Disparities in funding are causing frustration in Ethiopia, where the government is finding it difficult to align the priorities of donors with needs on the ground.
Ethiopia is both one of the world's poorest countries and one of the world's biggest recipients of foreign aid. The country's health system has expanded over the past decade, but improving the welfare of Ethiopia's largely impoverished population of 85 million people is a longer road. It is also an illustration of how the foreign aid priorities of wealthy donor nations are not always aligned with health needs on the ground.
In many ways, Ethiopia is typical within Africa. Most of the country's health problems are due to preventable infectious diseases, malnutrition, and complications from pregnancy and childbirth. More than 84% of the population lives in rural areas, and the income per head is US$174 per year, with about 40% of the population living on less than $1 a day.
The biggest needs for the country are also typical: water, transportation, and more doctors, nurses, and midwives. Yet all of these basics receive little attention from foreign donors. A large proportion of foreign aid to the cash-strapped country goes towards HIV/AIDS. The disease is largely concentrated in specific populations, like sex workers and soldiers, and in urban areas and on international trucking routes. A look at the funding from the USA is telling: even though the national prevalence rate of HIV/AIDS is a relatively low at 2·3%, the aid delivered through the USA's President's Emergency Plan for AIDS Relief (PEPFAR) programme, which is extremely popular with the US Congress, is ten times the amount spent on maternal health, despite the fact that Ethiopia's death rate for mothers giving birth is among the highest in the world.
Overall, lack of funds for the country's health systems remains a major problem. The country only spends $15·5 per head on health, which is nearly half the African average, and well below WHO's recommendation of $34. Given the limited resources, the government is making strides. Among these is a new system of 30 000 health extension workers—local women are given limited medical and hygiene training and set up health posts serving the surrounding villages. These community health workers give lessons on hygiene, maternal health, keep medical records, and provide immunisations. Some are also delivering children—this is supposed to be in the case of an emergency, but with so few medical staff available in the country it is likely to be increasingly common. The number of health professionals is desperately low. There are only 0·02 physicians and 0·24 nurses and midwives per 1000 people, compared with the WHO minimum recommended standard of 2·3 per 1000. Only 5·7% of women get professional medical assistance when delivering. An average of 19 000 women a year die from complications arising from childbirth. 75% of women have undergone circumcision.
Mortality for children younger than 5 years has declined from 166 per 1000 live births in 2000 to 124 in 2005. Still, 57% of children remain chronically undernourished, and 33% are underweight. Half a million children under 5 years die each year. At 5·4 births per woman, the country has an extremely high birth rate, despite contraceptive use more than doubling from 2000 to 2005 to 13·9%.
While the HIV prevalence rate is low, the country ranks seventh of the world's 22 high burden tuberculosis countries, and has only a 35% detection rate. Malaria is the country's biggest problem, resulting in more than 8 million clinical cases a year. More than 40% of the population has insecticide-treated bednets, but only 24·3% of the nation's children sleep under them.
Funding to address these problems is highly uneven. The US Government's anti-HIV/AIDS funding is $323 million a year, which dwarfs spending for every other disease programme (the combined US funding for malaria and tuberculosis is about $41 million). Meanwhile, assistance for maternal and child health is $17·5 million, nutrition is $9·7 million, and water supply and sanitation is only $7·5 million.
The biggest problem of all, say local health providers and villagers, is the lack of water. The difficultly of obtaining water affects every aspect of health, but has particular consequences for women, who are the ones tasked with walking several hours to fill up the 20 L jerry cans. “We teach women that they must breast feed 8—10 times a day. But a woman has to go to town so far to fetch water”, said Aziza Ismael, a worker at the health post in the town of Galato. “This means a child doesn't get enough breast milk.”
Soap is also lacking, so villagers are encouraged to wash their hands with ashes. In some villages, charities have set up pilot programmes to provide containers to collect rain water. If done properly, it makes a big difference. But such local, small-scale projects have caught the eye of neither the government nor big foreign donors.
The other major problem for health, often ignored by donors, is the lack of transportation. In the rural areas and highways, there are virtually no private cars in the countryside, just freight trucks and the ubiquitous Toyota SUVs beloved of aid organisations. Instead, villagers travel by donkey cart or by foot, the women and girls often carrying heavy loads on their backs or on their heads.
Although the government lauds its community health worker programme and new network of rural health clinics, officials admit that with such a big expansion, the staffing and quality of service remains a problem. This was driven home by a visit to the Shinshicho health centre, which serves more than 127 000 people. The health centre staff listed their problems: lack of funds, lack of skilled health workers, lack of transportation, and a lack of essential drugs. The health centre has one doctor and three nurses. The distance to the nearest hospital is 19 km. Basic equipment, like refrigerators, often fails.
While officials were speaking to The Lancet, four men entered the compound carrying a homemade stretcher, bearing the white shrouded figure of a woman, her husband trailing behind. The men, who had walked 2 h with the stretcher from their village, laid her gently on the concrete floor in front of the clinic, and then stood back to wait. Soon after, a 7-year-old child was brought into the clinic on a donkey cart. “This is our helicopter”, joked a local health official. The mother had travelled 20 km with her son, whom she said had been sick for 3 months. The boy, Anae, was listless, face and feet swollen. She carried him to a bench and was told to wait.
Even in the capital Addis Ababa, the lack of doctors is a problem. At the Gandhi Memorial Hospital, which specialises in maternal care, overcrowding is a constant issue. 30 women a day are given delivery assistance, but another ten are turned away, said Dereje Alemayehu, the medical director. Even basics like pap smears are hard to come by; when the hospital offered them in a pilot programme, 70 of the staff queued up to get checked.
But even as basic health care lags, the HIV/AIDS programme shows the benefits that heavy funding can have. In Galato, posters for the anti-AIDS campaign lined the walls of health centres and private huts, and at a community meeting with village elders, pledges were made to change behaviour, such as to stop practising polygamy and for men not to share razors, in order to reduce HIV infection. The HIV prevalence in the village is zero.
Dawn Broussard, the Deputy Director of the US Centers for Disease Control in Ethiopia emphasised that under the Obama administration's new Global Health Initiative, PEPFAR funds would be used for more general health systems strengthening. However, Keseteberhan Admasu Berkane, the Ethiopian senior government official in charge of health promotion and disease prevention, said that US funds would be better used by giving them directly to the Ethiopian Government rather than funnelling them through consultants and NGOs. He estimated that 50% of the $323 million allotted to HIV/AIDS through PEPFAR was spent in the USA, not in Ethiopia.
There are some aspects of the PEPFAR programme that are broader in scope than HIV/AIDS. One is a communal farming programme that provides a mix of income, nutrition, and the opportunity for the children to work together. The founder, a 21-year-old named Abraham Mahari who lost both his parents to AIDS when he was 12, said he did not want other children affected by HIV/AIDS to suffer the discrimination and deprivation that he suffered. “Working with other kids gives them psychological support”, he said.
The 1·5 hectare collective farm is on the shores of Lake Awasa, 4 h south of Addis Ababa. Beautiful rows of bluish cabbages, green lettuces, leafy sugar beets, sweet potatoes, and spinach are set in irrigated rows along the hills overlooking the water. More than 140 children affected by HIV, either personally or through a relative, work the area twice a day, visibly delighted as they water, weed, and compost. Working with the other kids, “I don't get depressed”, said Yiftu Sira Yohannes, whose father died of AIDS. She did not like gardening at first, but now she says “I'm happy to see all of this stuff grow.
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