NEW INDEX RANKS ETHIOPIA AS 17TH OF 20 WORST PLACES FOR CHILDREN By Keffyalew Gebremedhin
As part of its contributions to the 66th United Nations General Assembly Session (http://www.savethechildren.org.uk/en/docs/HealthWorkerIndexmain.pdf), Save the Children has ranked in a new index the best twenty and worst twenty countries for children in the world. By this index, Ethiopia is ranked 17th of the worst twenty countries in the world, i.e., above Lao P.D.R., Somalia and Chad. In the best twenty countries category, Switzerland, Finland, Ireland, Norway and Belarus have taken the first five rankings.
The index is constructed on the basis of threshold of just over two health workers for every thousand people. The news analysis on which the index is constructed shows that children living in the bottom 20 countries, which fall below the WHO minimum threshold, are five times more likely to die than those further up the index.
The index underlines that in countries such Ethiopia, Nigeria and Sierra Leone millions of children could die simply because of a lack of trained health workers. The index is not limited to measuring how many health workers. According to its architects, it also it looks into their reach and impact. It also tracks the proportion of children who receive regular vaccinations and mothers that have access to life-saving emergency care at birth.
The Ethiopian experience
With its 85 million people, it is reported that in 2009/10 Ethiopia has, according to data from the Central Statistics Agency, 408 health posts 1,814 health centres, 1,543 government run clinics and 2,135 others, 10,160 beds in government run hospitals and 2,135 others 110 government hospitals and 80 others. However, data by the ministry of health distinctly varies from that. It indicates that as of July 2010 there have been 2,142 health centres throughout the country that provide Integrated Management of Neonatal and Childhood Illnesses (IMNCI).
Finding data is one of the most severe handicaps of Ethiopia, which in the past decades has not shown marked improvements, despite technical assistance from the IMF and other multilateral-bilateral sources of assistance. For instance, the health data from CSA seems deeply flawed, as variations between the advance year sand the previous indicates regression, instead of increases, a sign of quality control. This is not helpful for policy and handling of the country’s chronic problems of underdevelopment.
Stressing the need for caution when using this data, therefore, I have put what the CSA reports in terms of health personnel. In that regard, Ethiopia has 1,203 doctors, 2,548 health officers, 15,754 nurses, 1,156 pharmacists and pharmacy attendants, 777 sanitarians, 2,786 laboratory technicians and 195 x-ray technicians. The numbers above do not include staff and facilities in police and military health services centres.
As regards, service delivery and quality of care, the ministry of health disclosed that implementation of the Maternal Health Program had mixed results. While antenatal care coverage has increased from 67.7 percent in Ethiopian fiscal year (EFY) 2001 to 71.4 percent in EFY 2002 and clean and safe delivery service coverage from 12.3 percent in EFY 2001 to 17.0 percent in EFY 2002, the percentage of deliveries attended by skilled health personnel has declined from 18.4 percent in EFY 2001 to 16.8 percent in EFY 2002.
By the admission of the government, as documented in Health Sector Development Programme III Annual Performance Report EFY 2002 (2009/10), this percentage is very low, even below the Sub Saharan African average of 47 percent in 2009. This has also been clearly noted in the document assessing Africa’s progress toward the Millennium Development Goals, MDG Report 2010).
Nonetheless, the ministry of health in its webpage claims strategies adopted by the government are working. In its, its Health Sector Development Programme III Annual Performance Report EFY 2002 (2009/10), the ministry states:
“These strategies [HEP, accelerated expansion of HCs, provision of Basic Emergency
Obstetric Care (BEOC) and Comprehensive Emergency Obstetric Care (CEOC)) have been implemented and there has been a decline in MMR from 871 deaths per 100,000 live births in 2000 EDHS to 673 deaths per 100,000 live births in 2005 EDHS. Trends in maternal mortality from 1990 to 2008 have been assessed and estimates have been developed by WHO, UNICEF, UNFPA, and World Bank.”
In terms of the overall challenges faced by the health sector, the Ethiopian misfortunes, according to the ministry of health, are:
Poorly functioning referral mechanisms;
Shortage of medical doctors, midwives and anesthesiologists;
Attrition of highly skilled professionals and high turnover of management staff;
Limited capacity of human resources management at various levels;
Shortage of qualified contractors willing to take contracts in remote sites;
Serious shortage and fluctuating high prices of construction materials;
Weak monitoring and follow-up capacity at regional and Woreda levels;
Inadequate availability of resources compared to the health care needs;
Inequitable distribution of funds among various priority health programs;
Poor progress in terms of adopting a common budgetary framework and reporting format by Development Partners;
Slow response of many Development Partners to join the IHP Compact and Joint Financing
Arrangement (JFA); and
Inadequate capacity for fund liquidation, reporting and auditing.
