Alemayehu G. Mariam calls our attention to the dire state of the healthcare sector in Ethiopia. His account is based on and inspired by an article from Hanna Ingber Win, the world editor of the Huffington Post who has reported on the Ethiopian malaise. This well-informed article also draws on data from the World Health Organisation (WHO) and comes to shocking conclusions about the healthcare situation in the country. Mariam calls us to action on this issue and argues that there is hope for ending child malnutrition and poor maternal and child health in Ethiopia, provided we ‘work together in unity – with malice towards none and charity for all’.
It is not only Mother Ethiopia that is in deep trouble today but also the millions of mothers in Ethiopia. Hanna Ingber Win, the world editor of the Huffington Post was ‘invited by the UN Population Fund to visit its maternal health programs in Ethiopia, which has one of the world’s worst health care systems’. Her investigative findings are shocking to the conscience, her analysis is compelling and convincing, and her conclusions are profoundly distressing but not lacking in cautious optimism. In a five-part series entitled Mothers of Ethiopia, Win paints a portrait of a country that is the epicentre – the ground zero – of Africa’s maternal and child health crises.
EXCERPTS FROM HUFFINGTON POST
'Zemzem and her husband, a poor farmer, collected 50 birr (US$4) from their neighbours for the trip to a hospital … and travelled 20 hours, while in labour, from her rural village to get to the hospital in the closest big town. By the time she arrived at the hospital, her uterus had partially ruptured. A resident and health officer were able to save her life and that of her baby… If she [had been delayed] two or three hours more, the baby – and even the mother – would have lost her life… No one else in the ‘Septic Room’ can empathise with Zemzem's joy. The other three patients all had fully ruptured uteri and lost their babies… When I enter the maternity ward at Jimma Hospital, the stench practically smacks me in the face. The smell, a combination of urine and faeces and other bodily fluids, overpowers all my other senses…
'Ethiopia ranks among the top 10 countries for child marriage, according to the International Centre for Research on Women’s Analysis… Early marriage can cause higher rates of maternal and infant mortality, vulnerability to HIV/AIDS, abuse, isolation and long-term psychological trauma from forced sex, according to UNFPA… Two centres in Addis serve about 600 girls between the ages of 10 and 19, says Habtamu Demele, the project coordinator of the centre. Most of them have escaped early marriage. Even though the legal age to marry in Ethiopia is 18, more than 30 percent of girls living in rural parts of the country are married by age 15, according to the Population Council…
'The white tile floors in the Ayder Referral Hospital in Mekelle, a large city in northern Ethiopia, look so clean they practically sparkle. Unlike the maternity ward in Jimma that reeks of human waste and sickness, this hospital smells sterile and clean. Nurses gather at their station writing down their patients' information in orderly files, and a small handful of visitors wait patiently in the corridors. The multi-storey hospital with a manicured garden and televisions in the hallways looks so modern and fancy it could easily belong in New York. There's just one problem: many of its new beds go empty. The hospital, which opened in September 2008, does not have enough doctors or medical equipment for the facility to be fully used. Of the 450 beds in the hospital, only about 65 per cent can be filled…
'In Ethiopia, the maternal health statistics suggest that the nation's health care system needs an overhaul. Less than six percent of women have access to a health professional while giving birth, according to Ethiopia's 2005 Demographic and Health Survey. The maternal mortality rate is one of the worst in the world. For every 100,000 live births, 673 women die giving birth, according to the survey.
'In the United States, eight women die during childbirth for every 100,000 live births, according to the UN Children's Fund (UNICEF). In Ethiopia, 673 women die, making the maternal mortality rate 84 times higher. UNFPA considers every single maternal death preventable. In the U.S., a woman has a 1 in 4,800 chance of dying from complications due to pregnancy or childbirth in her lifetime.
‘This government has failed at the very important task of training the professionals,’ says Dr. Beyene Petros, chairman of the opposition United Ethiopian Democratic Forces party and a member of the Ethiopian House of People's Representatives. ‘You can put up huge buildings, but if you don't have a program to properly train and maintain the manpower, what's the value?’
WIN’S ANECDOTAL DATA IS CONSISTENT WITH THE MACRO LEVEL HEALTH DATA
One may be tempted to critique Win’s report as anecdotal based on episodic observations of a few isolated cases. This, however, would be erroneous because the general statistics on the country’s health system are more frightening than the reports of individual cases. According to World Health Organisation (WHO) 2006 data, Ethiopia’s population was estimated to be 77 million. To serve this population there were 1,936 physicians (1 doctor for every 39,772 persons); 93 dentists (1 for every 828,000 persons); 15,544 nurses and midwives (1 for every 4,985 persons); 1,343 pharmacists (1 for every 57,334 persons); and 18,652 community health workers (1 for every 4,128 persons). The total expenditure on healthcare as a percentage of gross domestic product (GDP) was 5.9 per cent. General government expenditure on healthcare as a percentage of total expenditure on healthcare was 58.4 per cent, and private expenditures covered the balance of 41.6 per cent. There are less then 25 hospital beds available per 10,000 people. Per capita expenditure on healthcare was US$3 at an average exchange rate. The WHO’s minimum standard is 20 physicians per 100,000 people, and 100 nurses per 100,000 people. What more can be said? The numbers speak for themselves.
