The graphic above depicts the three-tier structure of the Ethiopian health system. The secondary and tertiary levels are comprised of general and specialized hospitals, and the coverage of each extends to larger portions of the population. The management, coordination, and distribution of technical support in each and every level is the responsibility of the Woreda District Health offices and the Regional Health Bureaus, whereas policy and significant decision making is in the hands of the Federal Ministry of Health.
The primary care level is established on the district level (or ‘Woreda’ level in Amharic) and includes a primary hospital, local health centers, and rural health posts. This decentralized primary system functions due to the implementation of Health Extension Workers (CEW’s) that can refer patients to health centers or the primary hospital for more serious health issues, monitor health and disease on a local level, educate their fellow Ethiopians about sanitation, how to avoid spreading communicable disease, childcare and nutrition, and family planning, as well as and provide basic primary care services like contraceptives, immunizations, and treatment for common childhood illnesses Each health center coordinates 5 health posts, and there are two health extension workers and one health post per community. The Health Extension Program uses task-shifting and ‘community ownership’ to provide basic health services at the grassroots. Since 2003, somewhere between 30,000-38,000 HEWs have been recruited and trained in Ethiopia with the aid of many international NGOs, the UN, and government agencies –the United States, Ireland, and multiple countries of the European Union. Since the implementation of the program, maternal and child health has improved.
For more information about the Community Health Extension Program, the video below explains the significance and effectiveness of the program in improving health at both the community and national level.
To check out what kind of information and services community health workers use and distribute, one can access their training packages (in English) by clicking on the picture below!
Despite the national efforts to change health system delivery, women in Ethiopia still do not seem to seek access or use services, as depicted in the table below.
There are many reasons why women do not use health services in Ethiopia.
1) Ethiopia has no national health insurance plan.
Although the government just approved and promised to implement a national insurance plan, citizens have to pay out-of-pocket until the plan is established. National expenditure of GDP per capita on health is $7.10, which when one considers the ubiquitous poverty in Ethiopia, this is not surprising, and not enough. (http://healthmarketinnovations.org/program/ethiopia-social-health-insurance)
2) Access to health services is difficult in rural areas.
Rural women reported having the most difficulty in accessing health care, and 76% of women in Ethiopia live in rural areas. In Ethiopia, women (94%) cited at least one barrier to accessing health care. Finding transport, a lack of money, and the distance to a health center are stated as the greatest barriers in accessing health services. Many are also concerned about arriving at a health center only to find there is no health worker or no drugs that they need. After spending the time and money, and taking off work, this is a legitimate concern that would deter anyone form seeking health care. Twenty-nine percent of women also worried about receiving permission to seek health (131). Finally, the infrastructure and roads to the remotest villages either don’t exist or are in poor condition, and women are oftentimes frightened to go alone due to the high rates of rape and abduction in Ethiopia. The table below displays the statistics regarding barriers to health that women in Ethiopia cited(DHS, 2011, p. 133).
3) Women in Ethiopia have little autonomy.
1. Employment and wealth contribute significantly to level of autonomy. Only 58% of women in Ethiopia were employed in the las 12 months at the time of the Demographic Health Survey in 2011. The largest group, 46% worked in agriculture (35). Three out of ten women received no pay for their work, nothing (35). And, although education is important as well, it is most valuable when it opens doors for employment for women. Women with the highest educational attainment and best reading abilities belong to the highest wealth quintile (40). In the Demographic Health Survey, women with more than secondary education and women in the highest quintile reported the least barriers to accessing health care.
2. Barriers to women’s empowerment and gender equality at policy, awareness, and cultural levels.
Not only is policy in Ethiopia not gender-forward (refer to the page on this blog for more information), but there is also a gap in the awareness of policies that do protect women. Furthermore, there is no feminist movement or ideological progression that speaks for gender equality in Ethiopia. In order for women to belive they have agency and power to make their own decision regarding health, they need to be empowered in addition to being economically dependent and educated. For example, women who have more autonomy in the household, measured by their ‘decision-making’ power, are more likely to use contraception. Women who believe that their husbands are justified in beating them for fewer reasons are also more likely to use contraception (depicted in the table below, taken from the Dempographic Health Survery 2011).
Women who are more empowered (have more decision-making power and believe their husbands are less justified in beating them) utilize other reproductive health services more often than women who are less empowered. The table below, taken from the Demographic Health Survey 2011, represents this data (p. 263).
Central Statistical Agency [Ethiopia] and ICF International. (2012). Ethiopia demographic and health survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA.
Central Statistical Agency [Ethiopia] and ICF International. (2012). Ethiopia demographic health survey 2005. Addis Ababa, Ethiopia and Calverton, Maryland, USA.
Federal Democratic Republic of Ethiopia. (2004). The criminal code of the federal democratic republic of Ethiopia, proclamation no. 414/2004. Retrieved November 14, 2012, from http://www.ilo.org/dyn/natlex/docs/ELECTRONIC/70993/75092/F1429731028/ETH70993.pdf
Federal Democratic Republic of Ethiopia. (4 July 2000). The revised family code [Ethiopia], proclamation no.213/2000. Retrieved 11/14, 2012, from http://www.unhcr.org/refworld/docid/4c0ccc052.html
Ministry of Health. (2010). Health sector development program IV 2010/11-2014/15. (). Addis Ababa, Ethiopia: Federal Democratic Republic of Ethiopia.
Venture Strategies Innovations, Inc. Accessed 5 December 2012: http://vsinnovations.org/ethiopia.html