extension workers are also now involved in case management of pneumonia, diarrhoea and severe acute malnutrition in more than 90 percent of health posts.
The Deputy Secretary-General, Mr Jan Eliasson studies the charts on the wall of the small health post. “You are doing an excellent job here,” he says while impressed with the statistics and service delivery provided by this health extension post.
Abebech explains that she is required to split her time between the health post and the community. Community outreach activities include working with model families, community groups or households. “Every day I’m very busy she continues. When I’m at the health post I provide basic services such as: immunisation; health education; antenatal care; family planning; delivery and postnatal care; growth monitoring and community treatment of severe acute malnutrition; diagnosis and treatment of malaria, pneumonia and diarrhoea; treatment of eye infections; treatment of selected skin problems; Vitamin A supplementation; first aid and referral of difficult cases… just to name a few of my daily activities.”
In addition, this young health worker, who has worked at this health post for the last seven years, has done thirty deliveries and many more postnatal checks. “I’m happy UNICEF provided delivery beds, but I also need clean water. Every single day I walk to the nearest water point, because I need clean water for the latrine and health interventions.”
WASH interventions at Health Post level
To date, UNICEF has provided a total of 160 health posts with a complete WASH package. This includes: providing capacity in the design of WASH facilities, construction of water supply and sanitation facilities and hygiene promotion to health institutions through construction and disseminating information on hygiene and environmental sanitation. In addition, WASH interventions at the health post level include: the provision of a hand-washing stand; a septic tank; incinerator; placenta pits; general solid waste and sharp pits.
“I’m lucky having clean water nearby,” says Ababech. “But too many of my colleagues really struggle, especially those who work in remote and dry areas.”
Ethiopia has been an active participant in the Sanitation and Water for All Partnership. In 2013, the Ethiopian Government, with support from UNICEF, was able to establish a Sector-wide Approach termed the ONE WASH National Programme with a dedicated budget line for sanitation in the Government of Ethiopia’s treasury.
Although good progress is underway in the area of water, sanitation and hygiene, still some challenges remain. In 2010, out of a population of over 80 million, about 46 million were without access to improved water supply and sanitation and Ethiopia had the highest number of people (38 million) practicing open defecation among African countries. The lack of access to adequate clean drinking water and sanitation services has a dramatic impact on the lives of people, especially women and girls, and undermines efforts to improve health, nutrition and education outcomes.
Mr Jan Eliasson underlines the need for clean water and sanitation. “We really must act now. We have to talk about sanitation and improving access to toilets and clean water. We also must change attitudes and behaviours,” he emphasises with passion.
Ms Gore fully agrees. “Since I have a latrine and we wash our hands at critical times, I see less disease in my family. The children go to school and we work on the land – for this, we need to be healthy.”