Southern Ethiopia - Gwent Health Link

Background

Ethiopia has a long history as an independent nation. Situated on the eastern side of Africa it is a landlocked country of great beauty and equally great poverty with 80% of the population living on a mere US$2 per day (Federal Democratic Republic of Ethiopia, 2006). Ethiopia has a large and growing population, estimated to be approximately 77 million in 2006/07 (Federal Democratic Republic of Ethiopia). The country has one of the highest maternal and neonatal mortality rates in the world with 673 women dying per 100,000 live births (Federal Democratic Republic of Ethiopia, 2007). Many women give birth without the presence of a skilled birth attendant so the risk of morbidity as well as mortality in childbirth is high. In 2006/07, only 16.4% of women in Ethiopia gave birth in the presence of a skilled birth attendant (Federal Democratic Republic of Ethiopia, 2007). Life expectancy in general for men is 48 years and 50 years for women, particularly low in comparison to world standards and low even in comparison to ‘less developed’ countries.

Shortage of trained health care staff is a major problem with health worker to population ratios three to four times lower than in other East African countries (Girma et al 2007). Ethiopia is working hard to address the deficit and increase the numbers of trained healthcare workers at all levels. There has been, and remains, a particular focus on the training of Health Extension Workers (Federal Democratic Republic of Ethiopia 2005; Federal Democratic Republic of Ethiopia, 2007). Ethiopia has also made some progress in improving health indicators, for example ‘under five’ mortality rates have reduced from 166 to 123 per 1000 live births over a five year period (Federal Democratic Republic of Ethiopia, 2006). Infant mortality and ‘under 5’ mortality rates and are now lower than in some other countries with a similar per capita income (World Bank 2005, cited Girma 2007).

Agriculture is the main source of revenue for Ethiopia but the vagaries of drought and limited, subsistence style agricultural practices inhibit yields. The production of excellent coffee is essential to the economy. The majority (84%) of the population live in rural communities (Federal Democratic Republic of Ethiopia, 2007). In rural areas in particular, provision of a clean water supply and adequate sanitation are major issues. Child malnutrition is a problem in some regions. Road networks are limited and of poor quality. Transportation between villages is by walking or donkey cart. Collective taxi for those who can afford it, or a lift on the back of a truck, may provide an uncomfortable but speedier transfer to a larger town.

The government of Ethiopia has developed a twenty year strategy to address the high mortality and morbidity rates which are primarily due to potentially preventable infectious diseases and also nutritional factors (Federal Democratic Republic of Ethiopia, 2007). Clear short term and long term plans have been designed and implemented in phases in order to improve the overall health of the nation by providing high quality services in the key areas of health promotion, illness prevention, cure and rehabilitation. The Health Sector Strategic Plan Phase 3 clearly sets out the vision, priorities and actions to be achieved in the period 2005/06 to 2009/10 (Federal Democratic Republic of Ethiopia, 2005). Health promotion and health education initiatives focus on the prevention of HIV, tuberculosis, malaria and parasitic intestinal infection. Training and deployment of Health Extension Workers is an important initiative in the country’s strategic plan as is the expansion of health care facilities including Health Centres. Meeting the reproductive health needs of a young and growing population in order to improve the health outcomes for childbearing women and their babies is also a key priority (Federal Democratic Republic of Ethiopia, 2007). Throughout the country there are many aid organisations, small and large, working positively with local populations as well as the government, to address the considerable health and welfare needs of the people of Ethiopia.

Ethiopia is divided into nine ethnically based administrative regions. The Link works in the Southern Nations, Nationalities and Peoples Region which is situated in the south of Ethiopia. Awassa is the regional town, located 275 kilometres south of Addis Ababa. The primary source of health care delivery for the rural population of SNNPR is the local Health Centre. In 2006/07, there were 163 Health Centres serving the Southern Nations Nationalities and Peoples Region with a population of over 15,000,000. The combined physician/health officer (all services) ratio to population in SNNPR was 1: 50,233 and the ratio for nurses 1: 7,149 – both considerably higher than the World Health Organisation standard of 1: 10,000 and 1: 5,000 respectively. These ratios of health professional to population are also higher in SNNPR than the national (Ethiopia) figures of 1 physician/health officer: 25,009 per head of population and 1 nurse: 4,250 per head of population. However, 35.5% of women in SNNPR gave birth in the presence of a skilled birth attendant in 2006/07, better than the national (Ethiopia) average of 16.4%. 73.8% accessed antenatal care and 28.7 received postnatal services, again higher than the Ethiopian national rates of 52.1% for antenatal care and 19% for postnatal services (Federal Democratic Government of Ethiopia, 2007).

Health Centres are central to the government of Ethiopia’s strategy for health. A Primary Care Unit is defined as one Health Centre and five Health Posts, planned to serve a population of 25,000. The target staffing levels for a Health Centre are ten health professionals and twelve administrative/support staff with Health Posts to be run by two Health Extension Workers (Federal Democratic Republic of Ethiopia, 2005). All Health Centres are designed to provide outpatient services for treatment as well as preventative care and to act as first level referral for patients whose health care needs cannot be met at Health Post level. Limited in-patient care can also be provided. Some Health Centres are designated to provide basic emergency obstetric services while others should be able to provide more comprehensive care in cases of obstetric emergency (Girma et al 2007). Health Centres also provide technical support for Health Posts and some training and support for Health Extension Workers. Health Centres are monitored by Woreda Health Offices (Federal Democratic Republic of Ethiopia, 2005). As part of the strategy for health care delivery in Ethiopia there has been an increase in the number of Health Centres over a five year period from 451 to 690 in 2006/07 and a corresponding increase in Health Posts from 1,432 in to 9,914 (Federal Democratic Republic of Ethiopia, 2007).

Health Centres then have no doctors but are generally staffed by qualified but young, relatively inexperienced health officers, clinical nurses, laboratory technicians and midwives, for on qualification they are normally sent to a Health Centre for their first posting. Midwives and health officers in particular may be the only trained person in their field working in the Health Centre. They can work very much in isolation. Currently there is little, if any, provision for continuing education to update essential knowledge and skills, no clinical supervision or formal mentorship arrangements and few opportunities to network and learn from/with others – all factors that seem inhibiting of development. Retention of experienced clinicians in the Health Centres can also be problematic as individuals leave to undertake further training that will upgrade their qualifications and salary, for example, clinical nurse or midwife to health officer. Many then prefer to seek employment in health offices, or in private hospitals where salaries are better, or in government hospitals that provide a wider range of services, rather than return to the relatively isolated setting of a rural village to work in a Health Centre (Federal Democratic Republic of Ethiopia, 2005; World Bank 2005, cited Girma 2007) Patients who require specialised care that a Health Centre is unable to provide are transferred to the nearest hospital, but this may be more than fifty kilometres away over poor roads and with no ambulance to assist in the transfer.