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Access to Health and

Education Services in Ethiopia

Supply, Demand, and Government Policy

Fra von Massow

First published by Oxfam GB in 2001

Oxfam GB 2001

ISBN 0 85598 4716

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Acknowledgements 5 Notes 48

Glossary 6 References and further reading 50

Executive summary 8 Appendix 1:

Micro-research methodology 51
Introduction 13
Appendix 2:
Poverty in Ethiopia 17 Tabulated findings 54

Health status of the poorest Appendix 3:

communities 20 Case study 1: Cherkos, Kebele 24,
Addis Ababa 60
Health-sector policy and planning 23
Appendix 4:
Water and sanitation 28 Case study 2: Yegurassa and Andaje,
Delanta, North Wollo 74
Food security 29
Appendix 5:
Education status of the poorest Case study 3: Ali Roba, Metta, Eastern
communities 30 Hararge 85

Education-sector policy and planning 33 Appendix 6:

Case study 4: Belhare, Jijiga, Somali
Conclusions 37 Region 96

Recommendations 42

This summary report gives me the opportunity difficult circumstances. In Deder and Jijiga the
to express my high regard for the members of team was additionally assisted by excellent
the team who conducted the field studies on translators, kindly assigned by the respective
which it is based. It was a very bright, energetic, government offices for health and education.
and tireless group of individuals, men and In each site visited, the team met with first-
women of mixed ages and experience. There level health and education service providers:
was a strong sense of devotion to the task and a teachers, school directors, health assistants, and
spirit of co-operation and support for one directors; and with local authorities. We were
another throughout the three months in which often overwhelmed by the time that they spared
we lived and worked together. The team and the hospitality that they accorded to us.
included Almaz Terefe (Senior Researcher, Many are devoted professionals, working in
Health), Dr Abebe Bekele (Senior Researcher, remote locations with the absolute minimum of
Education); Assistant Researchers Tsehay Haile, resources, in conditions of extreme deprivation.
Amare Worku, Awet Kidane Gebrehiwot, and Traditional practitioners shared their wealth of
Taddesse Koyra; Senior Statistician Samuel experience and their difficulties with the team.
Feyissa; and Damenech Zewdi (Logistics Co- Nor would the research have been possible
ordinator and Secretary). We were supported without the co-operation and time given by
by Zerfi Zerehoun and accompanied by Worku women, men, and young girls and boys, in
Taddesse and Berhane Gebre Egziabher: two Cherkos, Addis Ababa; Yegurassa and Andaje
excellent drivers assigned to us by Oxfam. villages in North Wollo; Ali Roba village in
The research was launched with the guidance Eastern Hararge; and Belhare and Sheik Umer
and support of Dr Mohga Smith from Oxfam's villages in Somali region. This summary report is
Policy Department in Oxford. Her input was dedicated to them. It aims to reflect as closely as
much appreciated by the whole team. Othman possible the reality of poverty, hunger, and
Mohamed, then Oxfam's Ethiopia Director, deprivation which they described to us and with
awarded the research high priority throughout which they have to cope every day. It is the
and put staff and facilities at the team's disposal. team's strongest wish that these reports might
The team's endeavours were at all times influence decision makers at local, national, and
supported by the Oxfam staff in Addis Ababa, international levels in the interests of reducing
who were extremely accommodating, friendly, poverty and increasing access to good-quality
and helpful, despite the huge demands on their basic health services and reproductive-health
time. The Oxfam block managers gave the team services for all, and elementary education for all
advice and support whenever it was required. In school-age children. To this end the team's
Addis Ababa the team could not have done its families and friends in Addis Ababa and London
work in thefirstsite without the daily support and provided the necessary support to facilitate the
assistance of the staff of the Voluntary Centre for work.
the Handicapped. In the regions we were guided The research into national policies and eco-
and assisted by the Oxfam staff in the regional nomic trends was carried out by Dr Abdulhamid
offices in Dessie, Wogel Tena, Delanta, Deder, Bedri Kello and Mr Getachew Yoseph.
Eastern Hararge, and Jijiga, Somali Region. For their insights and support I am indebted
They organised our accommodation and food, to all the contributors named above; but the
and they looked after our personal needs. They recommendations contained in this paper, and
made all preparations for the research, including the integrated analysis of the field-study findings
briefing the team and preparing the community, and the macro-economic data, are my sole
and they accompanied us in the field. The team responsibility.
developed a strong appreciation for the high
calibre and devotion to their work of the Oxfam Fra von Massow
field staff, who live and work in extremely Research team leader

Almaze a skin disease which can become FGD focus-group discussions

acute FGM female genital mutilation
ANC antenatal clinic FP family planning
Ato the term used for 'Mr' Ginbot May
Baldi a bucket with a capacity of 20 litres gote a village of 70-100 households.
Bega the dry or sunny season There are between five and eight
berberri hot pepper spice gotes in one Peasant Association
birrd a generic term for colds, Hamiley July
rheumatism, and chest problems Harafar a Muslim holy day
bonesetter a traditional physiotherapist who Hidar November
specialises in fractures idir a community savings club for the
buna bet coffee shop eventuality of a death or marriage
'chat an addictive stimulant, consumed in the community
mostly by men, who chew the IEC Information, Education, and
leaves of this plant Communication
damakesse a herb commonly used for injera a national staple: a flat pancake
practically all types of ailments made with teff(z local grain),
debtera a churchman, trained for the barley, or sorghum. It is typically
priesthood, who treats the sick by eaten with a spicy sauce or stew.
writing some script on a piece of Kebele the administrative unit which
paper and scrolling it into a very provides a link between the urban
small piece, which is then sewn government administration and
into a small piece of cloth to make the community. Kebele leaders
it into a charm that the sick person were local party members, elected
wears on his/her neck by by the community, during the
suspending it on a piece of thread. time of the Derg. They are now
The debtera is believed to have the appointed by government as state
ability to make somebody sick by employees.
using the same ritual.
Kerray informal savings association for
Derg the commonly used name for the weddings, funerals, and religious
regime of Mengistu Haile Mariam festivals
which ruled Ethiopia following a
popular revolution which Kerray the Elders of the Kerray, who meet
Abatoch to plan important community
unseated the government of
activities and to solve serious
Emperor Haile Selassie in 1974
crime and local disputes
DPPC Disaster Prevention and
Kiremt winter
Preparedness Committee
'kolo roasted barley or maize grain
EC Ethiopian Calendar
MCH mother and child health
ENT ear, nose, and throat
meda open fields
EPI extended programme for
immunisation Megabit March
EPRDF Ethiopian People's Revolutionary Meskerem September
Democratic Front Miazia April
MoA Ministry of Agriculture Tahissas December
mogne a common illness whose treatment TBA traditional birth attendant
bagenge requires a surgical incision tella beer brewed locally from barley or
Nehassey August wheat
NGO non-government organisation TGE Transitional Government of
OPD out-patients' department Ethiopia
Peasant the link between community and Tikmt October
Association development or local government Tin January
(PA) administration, with an TPLF Tigranian People's Liberation
organisational structure down to Front which, together with
village level Eritrean forces, overthrew
PNC postnatal care Mengistu's regime in 1991
PRA participatory research and action tsebel treatment at holy waters
methodology which has its origins TTI Teacher Training Institute
in 'Participatory Rural Appraisal' TTBA trained TBA
PTA Parent Teacher Association VCH Voluntary Council for the
RTI respiratory-tract infection Handicapped
samba lungs Weziro (W/ro) the term used for 'Mrs'
SCF Save the Children Fund WFP World Food Programme
WIBS Woreda Integrated Basic Services,
Sene June
a UNICEF-funded programme
shamma a white hand-woven shawl worn by including education, health, and
most women water and sanitation services
shurro a sauce made with finely ground wogeisha traditional physiotherapists who
chickpeas are particularly used for setting
STD sexually transmitted disease bones after a fracture
streetism the trade practised by young Woreda urban administration
female sex workers Yekati February
suk small corner store zabanya a guard or night watchman
Executive summary

This report presents the findings and better-off. Providers of health and education
recommendations arising from a research and services, both professional and traditional, were
advocacy project initiated by Oxfam GB. The also interviewed.
field study ('the micro research') took place in The field study demonstrates the definitive
Ethiopia in the three months January to March interconnections between livelihoods, income,
1999; the analysis of political and economic food security, and access to health and
factors ('the macro research') was conducted in education services. It mirrors and compares the
November/December 1999. The four study sites realities and problems faced by service users
were selected to represent the diversity of with those confronting service providers. It is
traditions and culture, and livelihood structures, intended to be useful to those planning and
in Ethiopia. They included Cherkos, a slum area programming projects at local level, and to
in the city ofAddis Ababa; Delanta, the highlands inform policy and planning at regional and
of North Wollo (Amhara); the highlands in federal government levels, and campaigns at
Eastern Hararge (Oromo); and the lowlands of national and international levels for the relief of
Jijiga, Somali Region. Four detailed site reports unpayable debt and increased investment in
were produced, closely reflecting the experience human development - the planning of which
and views of the participants, and their per- should take into account the views of the poorest
ceptions of how the provision of social services, women, men, and youth.
and their access to it, had changed over the past
few years. Edited summaries of findings in four
sites are given in individual case studies as Main issues emerging from the
appendices to this report. (There were five case
studies in all; the first site selected in Jijiga had to
four sites
be abandoned after two days, but sufficient Populations are increasing; resources are
information was gathered to merit a short case static or diminishing.
study, not reproduced here.) All households have become poorer because of
A total of about 500 men, women, girls, and drought, lost harvests, and dying livestock, and
boys participated in the research. The research in the Addis Ababa site because of a huge loss of
team comprised nine men and women, and more jobs among members of the armed forces.
than 50 people were involved in co-ordinating Increased poverty and loss of livelihood base
and implementing the research. In single-sex (the male head of household's main source of
focus groups of youths and adults, participatory income) have increased the workload on
research tools were used, including mapping, women in particular, and on girls and boys.
poverty ranking, seasonal calendars, and matrix There are few productive alternative sources
ranking to explore health-seeking behaviour and of income, apart from selling firewood and
the quality of health and education services, and petty trading.
Venn diagrams. The team was especially With the exception of Metta, traditional
impressed widi the information gathered from institutions, the church, and traditional prac-
youth groups - with their level of knowledge, tices are widely prevalent in the absence, or
awareness, and openness. They made valuable minimal presence, of external government or
recommendations for improving access to and donor organisations.
quality of education and health services. In each Women, their experience and concerns, are
site, individuals (70 per cent of them women) under-represented in all forums.
from 35 households were interviewed, having In all sites, external donor presence was min-
been identified during the mapping and poverty imal, and some donors had stopped funding
ranking as representatives of a range of groups: immunisation services, for example, without
the worst-off, those of medium rank, and the ensuring a replacement source of funds.
Executive summary

In Jijiga, the site was devoid of any donor or Most worst-off households (the majority in
government presence, no children went to each site), especially women, go to traditional
school, and most of the adults were illiterate healers or holy waters first, and seek profes-
and felt completely disempowered. sional advice only when dieir problems are
very serious.
The research identified numerous barriers to
The proportion of men using curative services
people's access to good-quality primary educa-
is marginally higher dian the proportion of
tion and professional health-care services.
women using them; preventative services are
mostly used by women.
Supply-side barriers Health education and reproductive-healdi
education do not reach men and young
There are insufficient schools and health people.
centres to cater for the potential demand. Rural women use outreach services if the
Existing facilities are under-funded, ill- services come to them, but diey tend not to
equipped, and lacking in basic requirements: attend clinics that are too far away from dieir
books, furniture, water and sanitation in homes.
schools; equipment and medication in health Most women and girls give birdi in the
facilities. villages without a trained attendant: health
Staffing in existing facilities is inadequate, centres/hospitals are too far away and too
and the health and education services are expensive.
short of qualified personnel. Sending children to school competes widi the
Services are based too far from the rural need for girls' domestic labour and girls' and
population; the majority of users are urban. boys' income-generating activities, including
Outreach services, and health and traditional roles in herding and agriculture.
reproductive-health education services, are Boys are given preference over girls when
under-funded and under-staffed. families have to make choices about schooling,
There is evidence of schools providing some most markedly in the Muslim communities of
education on environmental health and Eastern Ethiopia.
reproductive health. Girls lack support, and their lives are at risk
Traditional birth attendants (TBAs) in the from circumcision, female genital mutilation,
sites visited have no access to training or early marriage and early pregnancy, and a
medical kits. heavy labour-intensive workload from an
Herbalists (many of them men) have no early age.
dialogue with medical professionals.
Both TBAs and herbalists tend to be elderly
by Ethiopian standards (aged 60+).
Few people have access to the system of
The official policy context
exemption from health-care fees, and many The government's policies on health, education,
do not know about it or how it works. population, HIV/AIDS, and women's status all
contain elements that purport to respond to
Demand-side barriers concerns expressed in villages and by first-level
service providers. But die needs of the poorest
Most people are too poor to meet die costs of households and the demands of service providers,
education, which include food, clothes, especially in terms of healdi education,
uniforms (in Addis), exercise books and pens, reproductive-healdi education, and environ-
and soap; and die costs of health care: mental healdi, do not feature prominendy in die
transportation, fees, medication, nutritious policy documents and cannot be met by die
food, bribes to guards, and lodging. currendy low budgetary allocations for non-salary
Children are too hungry to go to school; recurrent costs, and widi existing staffing and
many are sick with diarrhoea and other logistics capacity. Investments in improving staff
malnutrition-related diseases, and have no training and development, and a significant
clothes; odiers leave school when there is not improvement in logistics and management
enough cash to buy an exercise book. capacity would have to be made by die
Adult illiteracy is high, and an understanding government and die international donor
of the value of education among parents is said community, in order to work towards achieving
to be low. Illiteracy also affects access to health die human-development commitments made to
services and other government institutions. die poorest.
Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

The gap between policies and demand is illnesses and deaths. Hunger and illiteracy are
matched by a gap between policy intentions and impediments to local initiative and action,
the ability of existing government structures to despite the strongly expressed desire of women
implement them under current resource and men to work for real improvements in
constraints, both human and financial. The livelihoods and for the well-being of their
process of transition to a federal state with families.
increased local government autonomy is
suffering from a low level of local planning,
management, and budgeting capacity. Ethiopia's Summary of recommendations
capacity to raise financing for social-sector
development cannot begin to cover the cost of
expanding health and education services and Financing social-sector development
consolidating existing ones, which are very To secure the confidence of donors and to
depleted. Ethiopia is committed to covering 55 increase accountability between government
per cent of its total budget for health, and 73 per and grassroots communities, the government
cent of the total education budget, from domestic should design and implement a fully trans-
resources; but with 65-85 per cent of the parent standardised system of reporting
population living below the poverty line, the income from donors, expenditures by region
state's capacity to raise local taxes is limited. At the and sector, and recurrent and capital
same time, Ethiopia is crippled by external debt, expenditures.
and the interest payable on it (debt constituted Donors need to agree on the format and
159 per cent of GNP in 1997; and while 0.9 per timing of budget reports, to avoid
cent of GDP was spent on health, 2.3 per cent was demanding different reporting procedures
spent on repayment of interest in the period and time schedules.
To release new resources for meeting health
There are demonstrable links between the and education targets, the World Bank and
low status of women and increasing population IMF should demonstrate a stronger com-
growth, infant and under-five mortality, and mitment to the HIPC initiative and write off
children's poor health and education status. or significantly reduce Ethiopia's debt stock.
Maternal mortality rates in Ethiopia are among The World Bank, together with the govern-
the highest in the world, and fertility rates are 6- ment, should review the impact of the
7 children per woman. All social-sector policies economic liberalisation policy on the reach of
emphasise the need to change attitudes towards non-salary recurrent budgets, which are
women and to recognise their contribution to currently not succeeding in maintaining basic
development; but laws inherited from the past supplies, including essential drugs and
inhibit the widespread distribution and use of textbooks, to the health and education
family-planning methods, allow for marriage at sectors.
15, and prohibit abortion. OECD countries should increase the
At least 70 per cent of women and 60 per cent proportion of national income allocated to
of men are illiterate. Illiteracy is an impediment development aid. This will facilitate the release
to participative democracy and local account- of increased financing for non-salary recur-
ability. As a result men, responsible for their rent budgets for health and education, in
communities through traditional structures, order to improve the quality of service delivery
feel impotent to seek assistance or take action to and meet donors' renewed commitment to
improve the condition of their families. Women achieving human-development targets by the
are under-represented in all decision-making year 2015.
forums. Oxfam's research does not indicate that
there will be a significant improvement in the
educational status of the next generation, Management and accountability
particularly in rural areas. The worst-hit areas Implementation of policy and management
are agro-pastoralist communities such as Jijiga of capital and recurrent budgets at all levels of
in Somali region, where an estimated 88 per regional government require training,
cent of children are not in school. Unemploy- support, and motivation of local government
ment in urban centres and the insecurity of staff, with technical assistance provided by
drought-affected rural livelihoods are resulting local and external consultants, as deemed
in increased poverty and hunger-related necessary.

Executive summary

Attention must be paid to gender equity in Reproductive health

planning, managing, and allocating resources Reproductive-health education must be
at all levels of government and social services. prioritised in view of the high fertility rate;
NGOs can be engaged (with official the prevalence of female genital mutilation,
development assistance funding) to mobilise high-risk births, and early marriages; a
and train local government organisations and growing incidence of HIV/AIDS; and a high
community-level institutions such as tradi- reported incidence of sexually transmitted
tional representatives, respected women, and diseases, which tend to treated only (and then
health and education committees (with an only partially) by men.
improved gender balance). Groups of A rapidly growing population will constantly
women, men, and young people, represent- undermine the government's efforts to
ing different clan, religious, and age interests, extend social-service provision. Population
should be encouraged to participate in growth needs to be tackled with a carefully
shaping and monitoring the development of considered programme, and treated as an
health and education services in their areas. issue of human rights and development.
To this end, adult literacy programmes for Family planning should be legalised, and
participative democratic involvement should communications media and local-level organ-
be planned and budgeted for. isations should be involved in campaigns to
raise public awareness. High fertility rates and
Expansion and consolidation of services high rates of maternal and infant mortality
need to be significantly reduced.
There is a need to balance resources There needs to be interaction between the
according to regional demand, for education and health services in tackling
expansion or consolidation of health and reproductive-health problems, increasing
education services. Expansion without an access to clean water, and improving san-
increase in non-salary recurrent budget itation, as well as highlighting the risks of
expenditure for essential supplies, equip- harmful traditional practices and HIV/AIDS.
ment, staffing, and staff training will not Non-government organisations (NGOs) can
result in increased service provision. Some play a strong supportive role with external
new health centres in Delanta were funding.
reportedly unused, because of the lack of
staff and supplies.
Expansion in health-service provision can Traditional medicine
best be achieved by responding to demands The government should invest in research into
to take health care to the poor with outreach traditional practice, with a view to regulating
service provision. The outreach should be bad practice and integrating valuable skills and
accompanied by increased funding for health resources into outreach services and service
and reproductive-health education and provision in health centres.
investments in food-for-work, water, and The government should reconsider the
sanitation programmes, and it should involve benefits of training traditional birth
both health and education personnel. attendants and integrating them into the
Expansion in education provision requires formal health-care system, to provide a
regional and rural/urban differentiation; service at village level and refer high-risk
while the government concentrates on cases to the local health centre in good time.
extending schooling to the poorest rural
areas, it should encourage private-sector Drugs
investment, for those who can afford it, in The government should draw up a standard
urban centres. list of essential drugs and equipment, taking
Government capital expenditure should into account the problems of reproductive
focus on under-serviced sectors such as agro- health raised by many participants. Issues of
pastoralist communities, for example in the reproductive health feature more
Somali region, and recurrent expenditure prominendy in Oxfam's research than in the
should concentrate on provisioning existing official health statistics reviewed, because most
schools with much-needed basic materials interventions are managed in the traditional
and equipment. health sector, outside the government health

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

service. Stocking health posts with adequate Secondary education

supplies of family-planning methods will Secondary education should not be sidelined.
require planning and funding. Provision for secondary schooling should be
Ethiopia needs an efficient system for the increased in rural areas, and made accessible
procurement and distribution of drugs to rural poor children. Special provision for
(recommended in the official health policy), girls from rural families should be made, to
which would also regulate the drugs supplied enable their safe attendance at secondary
via bilateral and multilateral agencies. school in town, away from their families.
Taxes on drugs should be reduced; essential
drugs should be subsidised.
Donors of Official Development Assistance Education for girls from Muslim families
(ODA) should provide additional non-salary It is necessary to investigate appropriate and
recurrent financing to increase the stocks of acceptable solutions to the problems of mixed
drugs and family-planning methods on the schooling that Muslim parents envisage.
official essential drugs list. Fathers in Jijiga were particularly concerned
about sending their daughters to school with
Teachers boys.
Teachers must be trained and their skills
upgraded, commensurate with the standard Data collection
of the grades and the new curriculum. Data collection should ensure that
There should be a drive to increase the quantitative statistics, such as average class
recruitment of women teachers, especially for sizes and health centre/population ratios, are
rural locations. Special needs of women qualified by qualitative data, preferably
teachers should be investigated and acted collected from focus groups to reflect the
upon. reality of the situation on the ground.
All teachers should have additional gender- Oxfam's four micro-research site reports are
awareness training to help them to a rich source of detailed qualitative and
understand the particular problems and quantitative data, giving a voice to the poorest
constraints faced by girls and boys from communities and providing information
urban and rural poor households. Oxfam's disaggregated according to gender and age
micro-research site reports would provide from various ethnic and livelihood groups.
good background material for such training.
A career and promotions structure for health Food security
and education personnel should be
introduced, responding to the particular Relief and development agencies should work
needs of those located in remote areas. hand in hand with government and donors to
Incentives to encourage applications for rural ensure the supply of food alongside develop-
postings should be considered, together with ment initiatives, ensuring increased food-for-
investment in supervision and support for work programmes, relevant mother-and-child
health and education staff. health services, and supplementary feeding
programmes in schools.
The translation and production of textbooks
and teachers' guides for all subjects and grades Investment in alternative urban and rural
need to be actively pursued and funded. employment, to improve women's and men's
purchasing power and economic and social
stability, should be increased on a significant
Materials and equipment scale. Micro-credit programmes can fill the
Investment is required in water supplies, cracks, but will not hold the wall up for long.
sanitation services, equipment, and furniture
for schools and health centres, including
funds for the repair of dangerous structures.


