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Comprehensive Analytical Profile: Ethiopia

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This analytical profile provides a health situation analysis of the Ethiopia and, coupled with the Factsheet, it is the most significant output of the African Health Observatory. The profile is structured in such a way to be as comprehensive as possible. It is systematically arranged under eight major headings:
1. Introduction to country context
2. Health status and trends
3. Progress on the Health-Related MDGs
4. The Health System
5. Specific Programmes and Services
6. Key Determinants
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Statistical profile
Introduction to Country Context

The Federal Democratic Republic of Ethiopia is located in the north-eastern part of Africa known as the Horn of Africa (see map). The country has a total surface area of approximately 1.1 million square kilometres.[1] Its topography ranges from peaks as high as 4550 m above sea level at Mt Ras Dashen in the north, to land 110 m below sea level in the Afar Depression.

Ethiopia is a land-locked country, sharing a border with six countries: Eritrea and Sudan in the north, Djibouti and Somalia in the east, Kenya in the south and South Sudan in the west.

Health Status and Trends

Ethiopia is characterized by a predominantly rural and impoverished population with limited access to safe water, housing, sanitation, food and health care. Estimated life expectancy at birth is 57 years for males and 60 years for females.[2] The burden of disease measured in terms of premature death is estimated at 350 disability adjusted life years lost per 1000 population, which is the highest in sub-Saharan Africa.

The disease burden, responsible for 74% of deaths and 81% of disability adjusted life years lost per year, is dominated by malaria, prenatal and maternal death, acute respiratory infection, nutrition deficiency, diarrhoea and HIV/AIDS.[3]

Progress
Progress on SDGs
The Health System
Health system outcomes

The National Health Policy emphasizes core principles of democratization and decentralization of the Health Care System of Ethiopia. Preventive, promotive and curative components of health services in the country have shown a remarkable improvement, meeting equitable and quality health components of health care for all parts of the population[4] and encouraging private and nongovernmental organization participation in the health sector.

The health sector follows a 5-year rolling plan as part of the national development plan. Since 1997–1998, three consecutive phases have been completed and currently the country is implementing the fourth comprehensive Health Sector Development Programme (HSDP).[5]

Leadership and governance

In Ethiopia, the Federal Ministry of Health at national level and the regional health bureaus at regional level are responsible for health sector leadership.

The Federal Ministry of Health. Source: Ministry of Health, 2009

There are four authorized agencies dealing with the Ministry's technical themes. These autonomous agencies report to both the Federal Ministry of Health and the Ministry of Finance and Economic Development.

Community ownership and participation

Ethiopia's overall national policy and hence its National Health Policy is founded on commitment to democracy for citizens to fully exercise their rights and powers in a pluralistic society. Community ownership and participation aims to empower communities to manage the particular health problems that are specific to their community. In 2003, a Health Extension Programme was introduced and its priorities were to create community ownership and empowerment in the health sector.

This objective is implemented through deployment of two community-selected health extension workers in each health post in nearly all of the estimated 15 000 kebeles. The Programme emphasizes an integrated approach, including health promotion, preventive health and referral health services through health extension workers, with the support of community volunteers and model family households. Similarly, with the same objective of ensuring community engagement, ownership and social mobilization, the Health Development Army has initiated a new strategy to scale-up best practices by organizing and mobilizing families.

Partnerships for health development

The National Health Policy of Ethiopia emphasizes that solving the multifaceted problems of the health sector requires timely collaboration from the Government of Ethiopia, the private sector, nongovernmental organizations, multilateral and bilateral development partners, global initiatives, other sectors and the public at large. In cognizance of this fact, the Government has devised several strategies to collaborate with development partners, nongovernmental organizations and various ministries to improve the health status of its citizens. For instance, the governance structure of the fourth Health Sector Development Programme (HSDP IV)[6] was revised to better coordinate development partners with the Government and other stakeholders within the health sector.

The Joint Consulting Forum is the highest governing body and serves as a joint forum for dialogue on sector policy and reform issues between the Government, development partners and other stakeholders and to oversee the implementation of the International Health Partnership (IHP+), the Millennium Development Goal (MDG) performance fund, Protection of Basic Services fund, GAVI Alliance and other donor-supported projects. The Joint Core Coordinating Committee serves as the technical arm of the Joint Consulting Forum.

Health information, research, evidence and knowledge

The health information system in Ethiopia is run under different authorities. The routine health management information system is run primarily by the health sector, while population-based information comes predominantly from the Central Statistical Agency of Ethiopia. Besides the Central Statistical Agency, the Ethiopian Health and Nutrition Research Institute, universities and individual researchers conduct various population and health facility based research activities.