HEALTH AND THE EMPTY RHETORIC OF ECONOMIC DEVELOPMENT
If empty political rhetoric and grandiose claims of double-digit development were concerned with medicine, Ethiopia would be the healthiest country in the world. Addressing the opening session of Ethiopia's ‘parliament’ recently, Girma Wolde Giorgis, the putative president, repeated the cockamamie fabrication of runaway economic development over the past half-dozen years: ‘The fact that our economy has been able continuously to register growth rates of more than 10 per cent annually for the last six consecutive years in such difficult global and domestic circumstances is an attestation of the success of our policies and strategies designed to speed up our development.’ But Girma and his confederates seem to be clueless about the singular importance of heath in economic growth and development. In fact, health is considered so important that five of the eight targets of the Millennium Development Goals (adopted by 189 nations and signed by 147 heads of state in September 2000) to be achieved by 2015 are directly related to improvements in healthcare services and nutrition: eradication of extreme hunger and poverty; reduction in child mortality; improvements in maternal health; combating HIV/AIDS, malaria and other diseases; ensuring environmental sustainability; the achievement of universal primary education; the promotion of gender equality and the empowerment of women; and the development of a global partnership for development.
It is a cruel joke to talk about runaway economic development in ‘one of the world’s worst healthcare systems’. There can be no economic development in a society that is ravaged by pandemics, suffers from a high incidence of child and maternal mortality, which is devastated by preventable and vector-borne diseases and abysmally lacks basic maternal and prenatal services and rational public health policies. To believe in the fantastic blather about ‘10 per cent plus annual economic development for the last six consecutive years’ is to believe in the purple cow that no one has ever seen and the pink elephant that some see too often in the land of living lies.
The empirical data overwhelmingly shows that heath is a fundamental determinant of economic development and poverty reduction. The health status of a population affects economic growth directly through labour productivity and the negative effects of morbidity (i.e., fewer worker-related illnesses, lower absenteeism rates and the diversion of scarce resources for treatment of ill health from other activities). There is vast scientific evidence to show that improvements in healthcare services lead to significant increases in per capita income directly as each individual is able to produce more per unit of labour input. Beyond the immediate effects of poor healthcare services on productivity, the impact of child malnutrition and poor maternal and child health services will have a devastating impact on the Ethiopia’s future. It is well-established that malnutrition-related health problems of children have lifetime effects. Simply stated, sick children perform poorly in school and poor performance negatively impacts on future individual income and overall labour productivity of citizens in society. Without massive investments in healthcare services, training of healthcare providers, improved child nutrition and maternal care and the establishment of clinics, health centres, hospitals and dispensaries, Ethiopia’s future economic growth, labour productivity and most importantly, its precious youth, are doomed.
WHAT IS THE VALUE OF ECONOMIC DEVELOPMENT?
So, we must ask some obvious questions: Why does Ethiopia have ‘one of the world’s worst healthcare systems’? What is the value of an ‘economic development’ that completely ignores the healthcare needs of the vast majority of its citizens? What is the value of an alleged 10 per cent plus economic growth if 85 per cent of the population has little or no healthcare services? What is the value of exporting flowers but not importing basic pharmaceutical drugs and essential medical equipment? What is the value of putting up shiny new buildings that offer little healthcare services but stand as magnificent political showpieces? Is there anything that has more value than ensuring the good health of a nation’s citizens? Is there even a slight chance that Ethiopia will meet its Millennium Development Goals?
WHAT IS HANNA INGBER WIN REALLY SAYING?
Win’s manifest purpose was to investigate certain projects supported by the UN Population Fund and report her findings. Her report sheds considerable light on the fact that the country’s healthcare system is terminally under-staffed, under-resourced, underdeveloped, mismanaged, over-bureaucratised and over-politicised, and its few health professionals under-qualified. But her findings also focus a beam of scrutiny on some stark policy questions: Why are scarce resources being wasted on shiny buildings and not in the recruitment, training and retention of physicians and other healthcare providers in Ethiopia? Why isn’t there a comprehensive programme of retention of Ethiopian doctors and other health professionals fleeing the country? Why is healthcare dominated and controlled by centralised planning in a country that is allegedly ‘federal’? Why isn’t healthcare planning decentralised to empower local communities? Why is there little investment in health education, prevention and disease control? What happens to all of the aid money that is earmarked for health?