Purpose of the paper characterise these factors. The planning process

for the development programmes of the
The main purpose of this paper is to fulfil a education and health sectors has been criticised
commitment made to participants in Oxfam's by some for not involving the experience of non-
programme of research on health and education government organisations (NGOs) and grass-
in Ethiopia, the majority of whom represent the roots communities. In this summary report,
poorest women, men, girls, and boys, aged quantitative and qualitative indicators of
from 10 to 85, in urban and rural communities. villagers' problems in accessing health care and
Teachers, nurses, doctors, traditional healers and education are compared. Data collected on the
birth attendants, and regional government staff allocation of funds between different services and
were also involved. They gave their time on the between capital and recurrent expenditures are
understanding that their experiences and analysed, in the context of die problems and
recommendations would be transmitted to needs expressed by communities3 and service
decision-makers in the Ethiopian government providers. Problems of funding, management,
and international donor community. This and service delivery are also discussed. Links are
process supports the aim of the World Bank/IMF made to wider policy and structural changes, and
and Ethiopian government to consult with civil trends in factors related to poverty, food security,
society on the development of a Poverty population growth, women's reproductive
Reduction Strategy Paper (PRSP) which, if health, gender inequities, and livelihoods.
endorsed, will qualify Ethiopia for the debt relief
that it so urgently needs in order to finance
development in the health and education sectors. Background to the research
The paper focuses on certain of the international
human-development targets for 2015. These Oxfam's Health and Education Research and
include the aims that every child should have Advocacy Project was prompted by concerns that
access to primary education, and that real many countries, including Ethiopia, are caught
progress should be made towards gender in a vicious cycle of deepening poverty and the
equality, reductions in the mortality rates of emergence of virulent diseases. Economic
mothers, infants, and children, and real growth and the distribution of benefits are
improvements in access to reproductive-health impeded by national economic stagnation, fiscal
services for all in the appropriate age groups. crises, and the erosion of high-priority social
The paper compares policy intentions services. There is now a broad consensus diat the
concerning the provision of health and education provision of basic social services can direcdy
services with the realities and problems faced by improve human-development indicators,
various groups of service users (differentiated by including gender equity, and can enhance
age and gender), and describes the problems livelihood opportunities and facilitate growth
faced by service providers and managers. The with equity.
latter are trying to deliver health and education The fieldwork for the research in Ethiopia
services in remote areas with minimal support (the 'micro research') was carried out between
and resources. The micro-research findings2 January and April 1999, and the analysis of
demonstrate acute deprivation in accessing economic conditions (the 'macro research') was
education and health services, and maintaining conducted in November/December of the same
regular and timely use of them. year. Four sites4 were selected to reflect the
This paper demonstrates the definitive diversity of urban, rural, and agro-pastoralist
interconnections between livelihoods, income, livelihoods and social structures in Ediiopia.
food security, and access to health and education They included Cherkos, a slum area in the city
services; and the gender-linked disparities that of Addis Ababa; Delanta Dawunt, in the

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

drought-prone highlands of North Wollo demise of the feudal regime of Emperor Haile
(Amhara Region); Metta in the more diverse Selassie in 1974, health and education services
cash-crop economy of the Eastern Hararge were underdeveloped, and about 95 per cent of
highlands (Oromo Region); and the remote the population were illiterate. The socialist
agro-pastoralist communities of Jijiga, Somali regime of the Derg (1974-1991) brought the
Region. A total of about 550 women, men, girls, villagisation programme of the 1980s and the
and boys participated in single-sex focus-group civil war with Eritrea and Tigray, which further
discussions, using participatory research tools. overshadowed development progress and
Semi-structured interviews were held with reduced the potential for attracting external
selected householders (70 per cent of them aid.9 The new Transitional Government of
women5). Interviews were also conducted with Ethiopia (TGE, 1991 to date) is committed to
traditional, private, and government service developing a market economy and a process of
providers and managers at the levels of village, democratisation through the creation of a
woreda (urban administration), zone, and federal state, with many powers decentralised to
region; most of these were men.6 die regions. The process suffers from a shortage
of qualified and experienced women and men to
plan, budget, manage, and administer the
implementation of social-sector policy at all
Country context levels.
Ethiopia is the third-poorest country in the Since the introduction of an economic
world.7 Its population had reached 58.2 million structural adjustment programme in 1992,
by 1997 and, widi a growdi rate of 3 per cent, is there has been a significant increase in the
projected to grow to 90.9 million by 2015. About country's debt stock. The UNDP estimates that
85 per cent of the population live in the rural external debt owed by Ethiopia increased by
economy. The micro research indicates that 93.6 per cent between 1985 and 1997 (from $US
70-80 per cent of rural families live on incomes 5,205.7 million to $US 10,078.5 million).
of $6.40 per month and spend 90-95 per cent of Ethiopia's debt-service spending is currently
their incomes on food. twice its budget for primary education. Overall
The population of the urban centres, where official development assistance (ODA) fell from
resources and skills are concentrated, is $1097 million in 1991 to $637 million in 1997
growing at an average annual rate of 1.9 per (before renewed conflict with Eritrea took
cent (1992-2000).8 The country is characterised place). This fact perhaps explains the large
by high fertility rates (6-7 children per woman), proportion of loan financing that is being used
shortage of arable land, recurrent drought, and to fund the education sector, in the absence of
climatic change affecting food and income from sufficient grant aid from (for example) OECD
harvests and off-farm livelihoods, including countries. This reflects an overall trend in sub-
those of women. Chronic malnutrition and Saharan Africa, where levels of aid have been
widely prevailing income poverty, coupled with falling steadily since 1994. In 1997 they
poor water sources (71 per cent have no access dropped by $US 1.9 billion.10
to safe water, and 81 per cent no access to Military expenditure was reduced between
sanitation facilities (1990-97)), contribute to a 1988 and 1996 from nearly 10 per cent of GDP
high incidence of communicable diseases which to 1.8 per cent, and the army was reduced by
largely remain untreated. Poverty, disease, almost 50 per cent by 1997 on 1985 numbers.
hunger, and the need for children's labour to Military activity on the border between Ethiopia
sustain the household economy jeopardise the and Eritrea became seriously intense in
attainment of national development goals, February 1999. This may have put a different
including that of achieving universal primary light on diese figures, and has changed donor
education. As it is, 71 per cent of women and attitudes to lump-sum budget-support funding,
nearly 60 per cent of men are illiterate and envisaged by die World Bank and the Ethiopian
suffer the humiliation, sadness, and frustration government for the new Social Sector
of not being able to provide adequate food, Development Programmes, particularly in
health care, and schooling for their children, healdi, education, and food security.
the next generation.
Ethiopia's development has been disrupted
by extreme events and trends in political and
structural organisation and change. At the


Structures for social-sector components of the Oxfam research highlight

service delivery and public- the lack of planning, management, and
budgeting capacity and experience in the
sector financing regions. There are also indicators diat, despite
Four issues are central to the financing of enormous need, poor management can lead to
development that is designed to benefit poor the under-utilisation of funds. Finally, women
communities in Ethiopia: are seriously under-represented in the whole
process of planning, budgeting, and prioridsing
the ability of the national economy to the allocation of resources.
generate sufficient wealth for taxation and
public-sector funding; Sources of public-sector funding
public funds allocated to the war with
Eritrea;11 According to Proclamation No.33/1992, die
the increasing debt burden; regions are empowered to collect taxes on
and the decline in official development selected goods and services internally, whereas
assistance (ODA) from OECD countries, the federal government manages taxes and
dudes on foreign trade and the personal
despite their commitments to human-
incomes of its employees and employees of
development targets.
international organisadons. A third source of
government revenue is tax from establishments
Public-sector financing structures jointly owned by regional and federal govern-
An understanding of national income sources ments, large-scale mining, and forest royalties.
and federal and regional financing is necessary Recent fiscal performance shows diat about
in order to assess Ethiopia's capacity to pay for 87 per cent of public funds is raised by federal
health care and education. Fifteen regional government, and die remaining 13 per cent is
states were established before the adoption of the collected by the regions. There are marked
Ethiopian constitution in 1994.12 Addis Ababa regional differences in tax-revenue generation
and Dire Dawa are currendy part of the federal capabilities. Income distribution in Ethiopia
state. All the other regions have regional state varies within and between regions. The region
status. widi lowestper capita income is Amhara, and diat
Block budget allocation is made to the regions widi die highest income is Harari.13 Oromia,
by federal government on the basis of a set of Somali, and rural areas of Addis Ababa have
criteria, namely size of population (60 per cent), better income levels, compared widi Amhara
the level of social and economic infrastructural region.14 More dian 90 per cent of the rural
development of the region (25 per cent), and population earn less dian $1.00 per day. This
regional capacity to generate internal revenue means that neidier regional nor federal
(15 per cent). Regions with larger populations government has access to the significant taxable
and those with a lower level of social and incomes that would be necessary for adequate
economic infrastructural development obtain a public-sector financing.
greater share in the government's total budget In 1997, Ethiopia's total GNP was $US 6.5bn.
allocation. Additionally, the greater a region's The share of net official development assistance
capacity to generate local revenues, die greater fell from 20.6 per cent of GNP (1991) to 10.1 per
the share allocated to it by federal government. cent (1997). The most important sector for aid
The aim is to provide incentives to increase in 1996 was agriculture, forestry, and fisheries.
regional efforts at revenue generation. These Disbursements for health and human-resource
resources are destined for allocation to priorities development amounted to 5.7 per cent and 8.6
in education, heakh services, and rural per cent of total aid respectively.15 Aid to support
infrastructure development. Budget allocations the recurrent costs of healdi and education
are made between the zones from the regional services is negligible. External assistance to the
level. Where management capacity at zonal level country's total recurrent-expenditure budget is
is inadequate, the regional office provides sector- 2.3 per cent of domestic sources, and it made up
budget allocations to die zones. The zones less dian 1 per cent of most regional recurrent
redistribute the funds to die woreda offices. budgets.16
While this has brought the administradon of The Ediiopian economy performed reason-
public expenditure under closer control by die ably well between 1991 and 1998, compared
regions, it poses a major challenge. All widi die preceding twenty years. GDP in 1997

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

was $US 6.4bn, 55 per cent of which was experience recurrent drought. Economic-
generated from agriculture, 7 per cent from growth statistics have to be read in the context of
industry, and 38 per cent from services. The rapid population growth (3 per cent),
World Bank17 reported an average annual widespread low-income poverty, and hunger.
value-added growth rate of 3 per cent in About 48 per cent of children under the age
agriculture, 4.1 per cent in industry, and 6.9 per of five are malnourished. The Ethiopian
cent in services. The low starting base, good government is not in a position to provide the
rainfall, and the increase in foreign input in funding necessary to meet international
1991 contributed to the improvements in human-development targets without a
agricultural output figures. However, the value reduction in the debt burden and increased
of the main cash crop, coffee, has been in decline external assistance that is not tied to long-term
since 1986, and several regions of Ethiopia loan agreements.

Poverty in Ethiopia

Indicators of poverty children. These households cannot feed, clothe,

or wash18 their children, nor send them all to
In Ethiopia, the major barriers to development school or treat them effectively when they are
and the main indicators of poverty include the sick. They are households where the husband
following: has died, or which have no reliable (male)
employment and survive on intermittent daily
the low status and under-representation of labour (by men) or on the proceeds of women's
women; petty trading. About 30 per cent of households
the fact that coping strategies have become were headed by women in Addis Ababa, Delanta
main sources of livelihoods; Dawunt, and Jijiga; they ranked among the
the low educational status of adults and poorest of all. Worst-off households have no
children; livestock and/or have no land at all. Households
the increased burden of labour on women where either or both adults are too weak to work,
and children, who must work to earn income or where there is a serious illness, are extremely
for daily food; poor. Children in these households contribute
widespread indications of malnutrition and their labour to domestic, agricultural, and
high mortality rates among infants and income-earning tasks. They cannot afford to use
children; government education and health facilities. In
miscarriage and anaemia among pregnant all sites the poorest made fatalistic comments
girls and women, and high maternal mor- such as ' We pray to Allah' or 'We lie on the bed and
tality rates; wait to die' when they get sick, and many children
widespread dependence on traditional struc- are not in school because of their family's low
tures and practices for governance, healing, income, or because of hunger and untreated
and childbirth; diarrhoeal diseases.
the persistence of harmful traditional practices The main 'shocks', apart from underlying
such as Female Genital Mutilation (FGM), climatic disasters, that seriously increase
uvelectomy, tonsillectomy, all interventions poverty are similar to all sites. They include the
involving children, and the use of blades or death or serious illness of the male head of
other sharp instruments. household, the loss of a job or harvest, other
serious illness, and death of livestock.

'Worst-off' households, as
described by urban and rural Key development challenges
communities affecting access to health care
Women and men in all sites stated that everyone
and education
was getting poorer, even those who were better
off before the drought. The main source of Low status of women
household income (men's) had been eroded. The National Policy on Ethiopian Women (1993)
Household food security had diminished to and the National Population Policy of Ethiopia
unsustainable levels, and the dependence on (1993) highlight the low status of the majority of
women's low-income petty trading had Ethiopian women as a serious development issue.
increased. Between 70 and 85 per cent of The micro-level research found that women are
households in each community were classified seriously under-represented in local government,
as 'worst off. on school committees, and in traditional
'Worst-off households are those with a family governing institutions; that they have less access
of 10 or more, or with at least three small than men to education and health services; and

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

that their reproductive-health status gives cause incomes. Unemployment in urban areas is also a
for extreme concern. They are highly likely to major problem and begs die question: education
experience genital mutilation, early marriage and for whatfuture? Employment generation has to be
early pregnancy, high fertility rates, and life- tackled, alongside education reforms.
threatening abortions. They receive almost no
medical attention diroughout their reproductive
Low incomes
cycle (see the section on reproductive health in the
next chapter). In all rural sites, men commented Increasing incomes and purchasing power is
that women and children suffer more from central to improved access to education and
poverty and hunger, and that women and girls to health and reproductive-heakh services.
suffer particularly because of their workloads, Reported monthly incomes in worst-off house-
which include regularly carrying heavy burdens. holds19 during bad months were as follows: in
Addis Ababa 79 per cent of households earn less
than $12.80; in Delanta 70 per cent of households
earn less than $6.40; in Metta 70 per cent of
livelihoods and coping strategies households earn $6-$ 11; and in Jijiga 83 per cent
of households earn less than $6.40. In Delanta,
Ethiopia's Education and Training Policy (1994) treatment for scabies costs $0.35, or two days'
seeks to provide 'relevant quality education to work for a woman collecting and selling cow
the rural population'. Rural livelihoods are no dung.
longer valued, nor are they perceived as Sources of income that were once secondary
sustainable. Relevant education is seen as that have become the main source, related largely to
which provides skills required for livelihoods women's work such as petty trade. There are few
outside the agro-pastoral economy. Successive alternatives for men or women: 'We are all
droughts and/or flooding have depleted struggling selling wood, dung, and wool. We are now
livestock numbers, ruined harvests, and eroded tired, and the eucalyptus is also lost,' reported men
women's and men's sources of income from in Delanta. In Metta the men lie around and
crops, livestock products, food processing, chew 'chat all day, while women and children
and/or daily farm labour. Increased poverty in trade. In Jijiga everyone had fewer coping
better-off households results in the loss of strategies than interviewees in the other sites.
employment opportunities for women, men, Unemployment and low-income poverty are
and children in the poorest households. The fall key issues to be addressed if access to healdi and
in the value of the narcotic drug 'chat (in Metta) education services is to be improved in Ethiopia.
has reduced incomes, threatened food security, Women need income-earning possibilities that
and reduced access to credit for personal needs. are less intensive in terms of labour and
Global 2000, an internationally funded distance, and result in higher returns per hour
agricultural development programme, aims to worked. Men need alternatives to agriculture,
provide seeds and fertilisers on credit to poor especially in areas prone to recurrent droughts.
farmers, through a scheme implemented by the
Ministry of Agriculture. The aim is to increase Hunger and food shortages
agricultural output. However, in drought-prone
areas like North Wollo, farmers who have taken Chronic malnutrition is a persistent problem.
out credit for seeds and fertilisers and have Farming families cannot produce enough to live
produced no harvest are indebted to the on, and secondary sources of income are
programme. Participants told us they would be inadequate to purchase sufficient food. During
imprisoned for non-payment. Several men had the frequent droughts, livestock prices
therefore left the area in search of work in the plummet, and grain prices increase. In Delanta,
while grain prices increased, the sale value of
lowlands to pay off the debts, while their wives
livestock had dropped by 65 per cent. When
and children remain hungry in the highlands.
livestock die or lose value, there is no safety-net
The challenge is to regenerate the rural economy
left, and no food aid to maintain nutrition
with alternative sources of employment and
levels20 until the next harvest.
income for both women and men.
Unemployment hit Cherkos, a military
community in Addis Ababa, after the reduction of Children's labour
the armed forces in 1991. The loss of military- Girls and boys are significandy engaged in
service incomes has also had a negative impact on income earning and domestic work. In all sites it
informal-sector trading, services, and women's was found diat girls' heavy domestic workloads

Poverty in Ethiopia

free their mothers for trading. Children's The main elements of die macro-economic
labour is viewed as preparation for their future stabilisation and structural adjustment pro-
roles and is crucial to subsistence. Girls in gramme in Ethiopia are the following:
Delanta said, 'If our fathers could get a harvest, we
could go to school'. In all rural sites, girls said that tax-regime reform, mainly by broadening the
if there were grinding mills nearby, 'we children tax base and reducing income taxes and taxes
would not have to grind grain by hand'. In Delanta on foreign trade;
boys and girls collect firewood on steep ravines controlling and prioridsing government
to sell 15km away. Children cited accidents on expenditure in favour of social and economic
the ravines as a main health problem. In Addis infrastructure;
Ababa and Metta, children are engaged in street restructuring public enterprises for manage-
hawking and petty trading, girls alongside their ment autonomy and eventually privadsing
mothers; this is a main reason for boys from the them;
poorest families to stop attending school. liberalising die factor and product markets
Children in urban areas become vagrants: 'Our and removing subsidies, so that resource allo-
children sometimes beg or steal money for food' cation is led by market forces;
(mothers, Addis Ababa). Girls in Addis Ababa devaluing the exchange rate and deter-
and in Delanta Dawunt worked in the sex trade mining it by open auction;
and in bars. changing die investment climate to encour-
age private investment;
liberalising the interest rate;
Poverty, structural adjustment, a commitment to poverty alleviation and
and economic reform mitigating the social cost of economic reform
dirough increased social-sector investments,
The key features of the Transitional Government mainly in education and healdi services.
of Ethiopia's (TGE) policy reform are a shift to a
market economy, agricultural-development-led Liberalisation, removal of subsidies, and tax
industrialisation (ADLI) as die long-term reform reduce die reach of recurrent-costs
development strategy, and die adoption of a budgets for healdi and education. The increased
macro-economic stabilisation and structural cost of drugs was direcdy attributed to
adjustment programme. More recendy die liberalisation policies. Drugs are too expensive
Ediiopian government, togedier widi the World for the majority of die poor. The increasing cost
Bank and IMF, is committed to die production of of materials and equipment in schools, clinics,
a Poverty Reduction Strategy Paper (PRSP) to and hospitals also affects the impact diat
replace die Policy Framework Paper. The PRSP recurrent-costs budgets for healdi and
has to be formulated widi die close involvement education services can have on die quality of
of civil society. government services.