Summary of health information system assessment scores in Ethiopia, September 2011. HIS, health information system

A national health information system assessment was carried out in 2007 using the Health Metrics Network framework and tools and this was updated and validated in 2011 as a step towards developing a national health information system strategic plan.

The results show that indicators and information products are considered adequate but data management is very poor. Health information system resources, dissemination and use, as well as data sources coverage, are also inadequate (see table). The capacity of institutions to generate, analyse, disseminate and use health information differs.

Health financing system

The Ministry of Health in Ethiopia developed and implemented a Health Care Financing Strategy in 2007 to increase funding for health by improving resource mobilization and to ensure equitable resource allocation, efficiency of resource utilization and financial protection of its citizens.

Performance-based contracting is also used to improve supply, by transferring money from purchasers (the Ministry of Health, regional health bureaus and woreda health offices) to service providers (health facilities) conditional on achieving predetermined performance targets.

Moreover, to address financial barriers to accessing health services and to pool risks of doing so, the Government of Ethiopia recently initiated community-based health insurance for the rural and urban informal sectors and social health insurance for the formal sector.

Service delivery

Ethiopia has a decentralized three-tier system of primary, secondary and tertiary care (see figure). The devolution of power to regional governments has largely resulted in shifting decision-making for public service delivery from the central to regional and district levels.

The Health Extension Programme is a flagship programme of the Ministry of Health. It serves as the primary vehicle for implementation of community-centred essential health care packages and as an effective referral system from the grass-roots level to broaden access to care at secondary and tertiary levels. A large Health Development Army was also initiated to expand the success of the Health Extension Programme deeper into the community to improve community ownership and scale-up best practices.

Health workforce

Most low-income countries suffer from a severe shortage of health professionals and Ethiopia is no exception. Ethiopia has a health workforce of 0.7 per 1000 population, which is low compared with the WHO recommendation of 2.3 health workers per 1000 population.[6]

Health extension workers and general nurses dominate the available supply of health workers and there are critical shortages of physicians, dentists, midwives and anaesthesia professionals. The greatest inadequacy is for physicians, whose numbers show a decreasing trend over past years and are now 1: 42 706 population, which is among the lowest ratio in sub-Saharan Africa.[6]

However, numbers of other health professionals such as health officers, nurses, midwives and health extension workers have shown significant improvement over the past 5 years. The country has also achieved the minimum WHO recommendation of 1 nurse per 5000 population.[6]

Medical products, vaccines, infrastructures and equipment

The pharmaceuticals supply core process started in Ethiopia in 2009 with the transformation of the profit-making Pharmaceutical and Medical Supplies Import and Distribution Agency into the service-providing Pharmaceutical Fund and Supply Agency.

The Pharmaceutical Fund and Supply Agency initiated capacity-building activities in terms of:

  • revolving drug funds
  • construction of hubs and transportation systems
  • deployment of human resources
  • designing a logistics management information system.

The Agency's health and health-related services, product regulation and policy documents have been refined, and a new proclamation is being prepared. Drug manufacturing plants and factories have been inspected for good manufacturing practices.[7]

General country health policies

Historically, the health system in Ethiopia was centralized and services were delivered in a fragmented manner with a reliance on vertical programmes. There was little collaboration between the public and private sectors. Administrative arrangements were also centralized until 1991. In 1992, a new health policy was developed following a critical examination of the nature, magnitude and root causes of the prevailing health problems of the country and awareness of newly emerging health problems.

The new policy was founded on commitment to democracy, the rights of the people, and decentralization as the most appropriate system of government for the full exercise of these rights and powers in a pluralistic society. At the core of the health policy is:

  • democratization and decentralization of the health care system
  • developing preventive, promotive and curative components of health care
  • accessibility of health care for all parts of the population
  • encouraging private and nongovernmental organization participation in the health sector.[8]
Universal coverage

The Alma-Ata Declaration signatories noted that health for all would contribute to a better quality of life and also to global peace and security. Although circumstances both within and outside the health sector contribute to the health status of the population, timely access to health services is considered key in promoting and sustaining society’s health.

Thus, in 2005 with the goal of universal coverage WHO Member States committed to developing health financing systems so that all people have access to service without out-of-pocket financial burden.[9]

Specific Programmes and Services
HIV/AIDS

Based on a single point estimate, there are nearly 1.2 million people living with HIV/AIDS in Ethiopia. The adult prevalence rate is estimated at 2.4% and the incidence rate is 0.29%. The prevalence and incidence rates significantly vary between geographical areas and gender. The urban prevalence rate is estimated at 7.7%, while the rural prevalence rate is 0.9%. The prevalence rate is 1.7% for males and 2.6% for females.