There are major policy prescriptions that follow Win’s findings. First, it is clear that something must be done to stave off the exodus of Ethiopian doctors and other health professionals. It is a national tragedy that there should be a pervasive belief among health professionals in Ethiopia that there ‘are more Ethiopian doctors practicing medicine in Chicago than in Ethiopia’, as Win reported. But Ethiopian doctors are leaving the country for many compelling reasons: They do not want to practice medicine in unsafe and wretched conditions; they are frustrated by their inability to meet even the most basic needs of their patients; they do not want to work in a health system that lacks basic medical equipment, medications and trained providers; they object to being overworked, underpaid and underappreciated; and they would like to earn fair compensation for their services.
In March 2007, Meles Zenawi, responding to a question on the Ethiopian ‘doctor drain’, shocked health officials and physicians attending the conference. He declared, ‘We don’t need doctors in Ethiopia … let the doctors leave for wherever they want. They should get no special treatment.’ When the life and wellbeing of 80 million people hangs in the scales, such a callow reaction and arrogant attitude must condemned. No effort must be spared to retain Ethiopian doctors in order for them to serve in the country, particularly in the rural areas. It is also an obvious fact that the flight of Ethiopian doctors necessarily means the importation of expensive foreign ones or the vast majority of Ethiopians will continue to die from preventable diseases and lack of basic health services.
It would be misleading and unfair to leave the impression that Ethiopian doctors who have left the country have been totally disengaged from it. There indeed are some Ethiopian diaspora physicians and other health professionals who have done their share to help out. These unsung heroes have organised periodic medical mission trips to Ethiopia with colleagues from other countries. Some have even gone to extraordinary lengths to establish foundations for the principal purpose of acquiring much needed medical equipment and supplies to meet critical medical needs. They are refreshing points of light on the dark sky of ‘one of the world’s worst healthcare systems’.
The second area of policy concern underscored in Win’s report is the need to undertake a broader initiative to establish a more equitable health system between the urban and the vast rural areas where health services are virtually nonexistent. Something has to be done to provide incentives to healthcare professionals to work in underserved rural areas. Instead of wasting scarce resources on state-of-the-art half-empty hospitals that have few doctors and other health professionals, it makes more sense to use those resources to build rural clinics, train health officers and community health workers. Furthermore, these resources should be used to attract students from rural areas who are likely to remain in their communities to be engaged in public heath services as well as supplementing the salaries and benefits of other healthcare providers to go into the rural areas. Donors may be in the best position to help bridge the urban–rural gap and improve the overall quality of rural medicine. What is also implicit in the interview responses of Ethiopian health workers is the need to reassess the roles of nurses, mid-level health workers and community health workers and explore ways of diversifying their responsibilities through training.
SPEAKING TRUTH TO THE DICTATORSHIP
Win deserves our gratitude and appreciation for calling attention to the massive healthcare problems plaguing the mothers of Ethiopia. She told the story as she saw it. Her findings may prove embarrassing to a dictatorship that seeks to paint a portrait of a country panting for air from the galloping economic development it is undergoing. The fact of the matter is that when the lives of millions of mothers and their children are at risk, there is only one way to tell the story: The truth, the whole truth and nothing but the truth. That is what Win has done in her anecdotal report based on her visits to facilities supported by the UN Population Fund. Her report will ultimately serve to empower Ethiopian women by forcing the dictatorship to face up to the fact that it needs to provide resources to protect Ethiopian women's basic right to maternal and reproductive health – one of the cornerstones of the Millennium Development Goals.
There is another fact that we cannot afford to gloss over. Win’s report showed an apparent gap in the location and sophistication of healthcare infrastructures. For instance, the stark contrast she draws between the state-of-the-art hospital in Mekelle and the deplorable conditions in Jimma could potentially leave a bitter aftertaste in the mouth of a reader who had digested all of the other facts about ‘one of the world’s worst healthcare systems’. It would be an egregious mistake to dwell on such distinctions without focusing on the real outcomes of the healthcare system. It is therefore necessary to belabour the obvious: The residents of Jimma and Mekelle are in the same boat. Neither one is getting basic medical care. Even with a state-of-the-art modern hospital (with 450 beds – of which 157 cannot be used due to staffing shortages – and 14 doctors consisting of 1 surgeon, 1 paediatrician, 1 gynaecologist, 2 internists and 9 general practitioners) people still do not have access to the most basic clinical procedures.
SAVE MOTHER ETHIOPIA!
It is simply preposterous and irrational to talk about economic growth or development when a country has ‘one of the world’s worst healthcare systems’. The ultimate question is whether a regime described by the Economist as ‘one of the most economically illiterate in the modern world’ is capable of meeting the dire health challenges facing the Ethiopian people. No need to hold our breaths waiting for an affirmative response to that question. But there is no question on what we need to do. We must work together in unity – with malice towards none and charity for all – to save Mother Ethiopia and the mothers of Ethiopia!
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* Alemayehu G. Mariam is a professor of political science at California State University, San Bernardino, and an attorney based in Los Angeles.
* Please send comments to [email protected] or comment online at Pambazuka News.
* This article was first published by Ethiomedia.
 Hanna I. Win’s five-part series on Huffington Post.