Health status of the poorest communities

Women's life expectancy at birdi in Ethiopia is were respiratory infections, diarrhoea, MCH
44.3 years, and men's is 42. Sixty-six per cent of illnesses, malaria, and HIV/AIDS. In all sites
the population are not expected to survive to the respiratory-tract infections are common, and
age of 60 (1997).21 Maternal and infant tuberculosis clearly on the increase. Medecins
malnutrition is a serious problem. Infant sans Frontieres in Jijiga estimates that 90 per
mortality occurred in 111 cases per 1000 live cent of the population of Jijiga have been
births, and under-five mortality in 175 per 1000 exposed to TB.
live births (1997). In the same year in the United Participants in the micro research also
Kingdom, infant and under-five mortality rates reported a high prevalence of communicable
were 6/1000 and 7/1000 respectively. In Ethiopia diseases,22 although HIV/AIDS and malaria were
there are four doctors and eight nurses per not commonly reported, except in Addis Ababa
100,000 people, with staffed services con- and Delanta23 respectively. Health problems
centrated in urban areas. The micro research related to social behaviour, and those
strongly indicates that most of the poor in urban consequent on harmful traditional practices and
and rural areas do not seek treatment at the abuse of drugs or alcohol, were commonly
government health facilities, because they mentioned by participants in all focus groups,
cannot afford to. Health centres are too far away, and largely remain untreated and outside the
women do not have the necessary time or the sphere of modern medicine.
money to attend them, staff attitudes to the poor Men in Metta reported the side effects of 'chat
are bad (They treat us like dogs'), and there are no chewing, including gastritis, 'paralysis', impo-
drugs available to treat diseases, once diagnosed. tence, and violent behaviour resulting in injury,
For many diseases women in particular prefer to sometimes death. The researchers noted other
visit holy waters or traditional healers. Men often indicators of the psychological impact of poverty:
choose to treat themselves at the local drug store. signs of mental and emotional stress, including
anxiety and fear among boys in Delanta, who
said, 'We just want to live and to learn' not die of
Main health problems hunger. Delinquency among urban male youth
and the abuse of alcohol and drugs lead to the
A survey by the Central Statistical Authority harassment and abuse of girls, and traumatic
(CSA, 1999) shows serious levels of malnutrition injury as a result of violence or muggings.
in rural areas. In Oxfam's research sites, 45-60 In Metta and Jijiga, infibulation is practised
per cent of participants reported eating two (see the section on reproductive health below),
meals per day, mainly a handful of liolo (roasted causing girls and women life-long untreated
grains). Health-service providers in all sites health problems. Girls' early entry into die sex
attributed the high incidence of diseases to trade reportedly results in unwanted preg-
poverty, hunger, and poor sanitation. Dirty nancies and abortions. Miscarriage and anaemia,
contaminated water results in a high incidence of and heavy bleeding after delivery, were reported
diarrhoeal diseases. 'Filth, lack of toilets, and the by respondents in all sites as 'main health
inability of the community and government to address problems' and attributed to malnutrition. A
these issues' are contributory factors, according to common complaint among women was severe
TBAs in Addis Ababa, implying that the problem abdominal pains, attributed to the regular
is one of poor organisation as well as lack of demands on women to carry heavy loads.
resources. The CSA survey (1999) found that 76 Reproductive health is emphasised to
per cent of diseases are communicable, 20 per highlight the fact that the government-sourced
cent non-communicable (e.g. heart disease), and health-service statistics used by planners do not
4 per cent caused by accidents and injuries. The include reproductive-health problems among
most common diseases found in the CSA survey common health-related issues. All focus groups

Health status of the poorest communities

in all sites identified reproductive-health (a condition of receiving STD treatment in

problems as being among their most common government services).
health problems. Issues of reproductive health Reproductive-health interventions are mainly
must be made visible and expressed in managed by untrained traditional practitioners
mainstream health planning and budgets. in unhygienic circumstances, using rudimentary
instruments, especially in rural sites. Male
circumcision27 affects 100 per cent of boys, who
Reproductive health are generally circumcised as infants. The
practice of female genital mutilation (FGM) is
Women's reproductive health receives too little estimated to affect 85 per cent of Ethiopian girls
attention from government and donors, because and women.28 Girls are circumcised in Delanta,
it is allowed to remain 'invisible'. Legally girls can Metta, and Jijiga as infants, at 5-7 years, and at
get married at 15; by law the use of family 9-13 years old respectively. In most of Ethiopia,
planning is restricted; and, while FGM is illegal, sunnaP and 'excision'30 are the most common
it is not mentioned in the health policy and is practices. In Metta and Jijiga the more extreme
widely practised. 'We don't know one woman who has form, infibulation,31 is the custom. In eastern
not been circumcised, nor one woman who has not had regions, impotence was found to be a common
problems during delivery,' said women interviewed problem, attributed to 'chat chewing and FGM.
in Metta. The National Population Policy states FGM is still practised in Addis Ababa, but the
that laws must be changed and reinforced, and campaign of the National Committee on
Information Education and Communication Traditional Practices in Ethiopia (NCTPE) has
programmes must be applied if attitudes clearly changed attitudes and reduced its
towards women are to be changed in reality. incidence. Although it is certain that the practice
In the Oxfam research rural sites, 0 per cent results in serious infections and heavy loss of
of women had been attended by a qualified blood, not one girl has been brought to the
medical practitioner during their last delivery hospital in Metta after the intervention, because
(compared with 48 per cent of women in Addis the practice is illegal. The doctor reported that
Ababa).24 Maternal mortality rates in Ethiopia very few come for delivery: 'FGM can cause
are among the highest in the world, at 1400 per obstructed birth, a ruptured bladder, and incontinence
100,000 live births (1990).25 The delivery of thereafter.' In Delanta health staff reported that
Reproductive Health Education (RHE) is 'women and girls experiencing obstructed birth or other
limited and very traditional; it includes family irregularities are most likely to die'.
planning, immunisation, child health, and
nutrition. In Jijiga 3 per cent of women had Girls were particularly concerned about FGM
attended antenatal care (ANC) in their last and early marriage, and they described prob-
pregnancy. In Delanta and Metta, 50-53 per lems faced by friends during delivery. Boys in
cent had attended ANC on between one and Delanta and Metta expressed the need to
three occasions. About 50 per cent and 70 per address the issue of early marriage and the
cent of these respectively had attended because termination of girls' education. It is not unusual
the mobile clinic had come to them. The mobile- for girls from poor rural families to marry at the
clinic programme in Delanta stopped when age of 10 and have their first pregnancy at 12.
external donor funding came to an end. Health Abortion is illegal, and not socially acceptable in
facilities reported an acute shortage of financial, the rural sites, although practised in Addis Ababa
logistic, and human resources to provide mobile and the rural towns. Illegal abortions in Addis
ANC, extended programmes for immun- Ababa have reportedly resulted in loss of life, and
isation (EPI), and health education, including were the subject of great concern to all focus
RHE services. groups there. The victims are often young girls.
By using ANC and MCH clinics as the
medium, only women (and in rural sites mostly
better-off urban women) are reached. Men and HIV/AIDS32 and sexually
youth are basically not reached. The only transmitted diseases
opportunity to contact them is through STD
clinics, but most men reported that they prefer There were nearly 60,000 reported cases of
to treat STDs at drug stores or by visiting AIDS in Ethiopia by 1998. However, the
traditional healers, to protect their privacy and Ministry of Health estimates that only 15 per
to avoid having to divulge their partners' names cent of total cases are reported, and that in fact

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

400,000 people are infected with AIDS and 2.5 and highest reported incidence of HIV/AIDS
million with HIV. Under-reporting is most was in Cherkos, Addis Ababa. In Delanta people
likely due to the fact that most people do not know about the disease, since men returning
have access to modern health facilities at all, and from the lowlands are sometimes infected and
that many probably die of other diseases before die. In Metta, while men and boys were aware of
being diagnosed. Of the total number of the causes of AIDS, only one known case was
reported AIDS cases, 90 per cent of the sufferers reported. In Jijiga, while 20 per cent of TB
are aged 20 to 49: the most productive sector of patients in Jijiga hospital were infected,34 there
the population. was a low level of knowledge about the disease in
A survey of pregnant women showed an the villages.
increase in infection from 13 to 21 per cent (1993 STDs, gonorrhoea in particular, are very
to 1997) in some urban areas.33 In 87 per cent of common, especially in Metta and Addis Ababa.
cases, multiple-partner heterosexual contact is The illness is typically described as a men's
the main cause of infection. Prenatal transmission problem. Women are not recognising and
is also significant. A small number of cases are due treating the disease themselves. Sexual promis-
to contaminated blood transfusion. Youth in all cuity in Muslim communities (Metta and Jijiga
field-study sites voiced concerns about being 'at sites) is taboo to the point of denial and
the mercy of health-centre staff and traditional therefore needs to be addressed with informed
practitioners using non-sterilised reusable needles and and sensitive campaigning, particularly in the
razor blades'. The government's 1998 HIV/AIDS light of the spread of HIV/AIDS infection. RHE
policy promotes the prevention of harmful should address STDs as an issue affecting both
traditional practices and illegal injections. men and women, promoting the right to
While all sites reported a high incidence of knowledge and treatment for all, and safe sex
STDs and TB infection, the strongest awareness practices.

Health-sector policy and planning

Historical perspective and promotive health care' and the development

of an equitable and acceptable standard of health
Until the 1950s there was no official health policy service, accessible to all sectors of the population,
in Ethiopia. Towards the end of Haile Selassie's within limited resources. Before the recent war
regime, the World Health Organisation with Eritrea, the TGE aimed to reach 80 per cent
influenced a more substantive policy for health- coverage by 2015. Support for the curative and
service provision, and preventative care was rehabilitative components of health care, includ-
emphasised alongside curative treatment. ing mental health and provision of essential
During the Derg regime in the 1970s and 1980s, medicines, is also a priority. This is important,
health-policy priorities included disease given the number of people who cannot afford to
prevention and control, with priority given to seek treatment: 'Many people die because they cannot
rural areas and the promotion of self-reliance afford health treatment. ^ The policy envisages user
and community involvement, and training and charges for diose who can pay, and special
engaging Community Health Workers (CHWs) assistance mechanisms for those who cannot (see
and Traditional Birth Attendants. The failure to 'Exemption system', below). The intersectoral
invest in a comprehensive health system in the aspects of health care are recognised to include
1950s and 1960s, and the redirection of population, food security, safe water, safe waste
resources to the civil war in the 1970s and 1980s, disposal, and environmental health. The policy
have bequeathed to the TGE a system in need of envisages the participation of the private and
substantial capital and recurrent funding, in the non-government sectors.
context of a greatly increased population. Priority will also be given to Information,
The TGE's new health policy (published in Education, and Communication (IEC) to pro-
1993) is consistent with the aims of decentral- mote public awareness of health-related issues.
isation and promoting 'the rights and powers of Health education is to include identifying and
the people'. Emphasis continues to be laid on discouraging harmful traditional practices and
meeting the needs of the rural population. discouraging the acquisition of harmful habits,
However, the policy does not fully reflect the including drugs abuse and irresponsible sexual
gender-specificity of certain health problems, behaviour. The National Population Policy also
and the need to address the fact that access to calls for IEC on women's status, family planning,
services is not available on an equal basis to and harmful traditional practices.
women and men, and that they have unequal The policy is positive about the potential for
opportunities to participate in decision-making. integrating the beneficial aspects of traditional
medicine into modern health-care practice.
However, Oxfam's research shows that, while a
The Health Policy of the TGE few TBAs have access to training in some
(1993) regions, there is no communication between
health centres and most TBAs, herbalists, and
The policy document closely reflects inter- religious healers ('holy waters' and Sheikhs).
national donor expectations of a developing- The majority of the people use traditional
country policy. It has been further elaborated in medicine in one form or another.
various strategy documents, plans, and policy
papers, including the twenty-year Health Sector
Development Plan, plans for regional govern- Financing health care
ments, HIV/AIDS policy, a policy on drugs, and
a human-resources development policy. The total planned budget allocated to health was
The main elements of the government's expected to be Birr 5 billion over three years
Health Policy are the 'development of preventive (1998-2001). In the Health Sector Development

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Programme (HSDP1998), the TGE made a a recent emphasis on construction to increase

commitment to fund 55 per cent of this sum, in the number of health facilities. Recurrent
the expectation of external contributions budgets are roughly allocated as follows:
equivalent to 43 per cent, and 2 per cent of the
total raised from user fees: a total of 64 million 37 per cent to Primary Health Care (PHC)
Birr by 2001.86 This figure assumed an increase facilities
of 69 per cent in user-fee revenues over the three- 1.9 per cent to training
year period. During 1999, however, inter- 6.5 per cent to anti-malaria programmes
national donors suspended their funding in 17.2 per cent to administration
response to the war with Eritrea. Meeting health 35.9 per cent to hospitals (used by not more
and education development targets will now take than 15 per cent of the community).
longer. However, during 2001 Ethiopia is due to These figures are representative of the distri-
come up to Decision Point on the HIPC debt- bution in all rural micro/macro research sites. In
relief initiative. If Ethiopia succeeds in meeting all Addis Ababa, 35.3 per cent goes to PHC facilities,
the conditions, new funds for health services may 3.9 per cent to training, 0 per cent to malaria
come available. Economic-policy researchers programmes, 7.7 per cent to administration, and
made the point that dependence on external aid 53 per cent to hospitals.40 These figures reveal a
for planning health-care delivery has been significant difference in administration costs
'perilous', given the 'on/off approach of the between Addis Ababa and the rural regions,
donor community to financing countries that are which might be worth analysing.
involved in conflict. A contentious issue to
overcome with donors is the imperative need to
maintain funding for social-sector development Structure of the system
despite wars and conflict in African countries.
Public expenditure on health as a percentage In theory, the new health system has four tiers of
of gross domestic product increased marginally facilities, with a strict referral system between
from 1.3 per cent to 1.7 per cent of GDP between each level. At community level there should be
1986 and 1995. On the other hand, the one Health Post per 5000 people. Five Health
proportion of debt to GDP increased significantly Posts refer to a Primary Health Care Unit (one
from 51 per cent to 159 per cent (1988-1997). PHCU per 25,000 people). The next tier is the
Ethiopia spends nearly three times more on District Hospital, serving 100,000-250,000
repaying interest on external debt than on people; beyond this is a Zonal Hospital for one
financing health services. However, the percent- million people. An emphasis on preventative
age share of recurrent budget allocations to services is envisaged at all levels of the health-care
health care increased from 1991, and the share to system. However, curative health care is also in
defence, until 1998/9, fell significantly.38 The great demand, as are outreach services. The field
percentage allocation to health from the total research showed that health-education and
capital budget also increased, from 2.3 per cent to outreach services are seriously under-funded
5 per cent over the same period. Real planned and lack an adequate number of qualified staff.
per capita expenditure on health care is still low, The existing and planned structures do not
however, in the context of increasing running match the needs of most rural and poor families,
costs caused by economic liberalisation, deval- particularly women and children.
uation, and rapid population growth. Statistics that are commonly used for planning,
The share of recurrent expenditure in the such as ratios of population per doctor and
total health budget fell from 80 per cent in population per health centre,41 provide a
1990/91 to53percentin 1997/98.39 This reflects distorted picture of reality and can lead to

Table 1: Percentage shares in government's recurrent budget

Health Education Defence Debt interest repayments

1984-90 3.6% 41.5% 6.9%

1991-97 5.8% 16.7% 18.5%38 15.3%

Health-sector policy and planning

assumptions about the availability of functioning Management of the service is poor. Primary
health care which imply adequately resourced Health Care Units are managed at woreda level,
and well-trained service delivery. In Delanta, only but there is little attempt at accountability.
two out of five health stations are functioning. In There is a serious need to strengthen the
Harari region, for example, there seems on paper planning and management capacity of die local
to be enviable hospital coverage, but in reality die government officials who are responsible for
hospitals are barely operational. There are also overseeing die implementation of the policy,
wide disparities between regions in die provision and to strengdien lines of accountability
of physical infrastructure. Predominantly agro- between local government, die healdi services,
pastoralist regions like Somali region have very and die community. In fact, few healdi-service
few health stations. Population/health-centre providers had even seen the healdi policy or
ratios are useful only if people actually use the population policy.
facilities when they are sick. However, in each site
participants reported that 'people cannot afford the
fees, so they do not go'. Women seek treatment only Traditional practice
'when it is really serious'.
In all sites everyone, and women in particular,
tends to treat their own problems at home,
Staffing and/or go to traditional healers. Many people
consult the holy waters or die Sheikhs, who also
The Ethiopian National Health Strategy (1995) do home visits. Of all sites, interviewees in Jijiga
identified the following personnel-related had less knowledge of traditional medicines and
problems: inappropriate staff mix, a shortage of made less use of diem. It was reported diat
front-line and middle-level professionals, and an traditional practitioners are close by and
urban bias in distribution of human resources. cheaper than formal services, and one does not
The WHO recommends a doctor/population have to wait for a consultation. The poor are
ratio of 1/10,000 and a nurse/population ratio of treated widi respect, and women in particular
1/5000, but in Ethiopia these ratios are diree or believe they will be cured. Young people,
four times higher.42 Given the urban bias in the especially boys, were less enthusiastic,
numbers of skilled, qualified staff, die ratios in commenting diat die herbalists were dirty and
rural areas are even worse dian die statistics did not cure diseases. They want good
suggest. The healdi policy prioritises measures to diagnosis, supported by proper medical
strengdien die human-resource base and man- laboratories.
agement capacity in die healdi service. Instead of Traditional healers treat a wide range of
using CHWs43 and TBAs, trained, front-line, illnesses. They perform interventions widi
community-based and middle-level health sharp instruments, including delivery (which
workers will be employed. Oxfam's research often needs an incision for FGM scars),
confirmed die need for more trained healdi tonsillectomy, uvelectomy, circumcision, and
personnel at all levels in die service, and more FGM. Traditional healers commonly treat men
trained staff for healdi-education and outreach for impotence and STDs. TBAs treat girls and
services. women for many gynaecological and
Healdi-service staff complain of being demor- pregnancy-associated problems.
alised, overworked, and underpaid, especially in The Health Policy envisages 'developing the
remote locations. There is poor supervision and most beneficial aspects of traditional medicine'
support, and a lack of die most essential drugs through research and regulation. In Metta,
and basic equipment. The healdi centre in however, government healdi workers were
Delanta reported a shortage of everything, and scadiing about traditional healers. People are
no funds or medication for at least diree montiis often treated in the villages and come to the
each year. There is evidence diat staff are leaving Healdi Centres when it is too late: You can die
state-funded services to work in die private waiting'. The TGE does not envisage using
sector, and diat they prefer to remain in die TBAs.44 In some areas TBAs still get training,
larger urban centres. In recognition, die health but die impact is minimal, given die enormous
policy includes plans to develop an attractive demand. Since traditional practitioners are
career structure, widi appropriate widely used anyway, die healdi system should
remuneration and incentives, for all employees. regulate them, draw on dieir skills, train diem,
There are no signs of diis being put in place. and integrate diem into die referral system.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Private practice and drug cultural and social impediment militating

vendors against their [women's] full enjoyment of
fundamental human rights.'45
Very important to health provision are the drug The policy states diat widiout a reduction in
vendors and pharmacists, concentrated in population growth, the achievement of national
urban centres. In more densely populated development goals such as food security,
regions there is on average one pharmacist to universal primary education, increased access to
600,000 people. In agro-pastoralist health services, and extended employment
communities in areas like the Afar and Somali opportunities will be seriously jeopardised. The
regions, there are fewer (1:1,000,000). The school-age population, 12 million in 1984, is
corner shop that sells painkillers, or drug stores, estimated to reach 42.5 million by 2020.
pharmacies, and private clinics are preferred Existing laws permit marriage at 15, and family
and used for diagnosis and medication. Men are laws currendy in force restrict die right of
women to regulate dieir fertility. 'Technically,
more likely to use this route than women are.
all institutions providing family planning,
All participants complained that the poor are including government, are doing so illegally.'46
not given the same treatment as the better-off in The prevalence of contraceptive use is estimated
government health facilities. In the private at 4 per cent nation wide.
sector, diey claimed, diey are treated with
respect. Women said the added advantage is that The Health Policy (1993) pays special
'someone can go for the patient'. While pharmacists
attention to 'the health needs of the family,
particularly women and children', 'intensifying
have been instructed not to diagnose patients,
family planning for die optimal health of the
they and die private clinics seem to be taking up
mother, child and family', and 'encouraging
the slack from the government services, and
paternal involvement in family healtiV. But real
sometimes give treatment or drugs on credit or
improvements require changes in die law
at reduced charges if the poor cannot afford
regarding family planning, the permitted age
for girls to marry, the availability of legal
Private clinics want grants from the govern- abortion, and an enforcement of the law
ment to expand their practices. Both private prohibiting FGM. IEC programmes, drawing
clinics and drug stores want to be involved in on knowledge and experience gained in
any government-run training programme for Ethiopia and Somalia, should include media
health workers. Given that they are involved in communications and collaboration with local
treating reproductive-health problems, and government and village-level organisations,
STDs in particular, their involvement in RHE including women's and children's groups.
would be strongly advised. Youdi groups in all sites recommended
However, for all practitioners outside die education in sexual health for women and men,
government health services diere should be young and old.
strict guidelines for practice and regulation.
There are injectionists, healers, and circumcisers
using non-sterilised blades and no painkillers,
illegal abortionists, and many others who
constitute a serious health hazard, particularly to The allocation of drugs per government-funded
women and children. health unit has stagnated at the level that it had
reached ten years ago. This is largely due to die
rising cost of drugs. As part of the economic
Family planning and reform programme, drugs are taxed, and direct
reproductive health subsidies have been removed. As a result some
hospitals attribute 80 per cent of running costs
Ethiopia's National Population Policy (1993) to the price of drugs.
describes die acute nature of reproductive- One of die most commonly cited problems is
health problems. Fertility rates are high, and die shortage of essential drugs. Patients from
population is growing by 3 per cent per annum. Addis Ababa to Jijiga, whedier exempt from
Both die National Population Policy and the paying health fees or not, could not get treatment
Policy on Etiiiopian Women stress the need to because die drugs were simply unavailable or
improve die status of women: 'Vigorous steps were too expensive. The healdi policy (1993)
have to be taken by government to remove all clearly states die need to standardise die system,