With 90 000 HIV-positive pregnant women, there are an estimated 14 000 HIV-positive births and a total of 28 000 AIDS death and an estimated 800 000 AIDS orphans annually.[8]

Following the approval of the declaration on HIV/AIDS known as Resolution 60/262 in June 2006 during the United Nations General Assembly, Ethiopia accepted the Resolution. A Multisectoral Plan of Action for Universal Access to HIV Prevention, Treatment, Care and Support in Ethiopia, 2007–2010''[10] has been developed and implemented. The programme is guided by the principle of the HIV Strategic Plan for Multisectoral Response, universal access commitment, and the ‘’Three Ones’’: one HIV/AIDS action framework, one national AIDS coordinating authority and one monitoring and evaluation system.[3]

Tuberculosis

Ethiopia ranks third in Africa and eighth among the 22 highest tuberculosis (TB) burdened countries in the world. The prevalence of all forms of TB is estimated at 261 per 100 000 population, leading to an annual mortality rate of 64 per 100 000 population. The incidence rate of all forms of TB is estimated at 359 per 100 000 population, while the incidence rate of smear-positive TB is 108 per 100 000 population. The TB case detection rate, treatment success rate and TB cure rate are 74%, 82.5% and 67%, respectively (see figure).[8]

Multidrug-resistant TB (MDR-TB) is a challenge. A countrywide survey between 2003 and 2006 showed that the prevalence of MDR-TB was 1.6% in new TB cases and 11.8% in retreatment cases. In addition, there was a high TB/HIV coinfection rate, with 25% of registered TB cases also testing positive for HIV.[11]

Malaria

Malaria is endemic in Ethiopia, with differing intensities of transmission. The disease is prevalent in areas below 2000 m altitude and is seasonal, with irregular transmission patterns. Areas below 2000 m altitude cover three quarters of the country’s land mass, with an estimated population of 52 million.[12] An epidemic occurs every 5–8 years in these areas, with frequent outbreaks within short periods. The last epidemic occurred in 2003 and recent outbreaks have been reported in consecutive years from 2006 until early 2010. With an average of more than 3 million clinical cases per year, malaria remains the biggest health problem in Ethiopia.

Although malaria is a major cause of child mortality, only 33% of children under the age of 5 years sleep under an insecticide-treated bednet.[13] The disease burden is broad, going beyond the substantial health concerns it creates. The population may be forced to abandon productive areas and to concentrate in malaria-free areas that are exposed to constant food insecurity. As a result, substantial environmental and ecological degradation and loss of productive land has left a significant proportion of the population threatened by recurrent droughts and famine. In addition, malaria affects the learning capacity of schoolchildren due to constant non-attendance of school in the absence of treatment.

Immunization and vaccines development

Neonatal tetanus is a major cause of early infant mortality in many developing countries, often due to failure to observe hygienic procedures during delivery. In Ethiopia, only 48% of births are protected against neonatal tetanus.[14]

Since 2007, three doses of pentavalent vaccine (DTP-HepB-Hib) (diphtheria-tetanus-pertussis/hepatitis B/Haemophilus influenzae type B) have been given in place of three doses of DPT vaccine. The Bacille Calmette-Guérin (BCG) vaccine is scheduled to be given at birth, while pentavalent and polio vaccines are given at approximately 3, 4 and 5 months of age. Measles vaccine is given when a child reaches 9 months of age or soon after. It is also recommended that children should receive the complete schedule of vaccinations before their first birthday, and that vaccinations should be recorded on a vaccination card given to the parents or guardians.[14]

Child and adolescent health

Improving child health is one of the priorities of the Health Sector Development Programme IV[8] covering the period 2010–2015. The infant mortality rate is 59 deaths per 1000 live births. The estimate of child mortality is 31 deaths per 1000 children surviving to 12 months of age, while the overall under-five mortality rate is 88 deaths per 1000 live births. In addition, 67% of all deaths in children aged under 5 years in Ethiopia take place before the child’s first birthday.[14] Malaria, pneumonia, diarrhoea and nutrition deficiencies are among the major causes of child mortality. A high mortality and disease burden from nutrition-related factors is also prominent among children aged under 5 years.[15]

Malnutrition is widespread across the country. Overall, 29% of all children are underweight and 9% of children are severely underweight. Also, 31% of male children are underweight compared with 27% of female children. The percentage of children who are underweight is eight times higher in children with mothers with no education compared with children whose mothers have more than secondary education.[14]