In highlighting that a child’s survival depends on where he or she is born in the world, Save the Children is highlighting a global shortage of over 3.5 million doctors, nurses, midwives and community health workers. It says, “Without them no vaccine can be administered, no life-saving drugs prescribed and no woman can be given expert care during her childbirth. Illnesses such as pneumonia and diarrhoea, which are easily treated, become deadly.”
Challenges to Ethiopia in increasing aid flows
It is important to bear in mind that for the last several years, new group of donors have entered into the realm of making a difference in developing countries by giving aid directly to attack one disease—vertical funding (HIV, malaria, etc.) or a group of diseases (infectious diseases, etc.). This group is pickier, especially emphasizing the rule of law and respect for human rights. Much as their generosity has been extremely helpful, it has also been impossible to coordinate.
In the case of Ethiopia, I am mindful that one of the major problems in aid coordination has been caused by political problems and government actions unpalatable to these funders. Javier Pereira, in a case study entitled Ethiopia: Aid effectiveness in the health sector (2009), makes this very point. He observes, “vertical donors remain outside alignment and harmonisation efforts, hence limiting the amount of progress which could be achieved.”
Therefore, Pereira sees Ethiopia as “a complex arena for aid processes.” By this he means more than 20 donor countries and 20 multilateral agencies are active in the country. For instance, during the High-Level Forum between the Government of Ethiopia and the Development Assistance Group (the High-Level Forum is Ethiopia’s highest level annual meeting on development assistance), three government representatives to sit with over 35 representatives of donor countries. This consumes a great deal of energy and precious time.
Another important point Javier Pereira makes is the rationale why Ethiopia is missing out from major funding for health, which before 2005 had been voluminous. The Key challenges for Ethiopia’s health sector in terms of increasing resource flows is the political side. In that regard, he writes: “Implementing the IHP+ [International Health Partnership and Related Initiatives (IHP+)] will not be easy in Ethiopia. Signing the document was an achievement, but donors are reluctant to start delivering on their commitments under the IHP+. A new and restrictive charity law and the Government’s poor record in human rights are the main obstacles… In addition, the IHP+ does not include Ethiopia’s largest donors, the Global Fund and PEPFAR [US President's Emergency Plan for AIDS Relief], which constrains the outcomes of the initiative.”
In simple point, the conviction on the other side is, “’Democratic ownership’” is still missing in Ethiopia. The Government is showing leadership in aid processes but it is not contributing to creating an enabling environment for Civil Society Organisations CSOs.” In his view, the way forward for the Ethiopian government is to change its attitude, without which the full implementation of the IHP+ is seen as unlikely. In the form of challenges, Javier Pereira lists the following:
“Major vertical donors in Ethiopia are showing positive signs of change. The Global Fund is making efforts to increase the impact of its activities on the health sector in general. PEPFAR has announced a move towards better alignment and harmonisation. But is still has to start implementing it. However, one should not expect to see a radical transformation of these donors. Internal regulations limit their movements and changing them will take time.
Political disagreements with the Government and different views on how to respond have further hampered coordination among donors. In principle, this situation does not seem conducive to achieving greater ownership but the truth is the Government is showing strong leadership in aid processes. Unfortunately, the same is not true of “democratic ownership”: both CSOs and Parliament play an insignificant role. Reinforcing the role of these actors in the aid process is one of the main AE [Aid Effectiveness] challenges currently in Ethiopia.”
What purpose would the index serve?
Save the Children aims to lobby world member states at this 66th UN General Assembly session to take action to end the health worker crisis. It also is trying to engage rich nations to step up their funding of health, especially as there is two-thirds shortfall of what is needed globally.
Nevertheless, with this huge flow of resources has also emerged the problem of coordination that has become a nightmare for poor developing countries.
In this connection, Save the Children should its voice to urge greater coordination between donor countries and entities. This is not something new, since the General Assembly has decisions on the importance of coordination. This would make it easier for developing countries to use their staff in other areas where they are needed most, instead of setting up desks for each donor to follow up their contributions and ensure recording and reporting where and when the funds have been utilized.
Save the Children also stresses that the commitment of developing countries is crucial. It recalls that in 2001, countries across Africa pledged to spend 15 percent of their national budgets on healthcare. So far it is only eight countries that have done so.
Save the Children argues that its rankings see that:
Success is possible in low-income countries. It attributes the successes of Bangladesh and Nepal to their investing wisely in community health workers. The report states, because of that these countries are on track to reach Millennium Development Goal number 4: cutting child deaths by two thirds. It also points out that these countries need more midwives to sustain progress in both countries.
Children living in the most remote areas are least likely to see a health worker. In Ethiopia just under 70 percent of women say that a clinic is too far away, whilst in Sierra Leone, Uganda and Niger more than half of all women surveyed say that the clinic is just too far for them to reach.
Female health workers are crucial in countries such as Afghanistan, Nepal and Ethiopia where women are unable to see a male health worker for cultural reasons. Afghanistan is increasing the number of female health workers that have helped to reduce child mortality.
This would certainly help to alert those that all that have been making their best efforts on behalf of children of the world.