Health-sector policy and planning

to prepare lists of the most essential drugs and service. Nor can many of these households obtain
equipment, and to develop an efficient system for exemption papers to get health care free of
procurement and distribution. Oxfam's research charge. On the other hand, in Delanta the health
shows that there is still a lot of work to be done on centre cannot begin to cover its costs, because 75
this matter. per cent of patients (mostly urban poor people)
Drugs are also supplied through the National claim exemption. It appears that rural house-
Drug Programme, via bilateral and multilateral holds have less access to exemption papers. The
agencies and NGOs. But the most frequently Peasant Association (PA) said that only families
needed drugs are either not delivered or with no livestock at all could qualify for exemp-
delivered in insufficient quantities and often tion. Women are not as well informed about the
close to the expiry date. Health workers system as men are: some women did not know, or
reported their dilemma when treating 'free' even believe, that it exists. All participants who
patients. Health facilities run two drugs supply knew about the system said it was too complex: in
lines, one to treat non-fee paying patients some cases, by the time exemption was obtained,
(government supply) and the other to treat fee- it was too late.
paying patients. Often the drugs required for
In the Jijiga site, no one was entitled to
treatment, if they are available at all, are on the
exemption, because there is no PA or kebele to
'for sale' shelf, not on the 'to be dispensed free of
process the applications. In Metta some women
charge' shelf. Drugs for sale are frequently
said that if the PA officials gave you exemption,
supplied by a revolving drug fund, such as the
you would be indebted to them, which deterred
one established in Jijiga by Medecins sans
Frontieres. However, most people visiting the people from applying. In Addis Ababa the kebele
health centres cannot pay for the drugs. Some was asking exemption applicants to pay Birr
health workers give drugs which should be paid 5.00 towards a maternity unit funded by the
for to poor patients, and risk facing the World Bank, being built in the neighbouring
consequences afterwards. Patients in Addis kebele. Many people said it was not worth seeking
Ababa believe that fee-paying patients get better treatment as a free patient, because there were
drugs than they do. Poor patients most often no drugs for their illnesses.
simply go without treatment: 'We pray to Allah'. More work needs to be done to improve the
In all sites, health workers and zone offices system of user fees and exemption, and in
agreed that the majority of people cannot afford particular to address the differences between its
to pay for drugs. operation in urban and rural centres. But it
must be admitted that the health service lacks
the capacity to cope with increasing numbers of
Exemption system free patients, and the drugs to treat them.
Health-service providers confirmed that
The majority of rural and poorest participants in everywhere everyone is becoming poorer and
Oxfam's research cannot afford to use the health cannot afford health care.

Water and sanitation

The health policy of the Ethiopian government blood in the stools. In all sites, boys and girls
recommends 'intersectoral collaboration' in were especially concerned for improvements in
(among other things) 'accelerating the provision water and sanitation services, including envi-
of safe and adequate water for rural and urban ronmental-health education for their parents.
populations' and 'developing the safe disposal Collecting water is most often the task of
of human, and household waste'. An estimated women and girls. Boys from the poorest families
75 per cent of the population do not have access also sometimes help in this task, and men in
to safe water, and 81 per cent have no access to Jijiga and Delanta help during the dry season,
sanitation facilities.47 In all sites the most when the water sources are farther away. Water
common health problems were attributed to costs money in Addis Ababa (but not in the rural
dirty water and poor sanitation. In the rural
sites), at 0.15 cents per 20 litres. In Metta there is
areas, the majority are 'sharing water sources with
piped water within 30 minutes' walk of each
wild animals and cattle'. In the urban areas, water
household, installed by the community with
contamination increases during the rains, and
there are few facilities for the disposal of human support from Oxfam. In Delanta, men and boys
waste. were digging a water source as part of a food-
for-work programme, but they had not received
In Addis Ababa there were open drains, food for the past four months. In Addis Ababa
overflowing public toilets, and streams of
the kebele had applied to the World Bank Social
sewage overflowing down paths and roads and
Rehabilitation and Development Fund to
into houses. There are barely any pit latrines in
improve sanitation, but since the kebele is too
the rural sites: people have to defecate in the
open countryside. In Delanta there is one poor to make a 10 per cent contribution in cash,
sanitation officer attached to the health centre, it is not eligible for this form of aid. There are
but no budget, transport, or team to facilitate his NGOs, such as Oxfam, Save the Children, and
work. In Jijiga the women said that when there the Ogaden Welfare Society, working on water-
is no rain the dirty stagnant water does not get supply projects, but no sign of any serious and
washed away, and they have no choice but to use widespread national effort to improve access to
that filthy water; everyone gets diarrhoea with safe water in any site.

Food security

In 1994-95 Ethiopia was the second largest Low-income poverty, repeated droughts, and
recipient of food aid in the world after lost harvests and livestock reduce household food
Bangladesh. The Health Policy (1993) highlights security. In the worst-off households, 90-96 per
the need for 'intersectoral collaboration', cent of income is spent on food. As cheap food for
including the formulation and implementation their families, women buy guaya, a leguminous
of an 'appropriate food and nutrition policy'. plant known to have toxic effects.49 Many families
Most of Ethiopia's people suffer from chronic were eating a handful of roasted grains twice a
food shortages for much of the year, which give day, and 85-100 per cent of households reported
rise to famine situations as soon as a crop fails. 'difficulties in maintaining nutrition'. Women
'Our women are malnourished and give birth to cannot afford to follow advice on child nutrition.
unhealthy children', reported men in Delanta. In all sites teachers reported hungry children in
Infant-mortality rates in Ethiopia are 111 per school, and parents said: 'Due to hunger we could not
1000 live births (1997). Miscarriages and send our children to school.' There is no supple-
anaemia during pregnancy, and heavy bleeding mentary feeding in primary schools.
after delivery, are common and are attributed to In all sites women and men (and even the youth,
malnutrition. The National Population Policy in Addis Ababa) expressed die need for more food-
links infant mortality to high fertility. The CSA
for-work programmes. Supplementary feeding
(1999) estimates that 66.6 per cent of children
should be made available through schools and
suffer stunted growth, and 46.7 per cent are
mobile clinics. Heath-education workers need to
underweight.48 In Jijiga men said, 'We are too weak
be more aware of women's ability to purchase or
to plough without food'. Men die from hunger
produce recommended foods at various times of
while carrying food aid home, or while carrying
firewood to the market (Delanta). The lack of the year, and they should provide support and
food security is responsible for general advice accordingly.
disillusionment among men, who express their Aid to Ethiopia has experienced swings
sense of helplessness and failure at not being able between relief and development phases. They
to provide grain for their families, observing that attract different funding packages, are managed
'our wives give birth to weak babies' because of through different government institutions, and
hunger. Many feel responsible for the suffering are assumed to have different objectives and
around them. Young people live in the shadow mixes of professional expertise. Oxfam's research
of hunger {'If we eat food one day, the next day wein Ethiopia demonstrates die need to integrate
don't'), and express their wish 'to live and to learn'. these skills and experience, in order to plan and
Girls and women suffer more; women believe implement parallel relief and development
that 'girls can stay longer without food'. programmes.

Education status of the poorest communities

Educational attainment in the Women in all sites had mixed views on

community educating girls. On the one hand, they need to
go to school '50 they lead a better life than us and get
Illiteracy rates in Ethiopia are high. In Delanta 70 equality'; on the other hand, 'Why do you need
per cent of the community are illiterate; in Metta education to build a house and grind grain ?' (Jijiga).
the figure is 78 per cent for women and 31 per It cannot be assumed that all women value
cent for men, and die figures in Jijiga are 79 per education for girls. Women's world-view reflects
cent of boys/men and 98 per cent of girls/women. their subordinate status and their dependence
While there are clear gender-linked disparities50 on girls' work. IEC materials promoting
in access to education, both sexes experience a education for all need to take this into account.
high level of educational deprivation. Nearly 60 Youth groups value education highly and see it
per cent of men in Ethiopia are illiterate. While as a means of improving the community,
enrolment is growing at a rate of 21 per cent per escaping from poverty, and getting jobs to
annum, primary net enrolment as a proportion support their families. Girls see education as a
of children of primary-school age remains means of improving their status as well.
around 35-38 per cent (1997). The proportion of Education is widely considered as a road to
female students is approximately 38 per cent, and employment outside the agricultural com-
girls' attendance appears to be in decline,
munity, even though 'those who have completed
especially in Muslim areas such as Harari, Dire
Grade 12 from our community could not get jobs or
Dawa, and Oromiya. School attendance in
further education' (men, Delanta). Rural children
$: r.oralist communities like Jijiga is negligible.
lack access to higher grades within primary
or the development of citizenship and school and to secondary school; 85 per cent of
participatory planning and implementation, the population and 6.2 per cent of all secondary
current educational levels and projections are in schools are located in rural areas.51
urgent need of attention, particularly in rural
areas, in pastoralist and Muslim communities,
and among girls. 'We always talk about problems School attendance and drop-out
after they happen and do not plan for them before ... rates
There is no one educated enough to lead us,'
complained men in Jijiga. In Addis Ababa52 only a small proportion of chil-
dren attend primary school at all. In the poorest
households53 41 per cent of the children in the
Perceived value of education families in the study were not in school. Of diese,
Providers of education services and youth 67 per cent were unable to afford schooling, and
groups believe that parents' low appreciation of 22 per cent had failed a repeated year.
the value of education contributes to low rates of In Delanta, 60-65 per cent of children of
enrolment and persistency, and high drop-out primary-school age were not in school. In Metta
rates. 'Large proportions of children, and about 50 an estimated 65 per cent of boys and 75 per cent
per cent of girls, do not attend school because of of girls were not in school. In Jijiga onlyfiveboys
poverty, repeated famine, early marriage and parents' from a village of 170 households were in school.
unwillingness to send children to school', according The education bureau in Jijiga estimated that 88
to a woreda education office in Delanta. per cent of children in the region as a whole
In Jijiga, where educational levels are the were not in school. In all sites, proportionately
lowest, there was a high appreciation of the value more boys than girls are in school. Generally the
of education: 'An uneducated person is blind.' drop-out rate for boys is higher than that for
Literacy and education are associated widi the girls, simply because they are greater in
ability to negotiate and engage witfi formal number. Table 2 shows that large numbers of
institutions: 'to tell the government about ourproblems'. children drop out during and just after Grade 1.

Education status of the poorest communities

Table 2: Low persistence in elementary schools

Grade Wokote, Delanta Ali Roba, Metta Jijiga (town)

1 253 students 100-120 students 100-120 students

6 14 students

5+6 50 students

4 27 students

(Source: Site reports 2 -4, Oxfam Policy Dept. Micro Research, Health and Education, Ethiopia, 1999)

L o s s of m a i n
Reasons for not going to school livelihood base
Shocks such as a drop in the household's main
Cost source of food and income, the loss of a parent,
The most common reason for not attending or especially a father, failure of a harvest, or
dropping out of school was lack of money: not unemployment result in renewed demands for
for school fees but for food, clothing, exercise girls' and boys' labour. Boys who drop out of
books, and soap; for warm clothes in Delanta, school often do so in order to earn income for
and for uniforms and better housing in Addis the family. In Metta, 38 per cent of children quit
Ababa. In Addis Ababa more children attend school because dieir families needed their
fee-paying schools. Registration in government labour. 'If our fathers could harvest a crop, we could
schools costs between Birr 1.00 and 10.00. go to school', said girls in Delanta.
Children drop out of school when they cannot
buy a new exercise book. There is no school in Domestic labour/early marriage
Jijiga, so the community had no idea of costs. Domestic labour and early pregnancy in all sites,
early marriage (at die age of 10+) in rural sites,54
Distance and abortion in Addis Ababa are all reasons for
In Cherkos, Addis Ababa, government schools girls not going to school or dropping out. Girls'
are too far away, and many children who cannot poor performance in school is attributed to
afford private-school fees are not in school. domestic work before and after school. If a girl is
Walking distance to school and unsafe in school, FGM and the three months' recovery
conditions on the way are serious barriers to period interrupt her continued access to
access to elementary school. Girls in Addis primary education. There are inadequate data
Ababa and other urban centres suffer abuse and on early marriage, early pregnancy, and
sexual harassment on the way to school. abortions; more information and openness are
needed to respond to these issues appropriately.
Urban bias
In Metta and Delanta, the village schools stopped Children's work
at Grade 4 and 6 respectively. To complete In Addis Ababa, 67 per cent of children in the
primary education, children have to go to town. household survey were engaged in daily labour
This is impossible for most, especially girls, activities. In Delanta, of those in school, boys miss
because of the distance involved and die cost of one-two days a week and girls two-three days, in
accommodation and uniforms. Girls cannot stay order to work. In bad months and peak
widi friends/relatives in town, especially diose agricultural-labour seasons, the demand for
from Muslim families. In Delanta rural children children's labour increases and takes precedence
were two years behind urban children. Those in over school. Women and girls have to grind
upper grades in town say they are discriminated grain manually; there are no grinding mills
against by teachers and urban pupils, because within easy reach.
diey are from poor rural families.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Coping strategies Some parents and children complained that

Girls work so that their brothers can attend the teachers are not up to standard, others that
school. Some families manage to send one child children are beaten in school. Discipline is a
to school, most often a boy, or send children for major problem in Addis Ababa.
fewer years.

Teachers' problems
Problems of accessibility and
quality of education Teachers report being demotivated by low
salaries, the lack of incentives, and the absence of
Children, especially girls, with heavy workloads a proper career structure. In remote areas they
and inadequate diets, cannot meet the academic experience problems with communications,
standard set by the Ministry of Education and housing, and healdi services. Women teachers
have to repeat years. Girls repeat more have no access to reproductive-health care, give
frequently than boys do. Girls' socialisation as birth without assistance in die villages, and have
the subordinate sex, according to teachers, inadequate child-care support. There are
makes them shy and affects their school no secondary schools for teachers' children. To
performance: 'Girls are victims of custom and provide competent instruction, they need
religion.' Girls do not know what to do during training, textbooks, teachers' guides, teaching
menstruation, so they stay at home. equipment, and libraries. Teachers respond to
Many children are hungry and tired in school local poverty by buying exercise books for the
and lack concentration: 'Children cannot work on poorest children and providing rudimentary
an empty stomach,' commented a teacher in Addis education on matters of environmental and
Ababa. In the highlands children are too cold sexual health, but there are no educational
and do not have adequate clothing. Diarrhoeal
materials and little liaison widi healdi workers.
diseases also often reduce attendance.
There are insufficient teaching and learning The translation of textbooks and teachers'
materials in existing schools. Children share one guides from Amharic into the regional
book between five or eight children; in Jijiga languages was raised as a problem. Some
town there is one book for every ten children, or higher-grade books, available in translation, are
no books at all. In all the schools visited, there used in lower grades. It was reported that not
are insufficient chairs and desks. Children sit on only could the children not follow the text, but
the floor, on stones or tree poles. neither could some (under-qualified) teachers.

Education-sector policy and planning

Historical perspectives growdi rates. In 1997 only 35.2 per cent of all
children of primary-school age were enrolled.55
Limited secular education was introduced into In the same year it was recorded diat only 45 per
Ethiopia by Emperor Menelik about a century cent of primary-school enrolees reached Grade
ago. Under Haile Selassie this was extended to 5.56 The Education and Training Policy (TGE,
respond to the needs of a modern bureaucracy. 1994, p.3) states: 'The gross participation rate of
However, the vast majority of the poor did not primary education is below 22% of die relevant
benefit. Participants in our research in Delanta age cohort. Of these a large number discontinue
and Metta recounted how during Haile Selassie's and relapse into illiteracy.' The figures show a
time only the affluent, urban population had faster increase in enrolment than in construction
access to education. As a result, disparities of schools (4 per cent expansion rate), confirming
between regions, between urban and rural die burden on existing facilities.
communities, and between males and females The cornerstones of Ediiopia's policy on
became fixed. education are expansion, quality, relevance, acces-
The Derg regime is associated with the sibility, and equity. Ethiopia is committed to
expansion of basic education and an adult achieving a gross enrolment ratio of 50 per cent
literacy programme which emphasised access to by 2002 and primary education for all by 2015.
rural communities, highlighting the need for The war widi Eritrea has compromised
women and girls to participate. The TGE argues Ethiopia's ability to fund diese commitments,
that the use ofAmharic in primary education, in and the targets will need to be revised.
regions where it is not the mother tongue, The planned targets of die Education Sector
hampered the spread of education. Moreover, Development Programme (ESDP) are as follows:
policy objectives were compromised by die
drain on resources occasioned by the war effort. Expansion of enrolment from 3.1 to 7 million
The percentage allocation of total government children (from 30 per cent to 50 per cent).
budget to education fell by more than half An increase in the proportion of girls attend-
between 1974 and 1988/89. ing school, from 38 per cent to 45 per cent of
In Jijiga no Ethiopian government had built total primary enrolment.
any school in die rural areas near the research Provision of one textbook per student in each
site. There has only ever been Koranic schooling core subject.
in Arabic, largely attended by boys. It is only Revision of curricula to make education more
now, as ecosystems fail, that the community relevant and gender-sensidve.
begins to see the value of education for the Improvement of planning and management
development of alternative livelihoods. In Addis capacity.
Ababa the introduction of school uniforms Improvement in school facilities and quality
about two years ago has made education of teachers to reduce wastage, dropouts, and
prohibitively expensive: participants say that it repetitions to a more acceptable level.
is more difficult now dian ever before to afford Increase in public funds to education from
schooling for their children. 13.7 per cent to 19 per cent of total govern-
ment budget.
Increased efforts to expand private-sector
Education policy and planning participation and introduce cost-sharing at
die higher levels, Grade 11 and above.
The National Population Policy sends a clear
message: by die year 2020, the school-age
population will have grown from 12 million in
1984 to 42.5 million at current population-
Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Financing the Education Sector secondary. The bulk of the modern-sector

Development Programme workforce is the product of secondary education.
In 1997 only 24.8 per cent of children of
Education is financed through public funds, secondary-school age enrolled for secondary
external grants, and soft loans. Spending is education, the majority from urban centres. Only
divided into recurrent and capital expenditures. 6.2 per cent of secondary schools are located in
Government does not manage NGO and rural areas. Children in villages have virtually no
community contributions to education. access to secondary schooling, because of die costs
The total budget for the ESDP (1996/7 - and the distance from their homes. Effectively the
2001/2) is US$1799.2 million, with a 73 per cent few rural children who manage to complete
contribution from the Ethiopian government57 primary education are denied the opportunity of
(van Diesen and Walker, p.23); of this, 16 per secondary schooling. Girls have even less access,
cent was pledged by donors. The resource gap since it is not acceptable for diem to live widi
was estimated at 11 per cent. Over the plan friends or relatives in die urban centres.
period, about 60 per cent of spending was
earmarked for primary education, 11 per cent
for secondary education, and 11 per cent for Management and implementation
tertiary. The remainder would be allocated to structure
capacity building, administration, adult
education, and vocational training. However, Planning and budgeting begin at the woreda
on the outbreak of war with Eritrea some donors level. The Woreda Education Office prepares a
withdrew their financing commitment. budget request for new schools to be built. The
budget is presented to the woreda, council by die
Capital and recurrent budgets 58 woreda administration for approval. On
approval, the plan is sent to die zone, together
On average, 70 per cent of the total education with an estimate from the woreda of how much
budget is earmarked for recurrent expenses, revenue can be generated locally. The zone
and 30 per cent for capital expenditure.69 About submits all woreda proposals to die zonal council,
90 per cent of the recurrent budget is consumed which passes it on to die regional office. The
by salaries, and 10 per cent is attributed to non- region consolidates all zonal plans for approval
salary costs.60 In 1995/96 and 1996/97 the
by die regional council. Schools, like healdi
regions used about 85 per cent of the recurrent
centres, get supplies but no budget. Regions
budget, i.e. the funds earmarked for recurrent
more advanced in the decentralisation process,
costs other than salaries were barely used. Non-
as in Amhara and Oromiya, provide lump-sum
salary recurrent expenditure per student is on
money to the zone, which dien manages the
the decline.
budgets. Odierwise, as in Somali region, where
Of the total sum of Birr 441.86 million allo- local government structures are not fully in
cated for capital expenditure, only 31.8 per cent place, the regional office manages financial
was actually spent in 1995/96. This rose to 54.6 resources. Teachers in Somali region often do
per cent61 in 1996/97. This under-spending of not receive salaries and do not stay in dieir jobs.
capital and recurrent budgets reinforces the
In practice bodi government and donors
need for management support at all levels of
recognise diat the realisation of ESDP objectives
regional governance. The micro research
is seriously compromised by poor management
highlighted a very large number of capital and
and implementation capacity. The Education
recurrent items needed.
and Training Policy envisages 'die evolution of a
decentralised, efficient and professionally co-
Allocations between primary and ordinated participatory system' (1994, p.5).
secondary education Governance in die regions is so far lacking in
Each year the primary schools sub-sector receives continuity and experience; die capacity for
the bulk of the education budget. In 1994/5 and management and implementation of budgets is
1995/6, primary education received 60-63 per inadequate; and diere is a high turnover of staff
cent of the total budget, while secondary in local government. While funding for die
schooling received 10 per cent. In 1996/7 there physical expansion of die service is insufficient,
was a slight change, with 53 per cent allocated to demands for materials, equipment, and staffing
primary education and 12.4 per cent to for die existing service also continue to grow.