Maternal and newborn health

The maternal mortality ratio in Ethiopia is 676 per 100 000 live births, which is one of the highest in the world and is mainly a result of lack of access to health care, and socioeconomic and demographic factors. This maternal mortality rate remains a major public health challenge facing the country. Every year, 22 000 women and girls die during childbirth or as a result of complications of childbirth.[8]

The lifetime risk of a woman dying during pregnancy or childbirth is 1 in 27. In addition, more than half a million women suffer from pregnancy-related disabilities. Obstetric fistula, a pregnancy-related disability, affects nearly 9000 women each year. For sociocultural reasons, the magnitude of the disability is significantly higher in rural areas where there is a strong tradition for young women to be married at a very early age.

Gender and women's health

Despite recent improvements, child mortality in Ethiopia is still high. The neonatal and under-five mortality rate, responsible for 30% of annual deaths, is caused mainly by diarrhoea, malaria and pneumonia.[15] In addition, the mortality and disease burden from nutrition-related factors in children aged under 5 years is high. A total of 34.6% of children are born underweight while 50.7% are stunted. Stunting (low height-for-age) reflects the cumulative effects of undernutrition and infections since birth and even prior to birth.

As in other countries, the child mortality rate for females is lower than for males. The average probability of dying by 1 year of age is 60 per 1000 live births for females and 78 per 1000 live births for males. In addition, the under-five mortality rate is 100 per 1000 live births for females, compared with 117 per 1000 live births for males.[15]

Epidemic and pandemic-prone diseases

Epidemic-prone disease and nutritional emergencies due to recurrent drought and pandemics are major health sector priorities. However, Ethiopia is not yet adequately prepared to respond efficiently to such threats.

Public health emergency management preparedness and response is one of the core processes introduced under business process re-engineering within the Ethiopian Health and Nutrition Research Institute and implementation has started. In order to establish public health emergency management teams at the Ministry of Health and rural health boards, 13 epidemic intelligence service officers have been trained.

Twenty diseases have been selected for surveillance and detection and new forecasting, early warning, response and record systems have been designed.[6]

Neglected tropical diseases

Leprosy, dracunculiasis, onchocerciasis, leishmaniasis, schistosomiasis, soil-transmitted helminthiasis, lymphatic filariasis and trachoma are among the neglected tropical diseases prevalent to varying degrees in different parts of Ethiopia. A target intervention for prevention and control of neglected tropical diseases is included in the Health Sector Development Programme IV, which covers the period from 2010 to 2014.[16] The eight neglected tropical diseases prioritized are dracunculiasis, onchocerciasis, leishmaniasis, lymphatic filariasis, trachoma, soil transmitted helminthiasis, schistosomiasis and podoconiosis.[6]

Non-communicable diseases and conditions

In the context of the epidemiological transition in Ethiopia, a double burden of disease is already emerging with the mix of persistent infectious diseases and increasing noncommunicable diseases and injuries. Noncommunicable diseases and injuries are already major contributors to the high morbidity and mortality burden of the country.

The prevalence of noncommunicable diseases is increasing, owing to lifestyle changes. Among these diseases, hypertension is the seventh leading cause of mortality.[17] Cardiovascular disease, diabetes mellitus and cancer are the leading chronic diseases, with significant contribution to the overall mortality rate.[3] Chronic diseases, along with injuries and cancer, accounted for nearly 30% of all deaths in 2005.[4]

Key Determinants
Risk factors for health

The rapid economic transformation of Ethiopia has increasingly been accompanied by changes in dietary and lifestyle behaviour that are contributing to a rising risk of preventable chronic illness. These chronic diseases risk factors include high blood pressure, inadequate intake of fruit and vegetables, overweight or obesity, high concentrations of cholesterol in the blood, physical inactivity and tobacco use.

The leading causes of the major noncommunicable diseases are unhealthy diet and physical inactivity. In the WHO African Region, noncommunicable diseases are projected to account for more than a quarter of all deaths by 2015. It is also estimated that the rate of increase of deaths from chronic diseases in the Region will exceed that from infectious disease, maternal and prenatal conditions, and nutritional deficiencies by more than fourfold in the next 10 years.

The physical environment

Ethiopia is one of the 52 countries in Africa that signed the Libreville Declaration on Health and Environment on 29 August 2008. Ethiopia has also been part of an international initiative to prevent environmental degradation, both at local and global level. The Ministry of Health and the Ethiopian Environmental Protection Authority are the leading institutions working on health and environmental health.

