• [Image: Negash Teklu]

    Negash Teklu

    Ethiopia

    Population Health Environment (PHE)

    "A sector-based approach has been used, but it does not meet the demands of families, which are multifaceted and comprehensive. Our approach should be multifaceted and comprehensive, too."


    Ethiopia has a good health strategy, and in recent years there have been positive programmes for reaching rural communities, which is where 84 per cent of people live. This includes the health extension package, through which health extension workers are responsible for dealing with health matters in their area, including family planning. We now have around 34,000 health extension workers, mainly women. Two health extension workers are assigned to reaching about 5000 families in their community. Sometimes the neighbourhood can be in a flat area, but in mountainous areas, reaching 5000 families is a huge challenge. These extension workers are stationed at 15,000 health posts throughout the country. All of this is helping to address unmet need. In the 2005 DHS, unmet need was 34%, but now it has decreased to 25%. This is still high, but promising. We have also seen very encouraging improvements in contraceptive prevalence, which went from only 14.8% in 2000 to 28.6% in the most recent DHS figures. Addressing demand through this local, community based approach is a best practice and a good example for other African countries. The Ministry of Health should be congratulated for this and supported to strengthen it.


    This is where PHE comes in: we are not trying to replace the Government, but to identify how we can contribute to meeting the MDGs and the country’s goals. We call it the Growth and Transformation Plan. We identified the Governments strengths and weaknesses with regard to family planning, health and the environment, and we aim to fill the gaps. Despite the great progress here, Ethiopia is still among the most highly affected countries in terms of global targets on maternal mortality, unmet need, infant mortality, and health coverage in general. We want to help to change this, and to meet our development targets. One way is through the population health environment approach. Population pressure is high in Ethiopia and growth is high, so in the coming years we must address population. Around 24% of our population lives in poverty, and while this is decreasing, it is still a challenge. We still have food insecurity and drought as well as other climate change challenges. This can best be tackled through an integrated approach that promotes sustainable development, where social, economic and environment are all addressed.


    We have 30 pilot sites with integrated population health environment components, which we implement by partnering with stakeholders in the poorest sub-districts. We bring leadership and knowledge to the project, and we bring local government leadership and knowledge, for example, health extension workers bring their health knowledge, agricultural extension workers bring knowledge about farming. We also bring together school teachers and directors of local clubs and associations for women, youth, farmers and others. These stakeholders have a joint weekly meeting. If the health extension worker needs support, they support her and her goals become the group’s goals. Through that collaboration and coordination, they aim to tackle the local community challenges jointly, not separately.


    Where we have done this sort of joint work, contraceptive prevalence has increased, gender equity has improved, and we have seen improvements in people’s livelihoods and income. There has also been more participation on the part of women and young people. This is because it involves genuine ownership by the communities and that’s why it works, and that’s what we mean by an integrated approach.


    We are using the pilot sites to generate knowledge that can be injected into national policies. We are not just looking to reach all places ourselves. We have to strengthen the pilot sites and generate evidence, which will inform how we can apply this nationally. This is new, but we have to generate evidence to enable the Government to strengthen its efforts.


    We are identifying the country’s major strategies and seeing how we can help. Ethiopia has about 30 protected nature reserves and parks or biosphere areas; how could we contribute to sustaining those areas? We have big rivers, including the Nile and how could we sustain those through this integration approach? We are selecting those areas because without identifying the real challenges of the Government, we can’t help. The Government says the parks have been protected, but our analyses found that this hasn’t happened, mainly because of population pressure and the need for resources such as charcoal, which people gather for a living. If our integration approach can be a solution, we can help to save these protected areas. We need to create this partnership in communities, including ownership of the process.


    We are dealing with environment, livelihoods, and population and the cheaper of the approaches is family planning, which is strongly accepted and offers added value to the environment and livelihoods, because a family with nine or ten children is much less resilient to climate change impacts, such as drought compared to families with two or three children. Investing in family planning is more economically sensible.


    National documents on climate change have identified population pressure as a problem, but not family planning as a solution. We want to show how family planning is a strategic issue in the second biggest country in Africa. We were poor in dealing with family planning in the past, and now we need balanced population growth. To do that, you need to have evidence, which is exactly what we are trying to generate.


    People destroy forests for a living, but if you offer them alternative livelihoods it leads to tangible changes. We need to have governance that empowers the community by involving the community members in planning and evaluation and they need to be consulted.