Education-sector policy and planning

External assistance is already called upon to assist resourced. Oxfam's research shows that the
in drawing up education-sector policy and plans, following factors affect teachers' and children's
and needs to provide stronger support during motivation and compromise die creadon of a
implementation. good learning environment.

Materials and equipment

Expansion versus consolidation The quality of primary-education delivery is
The Education and Training Policy (1994) aims compromised by die lack of textbooks, teaching
to achieve one primary school per Peasant materials, and teachers' guides, and by the lack
Association (PA). In Somali region, 31 out of 200 of proper equipment and facilities such as
primary schools are not operational, and one- furniture, drinking water, water, latrines, and
third of zones have no secondary school. In sports facilities. The buildings are in poor repair
North Wollo (Amhara), 96 PAs have no primary and in some cases dangerous. Like healdi
schools. In Addis Ababa, schools are not spaced centres, schools do not control any budgets for
out evenly, such that children in poor areas have running costs and the purchase of education
no government school nearby. New schools are materials. Stationery and other items are
being built in all regions each year, but delivered occasionally. Schools do not have a
transforming them into institutions of learning supply of basic medicines for common ailments.
with all the pre-requisite equipment, materials,
and teaching staff poses grave problems of Enrolment and a conducive learning
supply, as well as organisational and institutional environment
challenges. In Eastern Hararge, while efforts
and funds are concentrated on extending Teachers, parents, and students talked about an
primary-education facilities deep into the rural environment conducive to learning. Large class
areas, old and urban schools are deteriorating. sizes (especially in Grades 1 and 2), die problem
In all regions, supervision of existing facilities is of maintaining discipline, die use of physical
weak, on account of the lack of transport. beatings,63 and an environment of poverty,
hunger, and dirt, of vagrancy, traffic, and bars
Statistics such as pupil/teacher ratios that are
(Addis Ababa), were all quoted as inhibiting the
used to guide the planning process towards
provision of quality education.
expansion or consolidation of services are not
applicable in the Ethiopian context. Oxfam's While enrolment and persistence rates are
research demonstrates that the use of average influenced by demands for child labour, early
figures distorts the true picture, by including marriage, and the poverty-related factors
the large class sizes and high pupil/teacher ratios described above, diey are also related to the
in Grades 1 and 2. These change dramatically quality of die learning experience while in
from Grades 2-3 onwards, owing to significant school. On die whole, girls and boys want to
drop-out rates. The evidence indicates that if learn, and education is valued more dian in die
primary-school persistence rates were to past. Gross enrolment has increased, from 26.2
improve, average class sizes and pupil/teacher per cent in 1994/5 to 45.9 per cent in 1998/9.64
ratios would soar well above the current The overall drop-out rate can be as high as 50
estimated 60-8062 mark. In that scenario, the per cent between Grades 1 and 3, and children -
case for expanding die number of schools would more girls than boys - fail repeats and have to
be indisputable. However, the maintenance of leave school. There are many constraints on
teaching standards also demands budget children living in poverty, and girls have to
allocations to support die process of consol- contend with additional constraints. The
idating and improving existing facilities. gender gap grew between 1994/5 and 1998/9
from 11.3 per cent to 20.6 per cent.65 The
education system still cannot respond to the
needs of poor children, and to girls' needs in
Quality of primary education particular. The lack of women involved in die
education system, from planning to teaching,
The provision of primary education is not simply
from school committees to local government,
a matter offillinga room widi numbers of girls
exacerbates the problems. Girls do not believe
and boys. While there are insufficient numbers
of schools to provide elementary schooling for that schools, and male teachers in particular,
all, existing schools are overcrowded and under- understand dieir difficulties.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Staffing implemented at all. The curriculum for Grade 1

Primary schools and parents' committees is developed on the assumption that children
complained of a shortage of teachers, particularly have learned numbers and the alphabet in pre-
of teachers with appropriate qualifications. school classes. However, very few children
Students also complained about the quality of attend pre-school, so they start Grade 1
teaching. Graduates of Teacher Training illiterate. Some of the drop-out rate is attributed
Institutes (TTIs) should teach the primary cycle, to this learning gap.
Grades 1-4, and diploma graduates the second The education policy recognises the right of
cycle, Grades 5-8. Oxfam's research shows a 'nationalities to learn in their language', at the
serious shortage of diploma graduates, which same time as learning a national language
results in ill-equipped teachers teaching Grades (Amharic) and an international language
5-8. In Amhara region, 111 holders are teaching (English). The predominant regional language
Grades 5-8, and 50 per cent of teachers in is therefore the medium of instruction in
secondary education do not meet the standard primary schools. It appears, however, that
requirements. translated textbooks are not available for all
In Somali and Eastern Hararge, there are levels. To compensate, teachers with TTI
teachers practising who hold only the 11th or 12th training (Grades 1-4) in Oromiya, for example,
Grade school-leaver's certificate. In Somali use higher-grade books in the lower grades,
region, 67 per cent of teachers have had no whereby neither teacher nor students are able to
professional training, and only 19 per cent of understand the contents.
teachers are women. Overall, women teachers The education and training policy makes a
constitute 27.8 per cent of all primary-level commitment to ensuring that the curriculum is
teachers. The education policy provides for developed up to international standards, 'giving
special attention to the participation of women due attention to concrete local conditions and
in the recruitment, training, and assignment of gender issues'. Education should 'reorient
teachers. society's attitude to the role and contribution of
Teachers suffer from a lack of appropriate women in development'; this commitment is also
training, lack of supervision, late salary iterated in the National Population Policy and in
payments, and the absence of a proper career the Policy on Ethiopian Women, and should be
structure. The education policy recognises the accorded planned action, time, and funds.
need to provide teachers with training to up-
grade their skills, and incentives for diose in
remote areas. Summer programmes to up-grade The private sector
teachers' skills are under way, but the coverage is
not extensive enough to make the required Government is the main provider of education
impact. Teachers complained that there were in Ethiopia. Non-government schooling makes
insufficient training opportunities, and that up 4.5 per cent of the total, and 36 per cent of
political cadres gained preferential access. private facilities are in Addis Ababa. Since the
government focus is on expanding primary
Curriculum education in rural, indigenous communities,
The new curriculum for Grades 1-4 makes a the non-government sector is likely to expand in
significant departure in content and mode of urban areas, and also to include provision for
delivery from past practices. Teachers in Addis non-indigenous children, such as the Amhara in
Ababa were not happy with the demands on Oromiya. NGOs and the private sector did not
them to teach all subjects under the new system. participate in the planning of the ESDP but are
There is a need to 'retool' TTI graduates for the now represented on the Joint Steering
new curriculum. In some regions (such as Committee of federal government, regional
Somali), the new curriculum has not been governments, and donors.


Governance and human on health care, 2.3 per cent was spent on paying
resources interest on external debt (1991-97).66
ODA to Ethiopia is in decline. It fell from 20.6
Ethiopia has experienced three distinctly differ- per cent of GNP to 10 per cent (1991-1997). Of
ent forms of governance within the past 50 the total aid receipts, disbursements for health
years. War and political insecurity have drained amounted to 5.7 per cent, and human-resources
the country of resources, including experienced development to 8.6 per cent. External assistance
and qualified health and education personnel. to Ethiopia's recurrent expenditure budget is
The TGE inherited an underdeveloped, under- 2.3 per cent of domestic resources and makes up
resourced social-services sector. The TGE has less than 1 per cent of most regional recurrent
initiated a transition into a federal state with budgets. External aid, particularly to fund
increased regional government responsibility, health and education recurrent costs, is negli-
but the lack of experienced, qualified local- gible, given the enormity of the task and the
government administrators and managers is rapid rate of population growth.
proving a serious impediment to the develop-
ment of appropriate plans and budgets, and the Demands on recurrent expenditure
translation of social-sector policies into action. budgets
In the education sector, 70 per cent of the total
budget is earmarked for recurrent expenses,
Financing social-sector and 30 per cent for capital expenditure. About
development 90 per cent of the recurrent budget is consumed
by salaries, leaving little to cover the cost of
The transition to a federal state with increased teaching materials, textbooks, and equipment,
local government autonomy is suffering from a and teacher training. Non-salary recurrent
low level of local capacity in terms of planning, expenditure per student is in decline.
management, and budgeting. Staff turnover is Health facilities are short of equipment,
high, which disrupts the continuity of supervision essential drugs, and the appropriate balance and
and monitoring of plans, projects, and budgets. number of trained staff. There are inadequate
Supervision of schools and health posts is weak in funds for outreach MCH, education programmes
general, owing to a lack of logistical resources and to promote health and reproductive health, and
geographical inaccessibility. There is a serious for staff supervision and support. Despite huge
problem in implementing policy and expending recurrent-costs requirements, the share of
budgets in some regions. recurrent expenditure in die total healdi budget
Ethiopia's capacity to raise financing for fell from 80 per cent to 53 per cent between 1990/1
social-sector development, with or without the and 1997/8, and a significant proportion of that
war, cannot begin to cover the cost of expanding was used for staff salaries. Ethiopia spends nearly
health and education services and consolidating diree times more on debt-interest repayments
very run-down existing ones. Ethiopia is than it spends on health services.
committed to covering 55 per cent of the total The official policies on health, education,
health budget, and 73 per cent of the total population, AIDS, and women all contain
education budget, from domestic resources. elements responding to the concerns expressed
With 65-85 per cent of the population (taking at village and first-level service-provider levels.
account of regional variations) living below the However, the poorest households and service
poverty line, the state's capacity to raise local providers demand more activity at village level
taxes is limited. At the same time, Ethiopia's total in MCH, reproductive-healdi education,
debt has increased to 159 per cent of GNP environmental health, and water and sanitation
(1997), and while 0.9 per cent of GDP was spent services. The loud call to deliver healdi care to

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

the poor in rural areas is not echoed in the policy Access to health care
documents or in financing commitments and The majority of the poor, regardless of sex and
cannot be met at current low levels of recurrent- age, believe that better-off people from urban
cost financing, and with existing staffing and centres get better treatment than they do at
logistics capacity. health centres. The poor feel discriminated
Liberalisation, subsidy removal, and import- against. Most people do not seek treatment at
duty policies reduce the potential impact of the local clinic, because they cannot afford to;
already small recurrent-cost budgets, and affect they cannot get exemption from user fees, and
the price of drugs, which 'no one can afford to in some instances women did not know that an
buy". exemption system exists. There are frequently
no drugs, or no drugs supplied free of charge, so
Capital expenditure the patient returns home untreated. All
Allocations to capital budgets for health-care participants complain that waiting time is too
services have increased to fund the drive to long at the government health centres. This is
build more clinics, but there are not the staff, significant, because the poor, especially women,
equipment, or drugs to make existing facilities attend the clinic only when their condition is
functional. In addition, while existing clinics are extremely serious.
oversubscribed, the majority of the rural poor
do not use them. Building new clinics without a Fees-exemption system
major increase in recurrent-costs budgets, The system for granting exemption from user
increased availability of essential drugs, and a fees, which is managed by the PAs and hebeles,
functioning system of exemption from user fees excludes all but a few. Those who have obtained
for the poorest may not be the most appropriate an exemption paper do not think it worthwhile,
way of extending health-care provision to the because, once they are diagnosed, the health
majority of the population, particularly women centres rarely have the drugs in stock to treat
and children. 'free' patients. In addition, the exemption paper
does not cover the other costs of health care,
such as transport to the health centre, bribing
Health problems guards at the gate, and buying food and
sometimes lodging while attending the health
Hunger, poor sanitation, and dirty water centre. Women in rural areas tend to know less
supplies mean that 76 per cent of diseases in about the system than men do. Communities
Ethiopia are communicable. The incidence of living in areas with no first-level government
STDs, particularly gonorrhoea, is high and is structure such as a PA or kebele (Jijiga) have no
seen as largely a men's problem. HIV/AIDS and access to the exemption system whatsoever.
TB are both on the increase. Many of the most
common health problems, reported by
participants, are related to social behaviour. Population growth
They include the consequences of harmful Existing laws permit marriage at 15, but it is not
traditional practices, FGM, unattended birdis, unusual for rural girls to marry at 10 or 12 years,
and the abuse of drugs {'chat in Eastern and to become pregnant soon afterwards.
Hararge) and alcohol. These conditions remain Current family laws restrict the right of women
outside the formal health service, untreated and to regulate their fertility: 'technically, all
not included in the statistics that are generally institutions providing family planning,
used for planning health care. including government, are doing so illegally'.67
The Oxfam field study also brought to light the Contraceptive prevalence is estimated at 4 per
widespread negative psychological impact of cent nation wide. Fertility rates are 6-7 births per
extreme poverty. This included a deep sense of woman, and population growth is 3 per cent per
responsibility among men for the poverty around annum. Maternal mortality rates are among the
them, and a sense of failure for not producing highest in the world, at 1400 per 100,000 live
harvests. A lack of motivation and aspirations birdis. Both the national population policy and
results in destructive behaviour among youth in die policy on Ediiopian women stress the need
Addis Ababa, widespread paralysing 'chat for radical changes in attitudes towards women,
addiction among men in Metta, and a fear of and for improvements in dieir status. The health
dying of hunger among children in Delanta. policy stresses the importance of paternal


involvement in family health. But without a fall At the same time, a majority of the poor are
in population growth, the achievement of suffering from persistent communicable
national development goals such as food illnesses, such as diarrhoea and sexually
security, universal primary education, increased transmitted diseases, which go untreated. All
access to health services, and expanded focus groups stressed the need for increased
employment opportunities will be seriously access to affordable essential drugs.
jeopardised. The school-age population, 12
million in 1984, is estimated to reach 42.5 million Water and sanitation
by 2020.
An estimated 75 per cent of the population do not
have access to safe water, and 81 per cent have no
Reproductive health access to sanitationfacilities.68In all sites the most
Inadequate attention is paid to improving common health problems were attributed to
reproductive health, which, if addressed, may dirty water and poor sanitation. In the rural areas
fundamentally redress many development the majority are 'sharing water sources with wild
problems. Untrained local practitioners manage animals and cattle'. In the urban areas, water
most reproductive-health interventions and contamination increases during the rains, and
'cures', often using sharp instruments in there are fewfacilitiesfor human-waste disposal.
unhygienic surroundings. Girls' reproductive- In Metta there is piped water within 30 minutes
health problems are potentially life-threatening, of each household, installed by the community
beginning with FGM, early marriage and early with Oxfam support. Otherwise diere was no sign
pregnancy, and a heavy workload from an early of a serious effort to improve access to safe water
age. Men self-treat STDs at drugs stores or in any site. In Delanta there is one sanitation
herbalists, avoiding informing their partners, officer attached to the health centre but no
who remain untreated. Official statistics show an budget, transport, or team tofacilitatehis work.
increasing trend in the incidence of HIV/AIDS. Water and sanitation are among the
The real figure is likely to be significantly higher, intersectoral priorities specified in the health
since most people do not have access to policy; however, apart from Metta, there is litde
government health centres, or may die of other serious work being done to provide clean water
diseases before HIV/AIDS is detected. Men and and sanitation, despite the extreme deprivation
boys have no access to reproductive-health in all sites, and the willingness of communities to
education. provide their labour time.

Staff problems
Employees in the government health service are Poverty
overworked and underpaid. Supervision and
Oxfam's research has identified some key
support, especially in remote areas, is very poor.
demand-side barriers to accessing basic healdi
In Jijiga, staff have to walk several days to and
care and primary education; they are linked to
from the town to collect their salaries. The
low-income poverty and isolation. The low
health policy recognises that staff are demo-
status and under-representation of women are
tivated and that attention must be paid to
perpetuated by the dependence on traditional,
improving career structures, incentives, remu-
male-dominated institutions of governance and
neration, and supervision. The research did not
continued acceptance of harmful traditional
find any signs of improvement in these matters.
practices. With climatic change and lost
harvests, emergency coping strategies have
Preventative versus curative strategies become main sources of livelihoods, increasing
The research sheds light on the need for the burden of labour on women and children to
preventative outreach services, which would earn income for daily food supplies.
include MCH and reproductive-health The low educational status of adults and
education. There is also a strong demand for children, combined with poor health and
accessible clean water and for improved persistent hunger, perpetuates a sense of
sanitation. Youth in all rural areas demand impotence and isolates remote communities
education in environmental health for their further from government and international
parents. These are some of the intersectoral institutions charged with managing the
issues diat the new health policy aims to address. resources and process of development.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Everyone is getting poorer, even those who malnutrition. Malnutrition is described as a key
were better off before the drought. Household factor contributing to the difficulties experienced
food security has diminished to unsustainable during childbirth, to post-delivery heavy
levels. Between 70 and 85 per cent of house- bleeding, and to maternal mortality.
holds in each community were classified as Low resistance to infection as a result of
'worst off. malnutrition has increased susceptibility to TB
in Jijiga, and to die more serious consequences
Livelihoods of diarrhoea diseases in all sites, especially
among children. Male mortality in Delanta was
In all sites the main source of income, in cash or linked to malnutrition, as well as malaria and
kind, has been eroded by persistent droughts HIV/AIDS, contracted in the lowlands. Men in
and climatic change. There are few alternative Jijiga complained of being too weak to plough
productive sources of income for women and without food.
men, apart from selling firewood and petty
trading. These are mosdy activities which
diminish local natural resources, and which are
labour-intensive, with low income returns. Problems in the education sector
There were no signs of large-scale planned
The lead-in from the planning phase of the new
investment in rural or urban employment or
education policy to the implementation phase is
alternative livelihoods for women and men.
too short. There is no time for consultation and
amendments before implementation. Many
Child labour service providers have not even seen the policy.
The subsistence household in Ethiopia is
dependent on children for income and labour, Accessibility
which is viewed as preparation for future
The government is largely responsible for
gendered roles. Adulthood starts early, from
education, and participation by the private sector
1012 years in some cases, especially for girls in
is only marginal. In recent years enrolment has
rural areas, who have domestic work, marital, and
been growing faster than the rate of expansion of
income-earning responsibilities. Boys in the
schools, indicating a demand on die education
poorest households in urban and rural areas leave
service which is gradually outstripping supply.
school to help to support their families. Work such
However, die drive to increase primary
as collecting water and firewood, agriculture, and
enrolment, in rural areas particularly, leads to
livestock tending in rural areas and petty trading
'forcing' children into Grade 1 (Delanta), with a
and street hawking in urban centres are common
sudden drop in enrolment in Grade 2 onwards.
activities for both girls and boys.
In urban centres there is a growing deardi of
space in schools, and many run a shift system to
Food security accommodate die numbers. Yet in Addis Ababa,
Forty-eight per cent of children under the age of education authorities reported diat still many
five are malnourished. Oxfam's research shows children do not attend school. Aldiough official
that 70-80 per cent of rural families earn less statistics report average class sizes of 60-80, in
than $6.40 per month, for an average reality die figure in Grade 1 is often more like
household of six members; 9096 per cent of 100-120, while the figures for Grades 3-8 are
incomes is spent on food. At die time of the much smaller.
research, a meal was described as a handful of Despite an overall increase in enrolment, the
roasted grains Ckolo), and many reported eating gender gap is ever widening. Boys are given
only twice a day. Some parents drink coffee in preference over girls, most markedly in the
the morning and go widiout food. Muslim communities of Eastern Ethiopia, but
One of the main reasons for not going to school diere is a high drop-out rate for bodi sexes. The
and for poor performance in school is hunger. main causes are low-income poverty, poor
There are no supplementary feeding performance, failure of repeat exams, and
programmes in primary schools. Women in Metta household demands on children's labour time.
whose children were undernourished could not However many children do not attend school at
afford to follow advice on nutrition given by die all, because most households cannot cover the
clinic. TBAs link die high incidence of miscarriage costs of education, in which they include food,
and anaemia among pregnant girls and women to clothes, exercise books and pens, soap, and in


Addis Ababa uniform and housing. Children are Illiteracy

prevented from going to school by hunger and Illiteracy is an impediment to participative
diarrhoea, or because they have no clothes.
democracy and local accountability. In Jijiga
Others leave school when there is not enough
men went to the police station to ask for a school,
cash to buy an exercise book.
not even knowing about the existence of the
education office. At least 70 per cent of women
Quality of education and 60 per cent of men are illiterate. Women are
Existing schools are not able to provide quality under-represented at all decision-making
education because they lack basic textbooks (one forums. Men, responsible for their communities
book between 6-10 children), teaching through traditional structures, feel impotent to
materials and furniture, and there is no clean seek assistance or take action to improve
water or sanitation. The quality of teachers is not conditions in the community. Oxfam's research
up to the standard set by the Ministry of does not indicate that there will be a significant
Education, especially at the higher levels. The difference in the next generation, particularly in
attrition rate among teachers is reported to be
rural areas. Rural communities lack
high in rural primary schools, and everywhere
information and opportunities to participate in
in secondary schools, because of poor
remuneration, the absence of a proper career their own development. Illiteracy is a serious
structure, and the lack of facilities in rural areas. impediment to local initiative and action,
The proportion of female teachers in the total is despite a very strong desire among women,
quite low, about 28 per cent at the primary level, men, and youth to work for real improvements
and much lower at the higher grades. in their livelihoods and well-being.