The most obvious environmental risk factors affecting human health in urban settings are hazardous wastes from industry and transport, and poor chemical and household waste management. Indoor air pollution and poor housing, food contamination and disease vectors are also risk factors. Toxic wastes are most common in Addis Ababa where industries, automobiles and hospitals are concentrated.

Food safety and nutrition

In Ethiopia, the Food, Medicine and Health Care Administration and Control Authority of Ethiopia (FMHACA) is responsible for undertaking inspection and quality control of health and health-related products, premises, professionals and health delivery processes in an integrated manner. The FMHACA has regional branch offices to expand its function throughout the country. It also works collaboratively with the Ethiopian Revenues and Customs Authority and other Government institutions to prevent export, import and marketing of unsafe food items and to prevent and control the use of narcotic drugs, including tobacco.

Ethiopia has a National Drug Policy and a proclamation on food, medicine, health care administration and control. The new proclamation No. 661/2009 outlined requirements for registration and licensing food producers, imports and exports, food safety and quality, packaging and labelling, nutrition and food irradiation.

Social determinants

Ethiopia is the second most populous country in Africa, with a population of 84 million and an annual growth rate of 2.6%.[18] The country is committed to open, transparent and democratic governance that respects the rights of all of its citizens, as enshrined in the constitution. The Ethiopian economy largely depends on its agricultural sector, which employs 83.6% of the labour force and is responsible for 42% of gross domestic product and 83.1% of exports.[19]

Exports of agricultural commodities are predominantly coffee and oil seed. The year 2010 marked the end of the Plan for Accelerated and Sustainable Development to End Poverty (PASDEP),[20] which gave attention to poverty-related health programme targets.



References
  1. Ethiopian Government portal: government overview.
  2. World health statistics 2010 (pdf 4.62Mb). Geneva, World Health Organization, 2010
  3. 3.0 3.1 3.2 Government of Ethiopia, Ministry of Health
  4. 4.0 4.1 WHO Country Cooperation Strategy 2008–2011 Ethiopia (pdf 616.72kb). Brazzaville, WHO Regional Office for Africa
  5. Health Sector Development Program IV, 2010/2011–2014/15. Final draft (pdf 780.81kb). Addis Ababa, Government of Ethiopia, Federal Ministry of Health, 2010
  6. 6.0 6.1 6.2 6.3 6.4 6.5 Health Sector Development Programme IV, 2010/11–2014/15. Final draft (pdf 780.81kb). Addis Ababa, Government of Ethiopia, Federal Ministry of Health, 2010
  7. Health Sector Development Programme. Annual performance report. Addis Ababa, Government of Ethiopia, Ministry of Health, 2010
  8. 8.0 8.1 8.2 8.3 8.4 Health Sector Development Programme IV. Annual performance report. Addis Ababa, Government of Ethiopia, Ministry of Health, 2010
  9. Health systems financing. The path to universal coverage (pdf 2.82Mb) Geneva, World Health Organization, 2010
  10. Multisectoral Plan of Action for Universal Access to HIV Prevention, Treatment, Care and Support in Ethiopia, 2007–2010 (pdf 1.4Mb). Addis Ababa, HIV/AIDS Prevention and Control Office
  11. Global tuberculosis control 2009. Epidemiology strategy financing (pdf 6.95Mb). Geneva, World Health Organization, 2009
  12. Ethiopian national malaria indicator survey, 2007. Technical summary (pdf 173.25kb). Addis Ababa, Government of Ethiopia, Ministry of Health, 2008
  13. World malaria report, 2010 (pdf 9.85Mb). Geneva, World Health Organization, 2010
  14. 14.0 14.1 14.2 14.3 Ethiopian demographic and health survey, 2011 (pdf 683.08kb). Addis Ababa, Central Statistics Agency; Calverton Maryland, ICF Macro
  15. 15.0 15.1 15.2 World health statistics. Geneva, World Health Organization, 2010
  16. Health Sector Development Program IV. Annual performance report. Addis Ababa, Government of Ethiopia, Ministry of Health, 2010
  17. Health and health-related indicators, 2008. Addis Ababa, Government of Ethiopia, Ministry of Health, 2008
  18. Central Statistics Agency, 2011
  19. Government of Ethiopia, Ministry of Finance and Economic Development, 2008–2009
  20. Plan for Accelerated and Sustained Development to End Poverty (2005/06–2009/10). Plan for Urban Development and Urban Good Governance (pdf 1.32Mb). Addis Ababa, Government of Ethiopia, Ministry of Works and Urban Development, 2007