Women’s Edition Journalists Compare and Contrast Ethiopian Health Care System

By Population Reference Bureau

For several days before the start of the 2013 International Family Planning Conference, a group of journalists from eight sub-Saharan countries and India had a chance to examine the health care system that has won Ethiopia much praise. These journalists are participating in Population Reference Bureau’s Women’s Edition project, funded by USAID. In visits to Health Posts and Health Centers and through interviews with Health Extension Workers, Health Officers and other health staff the reporters learned how Ethiopia has brought reproductive health care, including family planning, into the furthest reaches of the country.

Two reporters from India, Aarti Dhar from The Hindu and Madhavi Rajadhyaksha from The Times of India, saw many similarities between Ethiopia’s Health Extension Program and their country’s rural health system. For the Women’s Edition project, they wrote about their impressions:

The Health Extension Program of Ethiopia is in many ways a mirror image of India’s National Rural Health Mission, both of which follow a bottom-up approach and are run largely by women from the community. Ethiopia has 35,000 Health Extension Workers (HEWs) vis-à-vis India’s 8.5 lakh trained female community workers popularly called ASHA (Accredited Social Health Activist), an acronym that spells hope in Hindi. Both sets of women workers play a pivotal role in community mobilization, family planning, maternal and child health.

There are, however, minute lessons that both programmes could learn from each other. Ethiopia, for instance, could benefit from a nuanced clause in recruitment of its HEWs. India’s programme enrolls only daughters-in-law as ASHAs, not daughters, with the long-term view that the former are more likely to spend a lifetime in the village community, as against daughters who are more likely to move out of their home villages to another hamlet once they get married. Ethiopia, in contrast, recruits young girls who have completed 10th grade.

India, on the other hand, could draw upon the encouraging incentives that Ethiopia doles out to its HEWs. Ethiopia not only pays its women foot soldiers an assured salary of 1,233 birr per month, but rewards those who perform well after a one- year training by enrolling them for a higher diploma that subsequently fetches them around 200 birr more. India’s ASHAs function largely on a voluntary model, on the promise of a measly honorarium to cover their transport and incidental costs. This, too, is linked to their performance in most states.

The Women’s Edition activities before the conference included a visit to the Hamlin Fistula Hospital that heals women with obstetric fistula, an injury that can result from obstructed labor, rendering the woman unable to control her flow of urine and/or feces. The reporters also traveled 170 kilometers outside of Addis Ababa to Tiyo woreda in the Oromia region to visit the Gonde Health Center and a nearby Health Post. On a shorter trip outside of Addis, they visited a Marie Stopes International (MSI) Health Center in Sululta and one of MSI’s Blue Star clinics nearby. They found much of interest everywhere, including Ethiopia’s law allowing abortion for girls under 18 without a parent’s signature. They were particularly impressed by women support groups and the involvement of elder men in helping to put an end to harmful traditional practices, such as female genital mutilation.

• A visit to some rural communities revealed that involvement of elders particularly is very effective in putting an end to retrogressive cultures. In Kenya, there are strict laws against child marriages and female circumcision. However, the practices still continue unabated, and statistics tell a grim story. More needs to be done, and the Ethiopia style is a good way to go. – Njeri Rugene, parliamentary editor at the Daily Nation in Kenya.

• The camaraderie that the women enjoy in small groups before turning to larger groups for help is a step in the right direction. – Sola Ayo-Aderele, features editor of The Punch newspaper in Nigeria.

• It is interesting to hear old men championing change, especially positive change involving the welfare of women. – Faith Kandaba of Zambia National Broadcasting Corporation, who interviewed one of the elderly men at the Gonde Health Center about female genital mutilation. “The practice has done more harm than good for our community”

Tuji Diababa, 76, told her. “It has over the years eroded the dignity of our women.” He also said that he and his elderly peers felt guilty that they had let the practice continue for so long. In his community, FGM is no longer practiced, and he said that the elders and religious leaders are determined to ensure that women are not subjected to this harmful practice, but rather are part of the development agenda.

Over the course of all the visits, the reporters took part in many, many coffee ceremonies, and two of the reporters from Uganda, Anne Mugisa of The New Vision and Evelyn Lirri of the Daily Monitor, took particular interest in the meaning of these customary rites. They reported that this long-standing social tradition had actually fueled harmful practices like child marriage but now is being used to promote community well-being.

The process has to strictly follow a certain pattern. As the coffee is being processed, another charcoal stove is burning incense, whose aroma mixed with that of the coffee would waft around. The meeting place would be laid with fresh green grass which signified life. The grass will have been picked from the bushes nearby. The coffee would be served in dainty cups from a clay pot with a long neck in which it will have been boiled.

The coffee ceremony hosting rotates and it is a must that one hosts neighbours or eye brows would be raised.

Prospective mothers-in-law and even grandmothers of intending suitors would use this opportunity to identify a young bride in a given home. The girls who had been groomed in the tradition since they were little would be watched to see how they processed the coffee beans including washing them, how they turned them during roasting and how finally the coffee turned out to be. Here the prospective in-laws would decide she is a well groomed girl and suitable to marry in their family or she isn’t. So parents felt it incumbent upon them to groom their daughters for marriage.  As a result, child marriages were frequent with accompanying under age pregnancies. An estimated 16 per cent of women ages 20 to 24 were married by the age of 15. Child births took place in the village with the help of traditional birth attendants or older women in the villages. The result was a high death rate among teenage mothers and their babies. Most of these deaths were the result of difficult labour, which subsequently also contributed to high cases of fistula.