While it is incumbent on the author to make The World Bank and IMF must move fast on
recommendations, in the interests of partic- HIPC2 if human-development targets are to
ipatory planning and action it is the responsibility be met. Ethiopia's debt needs to be reduced to
of readers to investigate and question further and a level whereby debt service constitutes less
to draw their own conclusions. The following than 10 per cent of government revenue. If
recommendations are drawn from the conclu- the government can show that further debt
sions of the micro and macro research docu- relief could help the country to attain the
ments.69 By definition the majority reflect the 2015 international development targets,
concerns, interests, and needs voiced by the especially improvements in health and
participants, who represent a cross-section of the education services, then further relief should
population of Ethiopia, differentiated by age, sex, be considered.
ethnicity, religion, livelihood, and professional OECD countries should increase the
status. proportion of national income spent on aid to
meet the agreed target of 0.7 per cent. Long-
term aid must be pledged now, to fund the
Financing social-sector realisation of 2015 targets.
development ODA should be directed to increasing the
non-salary recurrent-cost budgets for health
Dependence on long-term, maintained levels of and education in the regions. Emphasis
donor funding has become precarious. The should be laid on increasing outreach health
government has invested significant amounts of services and the provision of basic supplies
time in drawing up policies which accommodate and services in schools, including textbooks
World Bank criteria and other bilateral and
and teaching materials, safe water, sanitation,
multilateral ODA requirements. However there
and furniture. In addition, supervision and
is no guarantee that funds will be forthcoming
or maintained. support for staff living in remote areas need
to be managed and funded.
The Ethiopian government, and the regions,
should agree to full transparency in the Economic liberalisation, subsidy withdrawal,
reporting of budget expenditure, to increase and certain taxation policies reduce the impact
donor confidence and allow for account- of social-sector recurrent-cost budgets, essential
ability between government and grassroots for establishing and maintaining the quality of
communities. services.
This would require reporting on expen- The government, together with the World
ditures between regions, between sectors, Bank and the IMF, should review structural
between recurrent and capital budgets, and adjustment policies in the case of essential
between preventative and curative health- drugs, medical equipment, and school
care programmes. supplies, including exercise books and pens.
Procedures need to be standardised on a one- Import duties on free gifts to social services,
for-all basis, so that federal government and such as operating-theatre equipment, should
regions do not need to use up scarce capacity be lifted.
by responding to each donor's particular
reporting format and timeframes.
The World Bank/IMF have made the Expansion versus consolidation
production of an interim Poverty Reduction
Strategy Paper (IPRSP), developed with civil- Ethiopia's population is growing at 3 per cent
society participation, a condition to reach per annum, and most services are too far away
Decision Point in the HIPC debt-relief initiative. for the rural poor to access.


There is a need to construct new education Planning, management, and

and health facilities. implementation
This should be balanced with the need to
improve the quality of existing services and
the ability to staff and supply new facilities
Regional government level
adequately. A programme of technical support and
The balance between capital and recurrent training for local officials is required, in order
budget allocations needs to be reviewed to improve programme and budget
against regional needs. management, and to increase die capacity to
implement capital and non-salary recurrent-
costs budgets in particular.
Expanding health services The lines of accountability between all levels
In the health service, reaching more of the of regional government, die healdi services,
poorest may best be achieved through an and the community need to be strengthened.
efficient outreach service and investment in The reasons for high levels of staff turnover at
water, sanitation, reproductive-health all levels of regional government need to be
education and food-for-work programmes, addressed and incentives introduced to
in addition to improving the functioning of reduce attrition rates.
the PHCU structure, recommended in the Attention dierein needs to be given to gender
official health policy. equity, and representation and participation
Schools should be involved in health- of various edinic and religious groups at
education programmes, and teachers should all levels of planning, management, and
be given the requisite training in nutrition implementation.
and the promotion of environmental and Technical support to improve management
reproductive health. and implementation capacity at regional,
Construction of new clinics should take place zonal, and woreda levels via bilateral ODA is
where die need has been specified by die required. In 1997 about 40 per cent of total
community, and if sufficient staff and resources bilateral ODA was allocated to services supplied
are available to activate a service. by donors,70 including technical assistance.
Technical support at local-government level
should include locally recruited consultants, to
Expanding education services draw on and strengthen national human-
The education service requires more schools; resource capacity and experience.
the aim is to build one per Peasant Association.
The need is greatest in remote rural areas, Community level
pastoralist communities, and urban areas
Grassroots organisations such as schools and
served only by private schools.
health committees, traditional institutions like
Many more TTI and diploma-level primary- the Elders in Jijiga and die Kerray Abatoch11 in
school teachers are needed to staff existing Delanta, Peasant Associations and kebeles should
and new schools. build dieir capacity to participate in the
In order to attract women and men into die planning, monitoring, and evaluation of healdi
education service, a good package, including care and education delivery. This is a process
promotion opportunities, needs to be offered, which requires training, experience, logistics,
especially for rural postings. A definitive technical assistance, funding, and time.
career structure widi appropriate remuner- Attention should be paid to diversity, defined
ation needs to be designed and implemented. in terms of sex, age, religion, and ethnicity,
There should be an effort to recruit more and the need for equity in representation, in
women teachers by identifying and responding identifying healdi and education priorities,
to their particular needs, especially in rural and in communicating widi local government
locations. officials.
Practising teachers need 'retooling' training Women and men in community organi-
to equip them to teach the new curriculum; sations need to strengdien dieir capacity to
they should also benefit from new deals for communicate dieir concerns to local and
teachers. regional planners.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Local and regional government should Outreach clinics should carry essential drugs
become more transparent and accessible. for the treatment of the most common diseases.
One of the most pressing challenges will be Complications and high-risk maternity cases
improving the status and role of women at all should be referred to the health posts.
levels. This needs to be addressed dirough a Funding for research and development of
well-informed and orchestrated IEC IEC materials, training for health staff and
programme with appropriate staffing and managers, staffing, materials, drugs, trans-
funding, linked to programmes to support port, and fuel needs to be secured.
health and education, food security, Funding should be earmarked for specific
employment, and water and sanitation. campaigns such as Family Planning, STDs and
HIV/AIDS prevention, and discouraging
harmful traditional practices, particularly
Data collection those involving incisions, such as circumcision,
FGM, tonsillectomy, and uvelectomy.
Data such as health centre/population ratios and
average class sizes do not provide a true picture
of reality and can be misleading for planning Reproductive health
and evaluation purposes. Reproductive health should be accorded high
priority, both as a matter of human rights and as
Data collected for planning, monitoring, and a development issue.
evaluation should incorporate both qualitative
and quantitative evidence, sourced from Real improvements require changes in the
consultations with a wide range of age, sex, law regarding family planning, girls' age at
ethnic, and religious groups. marriage, and abortion, and an enforcement
Available data on the status of girls and of the law prohibiting FGM.
women are inadequate. Evidence is required Rapid population growth must be curbed
on the incidence of FGM, abortion, early and safe births promoted, to reduce
marriage, and early pregnancies, and maternal and infant mortality rates, and to
attitudes of the women, men, girls, and boys increase the possibility of achieving and
involved as parents, partners, victims, or maintaining the achievement of human-
practitioners. This information would assist development targets.
in producing IEC materials aimed at Youth groups recommended that all
reducing physical and psychological stress on members of the community should have
girls, and also young men, and increasing the access to sexual-health education.
proportion of girls who complete primary Women's access to information and treat-
education. ment needs to be increased, as does the
proper treatment of STDs among men, who
tend to visit the drug store or the herbalist.
Health Female genital mutilation, a practice endorsed
According to the women, men, and youth, and by women themselves, inflicts a most brutal
the first-level service providers interviewed, intervention on girls and condemns them to
'bringing health to the poor' should be a priority, painful and high-risk births, particularly in
alongside increasing access to essential drugs. Muslim communities, where infibulation is
practised and large families are sought after.
In line with health-policy objectives to focus
on preventative and promotive health It is recommended that experience gained by
services, outreach programmes should be the NCTPE in Ethiopia, AIDOS in Italy, and
developed which would include education Womankind Worldwide in the UK is drawn
for reproductive health and environmental upon to change attitudes and practice
health, MCH, ANC, and EPI programmes. throughout Ethiopia.
Outreach services should co-ordinate work Bilateral donors and international NGOs
with selected traditional practitioners, schools, should support this effort with financing
churches, mosques, Peasant Associations, under human rights and democracy budgets,
kebeks, and traditional community structures, if they cannot find justification under health
including respected women. budgets.


Local government and community action husbands. Women are currently carrying the
Local government should facilitate load, literally and economically.
interaction and co-operation between schools Crop diversity needs to be introduced more
and clinics to promote gender equity in the rigorously to reduce dependence on this
exploration of health and reproductive- crop, which 'sucks our blood' and which incurs
health issues. the risks of all mono-species cash cropping:
The whole community, regardless of age, sex, when the price falls, access to food, school,
or religion, should be involved in initiatives to and health care is reduced too.
reduce fertility, promote safe sex practices,
provide access to treatment for STDs, and Drugs
discourage harmful traditional practices, Oxfam's research shows that most people are not
while maintaining values important to the treating common ailments, because they cannot
community. obtain or afford the appropriate drugs.
Government, international donors, and
NGOs must provide the financial and The health policy (1993) clearly states the need
human-resource support required to to standardise, prepare lists of the most
instigate and maintain the process. essential drugs and equipment, and develop an
efficient procurement and distribution system.
Drugs supplied through the National Drug
Traditional medicine Programme via bilateral and multilateral
Traditional practitioners are both a potential agencies and NGOs should be regulated and
human resource and a potential health hazard. comply with the standards and requirements
A more informed and explicit policy is established by the Ethiopian government.
required on the issue of traditional practice in Additional financial support to the recurrent
Ethiopia. budget is required, to increase the supply of
Research should be conducted in order to drugs through health posts and outreach
create a list of standards, to define legal and services.
illegal practices, and establish lines of
communication between health centres, Education
schools, and traditional practitioners.
The training and monitoring of TBAs should Low enrolment rates should be addressed as
be reinstated, and funding provided from follows.
non-loan sources.
Such a programme should be integral to Reducing hunger and diarrhoeal diseases
regional health-care provision, including co- will increase enrolment and persistence rates.
ordination with the nearest health post. Increasing women's and men's incomes will
Herbalists' remedies should be the subject of reduce demand on child labour.
research, including audits of beliefs and Reducing fertility rates and introducing
values, with a view to formalising and labour-saving technologies will reduce the
integrating certain remedies into modern demand on girls' domestic labour time.
treatments. Increasing the age of marriage and providing
These practices need research and reproductive-health education can reduce the
regulation, if not made illegal by law and incidence of early pregnancy and abortions,
enforced. The activities of 'injectionists' who which cause girls to drop out or not attend
school at all.
practise in some urban centres should be
made illegal. Organising schooling around the agricultural
calendar and introducing shifts at certain
times of the year will enable children to co-
'Chat addiction ordinate schooling with agricultural work.
Consumption and sale of the drug 'chat Campaigns should be organised to increase
should be made illegal, as it is in other women's and men's awareness of the value of
countries such as Tanzania. education.
Total social and economic rehabilitation of Schools should be involved in environmental-
Eastern Hararge is required, in order for health and reproductive-health programmes.
men to acquire full productive potential and More women should be recruited to serve on
assume their responsibilities as fathers and school committees.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

The number of women teachers should be Drop-outs

increased, to respond to the particular needs The absence of pre-school preparation is given
of girls. as one reason for the high first-grade drop-out
Discussions should be held with Muslim rate.
communities to develop strategies for
educating girls and boys separately, and Grade 1 should be treated as the first intro-
duction to basic skills in reading, writing, and
acceptable ways of educating them together,
numeracy, and the curriculum should be
to increase girls' access to education.
adjusted accordingly.

Human resources Secondary education

Teachers require upgrading training In the drive for primary education, secondary
commensurate with the standards of the grades education is being left behind, with very poor
and curriculum that they are teaching. coverage in rural areas. Low enrolment is also
The teacher-training curriculum should attributed to the fact that there are no oppor-
include preparation for life in remote and poor tunities for further education in rural areas.
communities, with insights into differences There needs to be one secondary school per
between girls' and boys' experience of poverty. woreda.
Teachers should also have elementary training Children from rural families, particularly girls,
in basic health education, reproductive-health need to be integrated and accommodated.
issues, and water and sanitation matters, to Funds for teacher training, school equipment,
facilitate their collaboration with community and supplies, including textbooks and teach-
groups and the health centre. ing materials, are required.
The Oxfam Policy Department Micro Research
Site Reports Nos. 1 - 4 would provide useful Non-indigenous children
background and training material, and also Federal and regional governments need to
insights into participatory learning and action develop a policy framework to accommodate
techniques. non-indigenous children, where the size of
Resources should be directed at translating population warrants the establishment of
textbooks and teachers' guides into national separate schools.
languages for all primary-school subject
areas, and teachers should be teaching with
the appropriate texts and levels for each Food security
Non-salary recurrent budgets need inputs to Aid to Ethiopia has experienced swings between
increase the availability of textbooks. relief and development phases. They attract
Investment in providing teachers' desks and different funding packages, are managed
chairs and desks for children is required. through different government institutions, and
The provision of clean water and basic are assumed to have different objectives and
sanitation needs community action and mixes of professional expertise.
external funding. Oxfam's research in Ethiopia demonstrates the
Provision of basic medical supplies and need to integrate these skills and experience for
supplementary feeding would reduce the the planning and programming of parallel
anxiety felt by teachers faced with sick, relief and development programmes.
hungry, and tired children and would Food-for-work programmes were requested
increase motivation to teach and to learn. in all sites.
Supplementary feeding in primary schools
would improve performance and may
Private sector
increase attendance.
Regional governments should provide Women should be provided with appropriate
incentives to the private sector by allocating nutrition advice, and/or supplementary
land for expanding non-government feeding for infants. Alternative employment
education facilities in the towns and rural to increase women's purchasing power would
areas. be the longer-term solution.


Unemployment and low-income poverty are Water and sanitation

key issues to be addressed if access to food,
health services, and education is to be improved. Widespread clean-water programmes are
The rural areas visited, including their urban required; communities are ready to contribute
centres, are devoid of any serious attempts to their labour on a food-for-work basis, but in
introduce programmes for employment those cases food must be provided.
generation or rural industrialisation. Sanitation and pit-latrine programmes
Women need incoming-earning opportunities should be instigated, using relief-work
experience and mobilising communities
that are closer to their homes and less labour-
through schools and outreach health clinics.
intensive, and permit more value to be added
In urban centres the World Bank Social
to their work.
Rehabilitation and Development Fund
Men need alternatives to agriculture, especially programme should accept labour instead of
in areas prone to recurrent droughts. cash, in order to extend financing for water
Micro-credit support for existing rural and sanitation to the poorest urban commu-
livelihoods should be accompanied by nities. At current income levels, the need to
investment in alternative rural livelihoods for provide cash contributions can mean that a
women and men, alongside literacy and child must leave school, food is reduced, or an
numeracy programmes. illness is left untreated.


1 Ministry for Economic Development and Co- 15 The Changing Face of Aid to Ethiopia, Christian
operation (1999). Aid 1999.
2 Oxfam Policy Department Micro Research: 16 MOE planning and programming panel.
Health and Education Ethiopia: Site Report No. 17 World Development Report, World Bank 1998/99.
1 Cherkos Addis Ababa; Site Report No.2 18 Washing requires a change of clothes, and
Yegurassa and Andaje, Delanta Dawunt; Site access to clean water and soap; under the
Report No.3 Ali Roba, Metta; Site Report No.4 current gendered division of labour it also
Belhare,Jijiga. requires women's time. Women are out trading
3 'Communities' includes women, men, girls, and to earn 1.00 - 3.00 Birr per day to feed families
boys. of six.
4 Detailed site reports have been produced which 19 Average household size in worst-off house-
closely reflect the experience and views of the holds: six members.
participants. 20 This was die situation on the ground at die time
5 A larger proportion of women than men, in the of die micro research, January-March 1999.
reproductive-age group, were interviewed, Food aid was subsequendy distributed to Nordi
since the questionnaires had a strong focus on Wollo and (much later) to Somali region.
women's reproductive health. 21 UNDP Human Development Report, 1999.
6 For micro-research methodology, see Appendix 22 See Table 3 in Appendix 2.
1. 23 Men working in die lowlands often return widi
7 UNDP Human Development Report 1999. malaria and die.
8 UNDP Human Development Report 1995. 24 92 per cent of deliveries in Ediiopia are not
9 The Changing Face of Aid to Ethiopia, Christian attended by a medical or skilled attendant
Aidl999p.6. (UNFPA, 1999).
10 The Reality of Aid 2000, Earthscan Publications 25 In die UK, maternal mortality is 9 cases per
2000. 100,000 live birdis, and in the USA 12 per
11 This paper does not attempt or intend to 100,000.
analyse, comment on, or judge the Ethiopian 26 ANC: Ante-Natal Care; EPI: Extended
government financing of the war with Eritrea. It Programme of Immunisation; MCH: Modier
was a coincidence that the war broke out in and Child Healdi.
earnest during the micro-research phase. It was 27 Male circumcision has never been referred to as
not within die remit of the research objectives to genital mutilation. Some men's groups in Egypt
consider the issue of prioritising the allocation are beginning to question die practice and raise
of financial resources in war-time. awareness about potential reproductive healdi
12 Tigrai (Region 1), Afar (Region 2), Amhara hazards for boys and men.
(Region 3), Oromia (Region 4), Somali (Region 28 B. Spadacini and P. Nichols in Gender and
5), Benshangul Gumuz (Region 6), Southern Development, Vol 6 No 2 July 1998.
Nations Nationalities and Peoples Region (a 29 Sunna: die hood of die clitoris is removed.
region formed by Regions numbered 7 to 11 30 Excision: die clitoris and all or part of die labia
during the transitional period before 1994), minora are removed.
Gambella (Region 12), Harari (Region 13), 31 Infibulation: removal of die clitoris, labia
Addis Ababa (Region 14) and Dire Dawa majora, and labia minora, and stitching widi
(Region 15). diorns, binding die legs until die wound heals,
13 This may be an indication of sales of 'chat, coffee, to leave a small hole for urine and menstrual
and contraband items. flow.
14 A major consideration should be die level of 32 This section heavily relies on MOH
price differentials among the regions. The (Epidemiology and AIDS department): AIDS in
purchasing power of die Birr differs from area Ethiopia 2nd edition Addis Ababa (1998).
to area. 33 See Table 4 in Appendix 2.


