Steve Lewis, Health Advocacy Manager at RESULTS UK, reflects on recent progress in Ethiopia towards reducing under-5 child mortality and discusses 5 lessons that can be drawn from their achievements.
Earlier this year I visited Ethiopia, a country which has made dramatic progress in reducing its under-5 child mortality rate. Child deaths have been cut from 198 deaths per 1,000 live births in 1990 to 77 today. One of the effective approaches behind this success is that health services are delivered to the poorest children in an integrated way. The approach combines prevention, protection and treatment of the most common childhood illnesses.
RESULTS UK is currently developing its Child Survival advocacy strategy for the next 3 years. I looked at my notes from Ethiopia to see what lessons RESULTS can learn, and what recommendations to include in our strategy. This will help us to work with national and donor governments, and other international partners, to move towards ending preventable child deaths in developing countries. In this post I will focus on five points of learning.
Firstly, invest in Primary Health Care. A major success of the Government of Ethiopia (GoE) was to focus on primary care and prevention, including a massive scale-up in human resources for health. Unable to afford major infrastructure investment in hospitals or doctors, the Ministry decided instead on a radical and rapid scale up of Health Extension Workers (HEWs). In the last 8 years the ministry has recruited 34,000 female health outreach workers to support primary health care in rural, urban and pastoralist communities across the country. HEWs carry out vaccinations, give advice on neo-natal and maternal health, and can treat the simple cases of diarheoa, pneumonia and malnutrition, referring more complex cases to the Health Centre. The policy has been very successful in giving a rapid fall in the IMR and an expansion in national vaccination rates.
Ethiopia is the 12th poorest in the world. It is still known in the UK for the BBC coverage of terrible famine in 1994. The Ethiopian famines were the genesis of Bob Geldorfs involvement in Africa, Band Aid and Live Aid. Yet it is also the country where over the last ten years there has been a very successful attack on the worst forms of poverty, and health indicators have almost universally improved. The vaccination rate has increased dramatically, as the Infant Mortality Rate has fallen, and ministry officials informed us that “we will never have another famine in Ethiopia – we have learnt to manage so much better”. Ethiopia will meet the MDG targets in at least some of the MDGs.
Talking to actors involved in this transition, the second lesson that most agencies agree on is that the response has been strong because it was clearly Government led. Although DIFD and other donors are very major financial contributors, the health transition process has been designed and is led by the Ministry. “I have worked in various African countries”, said one DFID official we spoke to, “but never one with such a clear and defined health strategy and plan”.
Thirdly, there needs to be strong communications and mutual respect between donors and implementing ministries. I visited Ethiopian health programmes with a UK parliamentary delegation to assess the effectiveness of the health element of the UK aid programme, so this was a key area of discussion between the MPs and Ethiopian officials. We found that mutual respect was high: “The UK Aid programme is strategic, flexible and effective…. We much appreciate the excellent quality of DFID, one of our most important partners”, said Dr Kesetebirhan Admasu, the Minister of Health.
Fourthly, donors can support strong country-ownership of health programmes by putting their funding through the ‘Sector Wide Approach’. DFID put most (but not all) of their funds into a common basket at the disposal of the Ministry. The Ethiopians prefer it because they can programme the funds in the areas that need it most. Since DFID are the country’s second largest bilateral donor in the health sector it is very important that they take a lead in this way. The funds are still audited and DFID are confident ‘they know where every dollar is spent’ – but it is spent in areas determined by population needs and not by the whims of the donor. The ‘basket’ approach is also, importantly, supported by ten other donor countries.
And lastly, the fifth lesson is that progress in reducing child mortality relies on integrating services to address health in a holistic way. A comprehensive approach to child health requires vaccinations to prevent disease, clean drinking water, access to hygiene and sanitation, good nutrition including exclusive breastfeeding for the first 6 months of life, and access to appropriate treatments for the leading causes of death and disability.
These lessons, and others from other countries, will be included in the new RESULTS UK Child Survival advocacy strategy. If you would like to see a draft version of this please contact me at [email protected]. We are keen that some independent readers, with knowledge of child health issues, read the draft strategy before we finalise it.
The views and opinions expressed herein are those of the author and do not necessarily reflect the views of the RESULTS UK.