34 Reported by MSF Belgium, Jijiga. 61 Oxfam Policy Department Macro Research:

35 Micro Research Health and Education, Health and Education, Ethiopia (1999).
Ethiopia 1999: women in Delanta, echoing 62 Oxfam Policy Department Micro Research:
voices in all sites. Health and Education, Ethiopia (1999).
36 See Tables 5 and 6 in Appendix 2. 63 Parents and children complained about
37 MEDAC 1999, Oxfam Policy Department beatings in Addis Ababa and Wollo.
Macro Research Health Sector report 1999 p. 64 In agro-pastoralist communities such as Somali
38. region, enrolment is desperately low: 5.95% of
38 1999-2000 defence expenditures were not boys and 3.74% of girls in 1998/9, an increase of
available at the time of writing. 9.7% on 1997/8.
39 See Table 7 in Appendix 2. 65 Oxfam Policy Dept. Macro Research: Health
40 Macro research: Health and Education, and Education, Ethiopia 1999 p.43.
Ethiopia 1999 pp.46-7. 66 MEDAC 1999.
41 See Tables 9 and 10 in Appendix 2. 67 Opcit.p.18
42 See Table 9 in Appendix 2. 68 UNDP Human Development Report 1999.
43 CHW: Community Health Worker - members 69 There are four detailed micro-research site-
of the community in the Derg's time. reports; a summary of the micro research
44 TBA: Traditional birdi attendant. findings, a macro health report; and a macro
45 National Population Policy p.20 (1993). education report.
46 Opcit.p.18. 70 Refers to all recipient countries {The Reality of
47 UNDP Human Development Report 1999. Aid p. 4, Earthscan 2000).
48 See Table 11 in Appendix 2 for regional
71 Identified as one of the most important social
differences in infant and under-5 mortality and
institutions in Delanta. All households are
life expectancy.
represented and make contributions. The
49 Guaya or vetch (Lattiru sattirus) is a drought-
Elders (Abatoch) meet to organise large com-
resistant leguminous plant, resembling the
munity events around religious festivals or
chick pea. It produces a neuro-toxic substance
marriages and deaths. They also act as a court
called aflatoxin, which affects the nervous
and preside over disputes and crimes. The
system and can cause lameness. The disease
worst punishment is to be banished from the
associated with the consumption of guaya is
called lattirism.
72 PRA: Participatory Research and Action.
50 Female net enrolment as % of male ratio:
primary 62%, secondary 55%, tertiary 24% 73 There were more translators, but not all were
(1997). involved in the focus-group discussions when
the PRA techniques were applied.
51 See Table 12 in Appendix 2 for rural-urban
distribution of schools by region. 74 Including two separate locations in Jijiga.
52 Zone 2 Education Office, Addis Ababa, January 75 In Addis samba (lung) is a nickname for
1999. HIV/AIDS. Participants explained that when
53 Source: Oxfam Policy Department Micro people, especially young men, do not respond
Research: household survey (1999). to TB treatment, it is assumed that they have
54 In some parts of Ediiopia, kidnapping young AIDS.
girls into marriage is also common, but this issue 76 Mogne Bagne: fever, chills, nausea, abdominal
was not raised during this research. distension treated with an incision by herbalists.
55 See Table 13 in Appendix 2. 77 A common problem treated by herbalists and
56 UNDP Human Development Report 1999. perhaps associated with 'chat consumption.
57 Christian Aid: The Changing Face of Aid to Produces fever and rheumatic pains.
Ethiopia (1999). 78 Land disputes between male relations and
58 See Table 14 in Appendix 2. domestic violence against women and children
59 There are regional variations: Amhara allocated - violence attributed to 'chat consumption.
83% to the recurrent budget and 17% to the 79 Performed by a traditional practitioner with a
capital budget. Non-salary recurrent razor or sharp instrument.
expenditures remain very low and affect the 80 Research sites in italics.
quality of education in the region. 81 In Ethiopia as a whole, men's average life
60 MOE planning and programming panel 1994/5 expectancy is 49.7 years and women's 52.4.
-1996/7. 82 Research sites in italics.

References and further reading

Kello, Abdulhamid Bedri and Getachew Ethiopian government policy

Yoseph (1999) Oxfam Policy Department documents:
Health Sector Ethiopia Macro Report
Kello, Abdulhamid Bedri and Getachew Health Policy of the Transitional Government
Yoseph (1999) Oxfam Policy Department of Ethiopia (1993)
Education Sector Ethiopia, Macro Report
Education and Training Policy (1994)
von Massow, F., A. Terefe, A. Bekele, S.
Feyissa, T. Haile, A. Kidane Gebrehiwot, T. National Population Policy of Ethiopia (1993)
Koyra, A. Worku, and D. Zewdie (1999) Oxfam National Policy on Ethiopian Women (1993)
Policy Department Micro Research: Health and
Education Ethiopia, Site Report No. 1 Cherkos, Policy on HIV/AIDS of the Federal Democratic
Addis Ababa Republic of Ethiopia (1998)
von Massow, F., A. Terefe, A. Bekele, S. McGee, R., C. Robinson, and A. van Diesen
Feyissa, T. Haile, A. Kidane Gebrehiwot, T. (1998) Distant Targets: Making the 21"-Century
Koyra, A. Worku, and D. Zewdie (1999) Oxfam Development Strategy Work, Christian Aid
Policy Department Micro Research: Health and Randel, J., T. German, and D. Ewing (eds)
Education Ethiopia, Site Report No. 2. Delanta (2000) The Reality ofAid, London: Earthscan
Dawunt, North Wollo
Spandacini, B. and P. Nichols (1998)
von Massow, F., A. Terefe, A. Bekele, S. 'Campaigning against female genital mutilation
Feyissa, T. Haile, A. Kidane Gebrehiwot, T. in Ethiopia using popular education', Gender
Koyra, A. Worku, and D. Zewdie (1999) Oxfam and Development 6/2
Policy Department Micro Research: Health and
Education Ethiopia, Site Report No. 3. Metta, UNDP UNDP Human Development Reports
Eastern Hararge 1991,1993,1995,1999
von Massow, F., A. Terefe, A. Bekele, S. UNFPA (1999) Six Billion: a Time for Choices,
Feyissa, T. Haile, A. Kidane Gebrehiwot, T. New York: UNFPA
Koyra, A. Worku, and D. Zewdie (1999) Oxfam van Diesen A., and K. Walker (1999) The
Policy Department Micro Research: Health and Changing Face of Aid to Ethiopia, Christian Aid
Education Ethiopia, Site Report No. 4. Jijiga, publications
Somali Region
von Massow, F. '"We are forgotten on earth":
von Massow, F. (1999) Oxfam Policy international development targets, poverty and
Department Micro Research: Health and gender in Ethiopia', Gender and Development 8/1
Education Ethiopia Summary Report
World Bank (1998/99) World Development Report,
New York: Oxford University Press

Appendix 1: Micro-research methodology

Organisational structure Finally government, private, and traditional

providers of education and health services were
The health and education research and advocacy interviewed, using prepared questionnaire
project was initiated and co-ordinated by the formats. Responses from the community have
Health Adviser in the Oxfam GB Policy been cross-referenced and compared with the
Department. The research was funded by Oxfam views and statistics provided by providers of
GB and implementation managed and co- health and education services. This has created
ordinated by the Addis Ababa office of Oxfam GB a useful picture of the barriers facing different
in Ethiopia. The successful implementation of groups in their attempts to gain access to health
the research hinged on the support provided by and education services.
Oxfam Ethiopia staff, PA and kebele represen- Representatives of Peasant Associations,
tatives, and local government offices concerned kebeles, and Elders worked on developing a
with education, health, and agriculture. Venn diagram identifying the most important
The micro-research fieldwork took three local institutions and their problem-solving
months,fromJanuary to March 1999. The team channels. Women were very under-represented
included a team leader, two senior researchers in these sessions - except in Jijiga, when
and four assistant researchers, a senior statistician representatives of 'respected' women were
and one secretary, widi a well-balanced asked to join the (all-male) Elders.
combination of sex, age, and experience. A market study of products and prices was
conducted in the three rural sites, providing
Research tools and insights into the gender-determined and age-
related division of labour in bulk and petty
questionnaire content trading, and into prices and the cost of living.
The research, while aiming to maximise the input
of experience, needs, and interests of various
groups in the community, had specific objectives. Site selection and fieldwork
This resulted in a methodology combining PRA72
tools with a questionnaire format, which allowed Four sites were selected, including one urban
for focused discussions on poverty, livelihoods, slum, and three rural locations. The three rural
nutrition, health, reproductive health, and sites were near to Oxfam regional offices in
education. Working with single-sex focus groups Delanta, North Wollo; Metta, Eastern Hararge;
of men, women, girls, and boys facilitated cross- and Jijiga, Somali region. Two villages were
referencing and comparisons between different visited in Jijiga, but the first attempt was
gender and age perspectives, within the PRA data abandoned, owing to bad weather and poor
collected. security conditions. The relative proximity of
Time-line interviews were held with an the sites to the Oxfam regional offices helped to
elderly man and/or woman in each site. Their prepare the communities for the research and
perceptions of trends in poverty, disease inci- to invite people to participate. An important
dence, health-care provision, and schooling at criterion for site selection was that the
various periods since Haile Selassie's regime communities had not participated in any PRA
provided an historical background for each site. exercise previously. The team spent ten days in
The qualitative information gathered during each site, except in Jijiga, where two days were
the PRA was substantiated and compared with spent in one site and six days in the second site.
data collected in a series of 35 household Single-sex focus-group discussions took five
interviews, from which 30 were selected for days. Male researchers worked with the men and
analysis. Interviews were conducted with a boys' groups, and female researchers worked with
questionnaire. the women and girls. One of the main problems

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

experienced by the researchers was how to probe The household survey was designed to include
further into the experience of individuals' at least 30 household interviews, divided into
poverty. The question of what to probe further three poverty categories: worst off, medium
also requires a constant overview of the purpose of income, and better off. In each site 35 households
the research. While the senior researchers for were interviewed: 20 worst off, 10 medium
health and education undertook interviews with income, and 5 better off. Since an important part
service providers, the assistant researchers did of the household interview required intimate
household interviews. It was agreed that men knowledge of women's reproductive health,
should not interview women, because a lot of about 70 per cent of respondents were women. A
personal information was required. total of 140 or more (in some households
In Metta and Jijiga, the research was further husband and wife participated) participated in
complicated by the need to translate from the household interviews.
Amharic into Orominya and Somali respectively. Households with women of reproductive age
The key challenge for the researchers was to and children of primary-school age were
maintain control of the process and make sure selected for interview. In Metta and Addis
that the information did not remain with the Ababa, 30 per cent of the households
translators. One outcome of using translators for interviewed were headed by women; the
die research was in effect the provision of on-the- comparable figures for Jijiga were 17 per cent
job training in PRA techniques and translation and for Delanta 10 per cent. Most of them were
for about eight73 women and men, some of whom in the worst-off category.
will undoubtedly be employed by the Oxfam
Providers of health and education services
regional offices again.
known to and used by women and men in the
community were identified during the mapping
exercise, which was the research team's very first
Participant selection contact with the community. Healdi and
education professionals, parents' committees,
This was not a needs-assessment exercise. Koran schoolteachers, trained and untrained
People were asked to participate to facilitate the traditional birth attendants, herbalists, tradi-
communication of their views to decision- tional bonesetters and physiotherapists, priests
makers, within and outside Ethiopia, for the and healers, drug stores and private practitioners
wider benefit of communities in Ethiopia living were placed on the map and subsequendy
under similar circumstances.
selected for interview. Woreda and zone health
Each community was informed about the and education officials were also interviewed, and
number and age range of those needed for the health and education statistics collected. Local
PRA/focus-group discussions and was discour- government representatives and heakh per-
aged from recruiting couples, so that a larger sonnel were predominandy male, as were
number of households could be represented. In
teaching staff in die rural areas.
each site, two groups of 12 women, two groups of
12 men, and one group each of 12 girls and boys
(aged 10-18) were involved. In the rural sites,
villages were made up of between 70 to 170 Data processing and analysis
households. So with approximately 48 women
and men from different households partici- PRA focus groups and service-provider
pating, about 28-30 per cent of households of the questionnaires
village/s in the site participated in the research. The questionnaires were coded. Researchers took
In each site a meeting with the Elders and/or PA notes in Amharic and later transcribed dieir notes
leaders was organised. into English, widi a margin for die codes and
In Delanta the numbers of participants in the comments. A form, recording date, site, session,
women's groups varied because of their many sex, and number of participants, was attached to
domestic and productive responsibilities. The die notes and filed according to session. The data
research in Delanta also coincided with the first were dien entered in die computer.
distribution of food aid in four months, and a
major festival for which women had to prepare
food. A total of about 300 people participated in Household questionnaires
the focus-group discussions in the five sites74 The senior statistician had in-depdi discussion
visited. and feed-back sessions between sites widi die

Appendix 1

team. Much of the data was of a descriptive a basis for comparative analysis for the data
nature, with many open-ended questions. The collected during the focus-group discussions and
household questionnaire was translated by the service-provider interviews.
team from English into Amharic, to reduce
individual interpretations during interviews.
Problems arose in data collection because most Methodology for the macro
respondents had never been involved in a survey research
before and were not accustomed to the content
and construction of the questions. They also The research utilised a literature survey, a
survive in a very contradictory environment. review of official statistics, and a review of policy
Questions had to be explained, and the problems and planning documents. Key individuals
were compounded in Oromo and Somali involved in planning, financing, and managing
regions, when the researchers had to work the health and education sector programmes at
through translators. The time allocated for each the levels of federal government, region, zone,
site was not sufficient to allow for field editing and and woreda were also interviewed. The research
returning to households to verify responses. team visited the four regions involved in the
Despite these problems, the team was broadly micro research. Two donors, the World Bank
satisfied with the outcome, and the data collected and SIDA, long involved in the health and
provide a good reference point and back-up, and education sectors, were also interviewed.

Appendix 2: Tabulated findings

Table 3: Main health problems reported by communities in the four micro-research sites

TB/HIV/AIDS75 Mogne Bagne76 'Paralysis'77 TB

Hepatitis Skin diseases Scabies

Diarrhoea Diarrhoea Diarrhoea Diarrhoea

Typhoid Typhoid Gastritis

Abortion Pregnancy-associated Gynaecological Anaemia in pregnancy

Excessive bleeding Excessive bleeding Excessive bleeding

on delivery on delivery on delivery

FGM (infibulation) FGM (infibulation)

Early pregnancy

Common cold Common cold Tonsilitis/RTI Coughs and colds

Eye diseases Injury due to accidents Tonsillitis and uvelectomy79

and violence 8

Ear aches (insect) Swollen body - children

(Source: Site reports 1 - 4 and Oxfam Micro Research Health and Education Summary Report, 1999)

Table 4: Percentage of pregnant women testing positive for HIV

Place 1992/93 1997 Place 1992/93 1997

Urban (ante-natal care) Rural (general population)

Addis Ababa 11.2
Seya Debir (North Shoa) 1.3
Kazanchis Health Centre 16.7
Tekle Haimanot Health Centre 18.5 Shola Gebeya (North Shoa) 6.6
Gulele Health Centre 20.0
Enda Mariam Kanaro (Tigray) 0.0
Kefitegna 23 Health Centre 14.1
Akaki factory workers 12.7 Ayuba (Arsi) 0.2
Metu 10.7 Raytu (Bale) 1.0
Dire Dawa 12.3
Baher Dar 13.0 Beneste (South Omo) 2.0
Gambella Hospital 12.7 Country-wide (MOH estimates) 3.2 7.4

(Source: MOH 1998 pp. 4 and 5)

Appendix 2

Table 5: Health Sector Development Programme planned budgets (by component, in Birrs)

Planned Capital to

Component Capital Recurrent Total planned Percent ratio

Service delivery 267,105,000 2,044,756,600 2,311,861,600 51.4 0.13

and quality of care

Health facility 1,040,457,000 196,164,400 1,236,621,400 27.5 5.30

rehabilitation/ expansion

Human resources 65,735,800 71,971,100 137,706,900 3.1 0.91


Pharmaceutical 185,008,100 453,719,600 638,727,700 14.2 0.41


Information/ Education/ 20,644,500 36,317,710 56,962,210 1.3 0.57


Health sector 23,090,700 62,635,500 85,726,200 1.9 0.37

management MIS

Monitoring and evaluation 16,345,000 8,838,000 25,183,000 0.6 1.85

Health care financing 1,547,200 5,934,400 7,481,600 0.2 0.26

Total 1,619,933,300 2,880,337,310 4,500,270,610 100% 0.56

(Source: Health Sector Development Programme 1998)

The financing modalities anticipated to cover

the costs of the HSDP are shown in Table 6. The
government committed itself to financing 55
per cent of total health expenditure. It is
expected that external aid will cover 43 per cent,
and user fees 2 per cent.

Table 6: Indicative financing plan (in millions of Birrs)

Programme costs 1998/99 1999/00 2000/01 Total % of total

financed by expenditure

Government 447 487 1,840 2,774 55%

User fees 20 20 64 103 2%

External aid 310 527 1,289 2,125 43%

Total 777 1,034 3,192 5,002

(Source: Health Sector Development Programme 1998)

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Table 7: HSDP allocation for different regions by category of expenditure (in Birrs)

Region Authorised Capital Recurrent Total planned Contingency

HSDP allocation

Tigrai 346,864,000 70,702,681 241,474,919 312,177,600 34,686,400

Afar 228,200,000 104,440,077 100,704,100 205,144,177 23,055,823

Amhara 876,288,000 375,537,700 413,121,400 788,659,100 87,628,900

Oromia 1,154,692,000 353,064,000 686,581,960 1,039,645,960 115,046,040

Somali 342,300,000 140,350,360 167,729,700 308,080,060 34,219,940

Benshangul 173,432,000 58,015,800 96,865,500 154,881,300 18,550,700


SNNPR 725,676,000 253,721,500 399,117,400 652,838,900 72,837,100

Gambella 127,792,000 53,058,000 61,954,800 115,012,800 12,779,200

Harari 82,152,000 21,221,400 51,796,700 73,018,100 9,133,900

Addis Ababa 333,172,000 68,995,000 231,839,600 300,834,600 32,337,400

Dire Dawa 173,432,000 46,495,400 109,281,300 155,776,700 17,655,300

Centre/MOH 438,000,000 74,330,600 319,869,400 394,200,000 43,800,000

Total 5,002,000,000 1,619,932,518 2,880,336,779 4,500,269,297 501,730,703

(Source: Health Sector Development Programme 1998)

Tigrai's 77 per cent planned expenditure on Table 8: Share of recurrent expenditures

recurrent costs is similar to that of Addis Ababa, of total planned budget
Harari, Dire Dawa, and the federal MOH-run
services. Regions such as Afar, Amhara, Somali,
and Gambella spend 49 per cent, 52 per cent,
and 54 per cent respectively on recurrent costs,
Tigrai 77%
significantly less than the other regions.
Afar 49

Amhara 52

Oromia 66

Somali 54

Benshangul Gumuz 63


Gambella 54

Harari 71

Addis Ababa 77

Dire Dawa 70
Centre/MOH 81

Total 0.64

Note: the above calculation excludes contingency plans.

Appendix 2

Table 9: Ratios of health worker to population in regions of Ethiopia

Physician/ Pharmacist/ Nurse/ Health Assistant/ Population per

Population population population population hospital bed

Tigrai 39,068 559,980 6,899 2,687 3,240

Afar 75,676 1,135,149 25,798 8,665 17,464

Amharagl 59,889 616,361 22,144 6,431 14,376

Oromia 55,052 607,248 19,860 6,254 12,595

Somali 79,996 1,146,620 24,396 10,298 9,828

Benshangul 17,002 123,270 6,241 2,211 1,941

SNNP 43,479 554,367 21,487 6,564 10,681

Gambella 12,177 38,967 3,542 1,464 2,051

Harari 3,392 47,491 2,064 1,024 414

Addis 11,176 82,624 4,123 3,672 2,509

Dire Dawa 8,320 91,520 3,813 2,640 1,551

(Source: Health Sector Development Programme 1998)

Tigrai, Amhara, Oromia, and SNNP are the Table 10: Population per health centre
regions with highest population densities. The and health station in regions of Ethiopia
regions with lowest population densities, Afar
and Somali, have the highest population/health
Region Population per Population per
worker ratios and an extremely low drug-store
Health Centre Health Station
availability, compared with other regions. These
figures show the poverty of the health
Tigray 176,836 17,591
infrastructure in these regions.
Afar 227,030 19,572

Amhara 264,155 21,346

Oromia 263,674 15,427

Somali 343,986 38,650

Benshangul 123,271 6,755

SNNP 133,583 24,860

Gambella 48,709 4,236

Harari 142,474 5,480

Addis 128,527 6,824

Dire Dawa 137,281 10,560

(Source: Ministry of Health, 1998)

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Table 11: Infant mortality and life expectancy by region

Region Infant Under-5 % of children Life expectancy

mortality Mortality underweight at birth81
Addis Ababa 78 109 45.4% 58.4
Harare 113 166 27.8% 51.4
Dire Dawa 115 168 42.5% 51.1
Tigrai 123 161 57% 49.6
Amhara 115 170 55.6% 50.8
Oromia 118 173 37.4% 50.4
Benshangul Gumuz 140 206 43.8% 46.8
Gambella 96 142 33.4% 54.2
SNNP 128 189 49.6% 48.6
Afar 118 174 39% 50.3
Somali 96 137 41.2% 54.8

(Source: CSA statistical bulletin 1999)

Table 12: Rural-urban distribution of schools by level and region (1998/99)

Region Total Total No. schools %of No. schools %of

Primary Secondary Primary total secondary total
(rural) (rural)
Tigray 811 26 683 84.2 0 0

Afar 101 4 74 73.3 0 0

Amhara82 2,819 84 2,548 90.4 9 10.7

Oromia 4,200 128 3,604 85.8 2 1.6

Somali 167 3 129 77.2 0 0

Benishangul-Gumuz 257 9 237 92.2 0 0

SNNP 2,228 81 1,968 88.3 10 12.3

Gambella 123 6 113 91.9 3 50

Harari 44 3 22 50.0 0 0

Addis Ababa 248 41 1 0.04 0 0

Dire Dawa 53 4 25 47.2 0 0

Ethiopia 1,1051 386 9,404 85.1 24 6.2

(Source: Education Statistics Annual Abstract, 1998/99)

Appendix 2

Of the research sites, Somali region is the worst- schools constructed in Amhara region, a 15 per
serviced in terms of rural secondary schools cent increase in Oromia, and an 11 per cent
(none), and new primary-school construction increase in Addis Ababa. This is, however, no
since 1994/5 (none). Between 1994/5 and indicator of difference in the quality of service
1998/9 there was a 10 per cent increase in new provision.

Table 13: Rural-urban dimensions of primary enrolment, 1997/98, by region

Region Urban Rural

Boys Girls Total Boys Girls Total

Tigray 83,204 73,212 156,416 139,089 102,438 241,527

Afar 4,564 3,624 8,188 4,476 2,127 6,603

Amhara 152,651 151,275 303,926 440,117 316,043 756,160

Oromia 348,855 250,338 599,193 820,832 290,893 1,111,725

Somali 16,984 6,858 23,842 27,753 10,242 37,995

Ben.- Gumuz 9,682 5,712 15,394 40,960 16,371 57,331

SNNPR 170,477 109,876 280,353 743,248 307,592 1,050,840

Gambella 3,728 2,784 6,512 17,471 8,589 26,060

Harari 7,988 7,323 15,311 4,145 1,372 5,517

Addis Ababa 171,005 186,579 357,584 88 57 145

Dire Dawa 13,882 12,669 26,551 2,866 631 3,497

Total 983,020 810,250 1,793,270 2,241,045 1,056,355 3,297,400

(Source: Education Statistics Annual Abstract, 1997/98)

Table 14: Total budget allocated to education and capital budget 1994/95 to 1996/97

1994/95 1995/96 1996/97

Birr millions Birr millions Birr millions

Capital Capital Total Capital

budget budget budget budget budget budget

Primary 811.4 209.4 846.4 206.4 804.2 158.34

Secondary 131.1 26.6 136.89 28.0 186.3 78.7

Tertiary and others 163.2 72.7 355.93 106.6 506.1 116.47

Total education budget 393.9 480.39

1,297.2 411.9 1,339.22 (441.86)a 1,496.6 (429.47)b

Total government budget 9,964.6 4,595.2 9,667.35 3,966.41 10,923 4,835.1

Share of education in 13.0% 9.0 13.9% 9.9 13.7% 9.9

total (%)

(Source: MOE, Planning and Programming Panel)

Appendix 3
Case study 1: Cherkos, Kebele 24, Addis Ababa

Poverty, livelihoods, and Factors contributing to poverty

nutrition Cherkos is an area strongly associated with its
market and with the military camp that it
The ranking exercise in Cherkos told us that surrounds. The economic status of the area is
about 70% of the community are classified as the closely linked to the fate of the Ethiopian army.
'worst-off. For the vast majority of families, this At the downfall of Mengistu's Derg regime in
means that they do not have sufficient income to 1991, a significant proportion of his army was
cover their basic food requirements, basic demobilised, resulting in high male unemploy-
health-care costs, or the costs of sending all their ment, and a reduction at the same time in custom
children to primary school. Table 15 shows how for women's food and drink trade and the sex
women and men in Cherkos define poverty and trade. In addition there are many older military
relative well-being. pensioners in the area, and high male and youth
unemployment. Many families depend on
women's daily petty trading for a living.

Table 15: How the poor classify poverty in Kebele 24

'worst-off households 'medium' households better-off households

71 % of the sample 21% of the sample 8% of the sample

Large family size (10+). Married couple, no children, Small family size.
Small pension (less than 50 birr with low insecure income He has an adequate pension,
per month). (musician), enough for the family.
A very sick head of household They have (his) small pension, He/she has a well-paid job.
(male). which they supplement with Someone who is permanendy
The husband has died or left other jobs. employed.
the household. They have support from other Both the husband and wife
W/roTeitu: 'I am a mother of 7, sources (children). work.
my husband died. The oldest is in Pensioned but with a large He has his own house.
government school, the others are at family. He/she has good pay.
home. My children havefood one The husband or wife has He/she has support from
day and not the next.' permanent employment but children (some overseas).
Lack adequate food and only a small income (e.g. the
clothing and treatment when husband is a zabanya).
sick. Good heakh, ability to work
No reliable job (both husband and be active.
and wife). Some men have trades
Loss of means of income due to (carpenter, weaver, tailor) but
age and/or sickness. Families have no permanent work in
surviving on a daily income e.g. the market and do not get
women's petty trade - fuel regular work.
wood, preparing and selling
berberri, washing clothes,
brewing the local beer, 'tella'.
Widows looking after
orphaned children.
The family size is smaller.

(Source: Focus-group discussions)

Appendix 3

The population of Kebele 24 is around 15,000, the level of poverty in the area. Table 16 shows
and has grown. With the increasingjob losses and broad categories of livelihoods by gender and
a drop in incomes, and no serious investment in the factors affecting income levels over the year.
poverty reduction, health care, water and In the dry season (December to May) there is a
sanitation, or primary education services, the higher demand for daily labour and construction
prospects for the next generation are bleak. One workers. The harvest seasons (December to
woman predicted that there would be no one left. February) are important for women traders, as
They are dying, they said, but it's a slow and prices are lower and diere is wider range of
miserable way to live and die. The key causes and products available to sell. During diis time some
effects of poverty highlighted by the participants men trade in larger quantities of grains and
(women and men) were as follows. chickpeas, selling to smaller traders.
Income levels decrease dramatically during
the rainy months from June to September.
Poor health
Everyone is less mobile, because of heavy rains
Shortage of water
and flooding. The agricultural prices are higher,
Poor environmental sanitation: rubbish, no
and there is little or no construction. Business
toilets, overflowing public latrines, open drains
and trading are depressed. In June students
Bad infrastructure: no access roads, poor
compete widi adults for work. In July and August
sanitation, irregular water supply, contam-
there is no work in the coffee-cleaning plant, an
inated water
important source of income for women and girls.
Overcrowded housing
All these factors affect die livelihoods of women
Large family size (86 per cent of the 'worst-off
and men and children and reduce die availability
households' in the survey had 4-8 children)
and circulation of money in die community. This
Security problems: street violence (boys), fear
coincides widi the season of high expenditure
of abuse and rape (girls and women)
needs, and dierefore borrowing. School fees,
Delinquency, drug abuse, and alcoholism
exercise books, and uniforms have to be
(mosdy boys, young men)
purchased in September, which is also die month
Lack of employment perspectives for young
of Ethiopian New Year celebrations. The rains
men and women
bring an increase in die incidence of illness, and
'Mental unrest and disturbance amongst young
the need to seek and pay for cures is at its highest.
people, as a result of unemployment' (a main
health problem raised by young girls).
Incomes and food security
An older man in the group explained: 'Many of
the population in this Kebele are very, very poor. In old Many households right in die centre ofAddis are
days most of the people had large income. Now they do seriously lacking in food most of die year: 85% of
not even have enough to get food. When we say better worst-off and 43% of medium households report
off here, we mean people who get enough food. difficulty in maintaining adequate nutrition.
Categorising very poor indicate here for those who do 'Absolutely unbearable and difficult condition has come
not get food once a day.' about in the last four years. Virtually the people have
little or nothing to eat' (men's group). Two diings
Livelihood patterns became clear from our household survey:
incomes in die worst-off and medium households
In Cherkos, there is a significant number of are too low to buy adequate food supplies for
army pensioners whose families wholly or in large families; and almost all income in worst-off
part depend on their pension for an income. and medium families is spent on food.
However, there are also many families with a The women's group said diat most people eat
very small pension or no pension, and a 'shurro' (a sauce made widi finely ground
significant proportion of households, maybe chickpeas) and njera, and diat diey lack fruit and
more than 30%, are headed by women. Some vegetables in dieir diet and rarely eat meat. Some
people are forced to beg for a living. Livelihoods make die shurro widi 'guaya', a plant known for
are vulnerable, varying with fluctuations in the its poisonous properties. People who eat too
agricultural calendar, the rainy and dry seasons, much of it become lame and permanendy
festivals and holidays. As a rule, however, disabled. They eat it because it is very cheap. In
women's earning power is less than men's. A die household survey, 95% of worst-off and 100%
high proportion of households is dependent on of medium households gave 'insufficient income'
women's low incomes, a contributory factor to as die cause of inadequate nutrition for children.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Table 16: Factors affecting seasonal fluctuations in income by source of income and gender

Source of income Gender Factors affecting the market Season

Increase in income Decrease in income

Petty trade in agricultural Mostly Fasting Hidar (Nov)

products Women

Charcoal production & Women & Christmas Tahisas (Dec)

sale men Weddings & Tir Qan.)
Easter Miyazia (April)
New Year Meskerem (Sept)

Petty trading Women & Harvests Tahisas (Dec)

Beer/alcohol producers girls Tir (Jan)
Baking njera
Producing berberri Chilli harvest Tikmt (Oct)

Bulk purchases for resale Mostly Harvests Tahisas/Tir (Dec/Jan)

men, some

Petty trading Mostly No purchasers Ginbot (May)

Food/alcohol production women after Easter

Coffee -cleaning plant Mostly No beans Hamiley/Nehassey

Daily labour women (July/Aug.)

Daily labour Mostly men Heavy rains & Seney - Meskerem

Construction work flooding (June - Sept.)
Transporting goods

Petty trading Women Heavy rains & Seney - Meskerem

and girls flooding (June - Sept.)

(Source: focus-group discussions)

A staggering 90% of worst-off households, and reported just eating maize or potatoes, and 20%
50% of medium households, reported failing to just eat 'kita', a local bread; 50% of the medium-
maintain adequate nutrition for their children. poverty group and 20% of the worst-off
In the worst-off households, 25% of children reported eating roasted cereals ('kollo' or
were reported to be showing the signs of 'nifro', a type of bread). Parents eat less, so that
malnutrition. This may well be an underestimate, their children can eat what little there is. Some
as mothers are reluctant to admit to what they see adults manage on just coffee in the morning and
as a failure on their part. In one household water at night for several days. Some women
interviewed, it was the 16-year-old daughter who said: 'If he is a considerate husband he would eat with
'reminded' her mother that the clinic had said his wife, but there are those who eat all the food by
that her little brother's illness was related to lack themselves.' Women believe that they can
of food. Her mother had been saying that none of manage longer without food than men. They
her children suffered from nutrition-related also said that girls 'can endure hunger better than
problems. boys'. Some girls give their breakfast to their
The most difficult period is the rainy season, brothers before going to school. 'In hungry
when incomes are low and food stocks run out. seasons children even steal food and money to buy
Families adjust their diet and the number of food,' said one mother.
meals they eat per day. In worst-off households Finally, during the focus-group discussions
10% reported only drinking water, 40% and service-provider interviews, there were

Appendix 3

allusions made to men's drinking and and were full or overflowing and filthy at the
socialising, and to young boys indulging in time of the study. One neighbourhood has
alcohol, cigarettes, and drugs. The survey has formed an association of 50 households widi the
not extended to investigating the details of assistance of the Oxfam-funded NGO VCH.
men's and boys income and expenditure habits, Members contributed to the costs of having a
nor who controls men's access to income for tanker come and empty die latrines standing in
socialising, including extra-marital sexual their midst. They pay 5.00 Birr per month to use
activity (source: Kebele leaders). This may well the latrines. Two women are employed to hold
be a circulation of money outside the household the keys and to clean the latrines.
budget and merits further enquiry. The Kebele has built two more blocks of
latrines, using contributions from the
community. These are not yet in use. No odier
Health actions to address this very acute problem are
being taken by government or NGOs. Hopes
had been raised by die prospect of possible
Water and sanitation funding for a roads-improvement and urban
Water: According to the PRA there are about 15 sanitation programme, but die community is
owners of private taps in the community, and too poor to raise die required contributions in
people buy water at around 0.15 cents per cash to die World Bank Ediiopian Social
'baldi'. Most households interviewed said that it Rehabilitation and Development Fund.
takes an average of 20 to 30 minutes to collect
water. Several participants were concerned
about the quality of the water, believing it is Main diseases identified by men and
contaminated because the piping system is so
old and rotten. The Kebele is very congested. The insanitary
There are no significant seasonal differences conditions described above are insupportable
in access to water; however, water often has to be and are causing serious environmental healdi
collected in the evening, as the supply can be cut problems. Waste matter and odier dirt are
off in the day. It is mostly women and girls who dumped along the road or in any open space.
collect and carry water, although boys from die Unbalanced diets, poor housing, and die cold
poorer households also undertake this task exacerbate die problems. Diarrhoea was
from time to time. This is significant not only reported as a serious health problem, mainly
because of the extra burden placed on women's affecting children under die age offive,who also
and girls' time and strength, but because it is get typhoid. A TTBA interviewed said diat the
simply unsafe to go out in die evening. There causes of disease in diis area are filth, lack of
was a lot of talk of abuse and rape of young toilets, and inability of die community and the
women, and the Kebele officials said that people government to address these issues.
were most vulnerable to muggings, stone- The incidence of diseases peaks during die
throwing, theft, and beatings between 7.00 p.m. rains, when sanitation deteriorates furdier, diere
and 9.00 p.m. is a shortage of work, a problem compounded by
low incomes, and little or no food. The incidence
Sanitation: The sanitation situation in the of diarrhoea, colds, and respiratory problems
Kebele is appalling, with open, overflowing including TB increases considerably. These
sewers, and streams of human and other waste problems are particularly serious among women petty
running down the streets and padiways between traders in the market. You can see them coughing
the tightly packed dwellings. The whole area is whenever the weather changes,' said one man.
littered with rubbish. Few households have Women suffer from umbilical hernias, mainly
toilets. Some bore a hole from dieir houses into caused by overwork and carrying and/or lifting
die underground concrete waste pipes and heavy loads. They are treated by TBAs.
pour their waste down diem, blocking them up Most of die healdi problems identified
furdier. Odier households have a bucket or during die focus-group discussions and from
other container as a toilet and pour its contents the household survey were similar to diose
into die open gutters in die streets. identified by the drug-store owner and the
In the Derg's time some public toilets were private clinic, and to die top ten diseases
constructed as part of Kebele-organised com- reported by die health centre for 1998 (see
munity development. These ran into disrepair, Table 18).

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Table 17: Major diseases and health problems identified by men's and women's focus-group

Women's group Men's group Youth groups


Hepatitis* Abdominal complications HIV/AIDS*
Diarrhoea* (under 5) Diarrhoea* (jardia common) Common cold*
Typhoid* Abortion* (young women and Diarrhoea*
Asthma girls) Mental unrest and disturbance
Liver problems Common cold* Unwanted pregnancy and
Typhoid - contaminated water
Asthma - air pollution
HIV/AIDS Venereal disease

(Note: those marked * are the four most prevalent problems identified.)

Table 18: Top ten diseases reported by Kebele 09 Health Centre, Woreda 21 (1997/1998)

Diagnosis Number Percentage

1 Acute upper-respiratory infections 2500 12.76

2 Bronchopneumonia 2068 10.55
3 Infections of the skin and subcutaneous tissue 1630 8.32
4 Gastritis and Duodenitis 1350 6.89
5 Other Helminths 1317 6.72
6 Hypertrophy of Tonsillitis 907 4.63
7 Other diseases of reproductive system 825 4.21
8 Infections of kidney 635 3.24
9 Gastroenteritis and colitis (4 weeks - 2 years) 594 3.02
10 Muscular rheumatism and arthritis 585 2.98
Total 12411 63.32

(Source: Cherkos health centre Kebele 09, Woreda 21. Note that these records reflect the incidence of illness of
those, from the whole woreda, and neighbouring woredas, who seek treatment at the health centre. Many in
Kebele 24 do not have access for a variety of reasons: see 'Health services' below.)

Reproductive-health problems said: 'Abortion is one of the most important health

The girls' group linked mental unrest among hazards affecting our sisters. They are dying, and those
young unemployed males to their deviant who escape death end up having permanent damage.'
behaviour, resulting in unwanted pregnancies According to both men and women, the
and STDs among young girls. Girls are victims of TB and HIV/AIDS are young men
reportedly subjected to violence and rape, and between the ages of 15 and 40. People believe
many resort to abortion. The resultant fear and that boys more than girls are affected; they said
lack of security, they said, had affected their that they die sooner because they smoke and
education and their health. Young boys are more drink a lot. TB of the 'samba' (lung TB) is
affected by other forms of street violence: There considered a nickname for HIV/AIDS in this
are lots ofyoung people (male) who have been wounded Kebele. They know that it is AIDS, because the
and killed due to urban violence,' said the women. TB treatment should work but doesn't. They
The men's group included abortion as one of said, 'They get very thin, they cough and there is
the four main health problems. A private clinic diarrhoea, many people die.'

Appendix 3

Young girls said they need reproductive- Mothers going for antenatal care and other
health education. The boys' youth group MCH services are the target group for family-
identified sex education as one of their basic planning education. Note that men and youth
health-education needs. are thus not reached by family planning or
reproductive-health education.
Circumcision: Although some TBAs stopped
performing female circumcision three years ago According to the survey, a very small per-
in response to health education, circumcision of centage of women is using family planning.
boys and of girls is still performed. The most There appears to be a relationship between use
common form of female circumcision in Kebele of family planning and income. While 74% of
24 is the removal of the tip of the clitoris. There worst-off and 80% of the medium households do
were strongly differing views on the practice in not use family planning, 67% of better-off
the women's group, between those who believed families do. About 30% of die worst-off
it should stop and those who were insistent on households are headed by women; however,
circumcising their daughters. they may still have partners.
Family planning also needs to be differ-
Antenatal care: The majority of women in the entiated by users. W/ro. Mitikie, a TBA, said diat
household survey reported that they use the number of women whom she was called to
antenatal services: 75% from the worst-off assist during delivery had declined. She thought
group, 86% from the medium group, and 100% that one of die reasons was that prostitutes are
from the better-off group. During their last increasingly using condoms to protect diem-
pregnancy, 56% of worst-off, 29% of medium, selves from HIV/AIDS infection, thus at the
and 67% of better-off reported having health same time protecting diemselves from
problems. The main problems were related to unwanted pregnancy.
malnutrition, including anaemia and mis- A widow, and mother of eight, said that she
carriage. The worst-off families have a very poor
would have limited the number of children if
diet, and women tend to give what food there is
she had known what it was leading her to.
to the children. Antenatal care is free, so the
Having eight children, she is unable to satisfy
majority of the women in the worst-off group
their needs. They are not fed adequately, they
(72%) go to the government clinic and hospital
do not have the necessary materials for school,
for treatment when they are sick during
and diey do not get access to proper health
Delivery: Women in Kebele 24 do not have a
maternity centre nearby. They deliver at home, Health services
at Kebele 18 health centre, or at government
hospitals. Whereas 52% of women from die Types of service: The types of service available
worst-off, and 43% from the medium-poverty include health centre; hospital; private clinics;
categories delivered at home, all in die better-off illegal private pracdtioners; drug stores;
category gave birth in a hospital or government traditional healers; Ato Mamo, famous
health centre. Of the home deliveries, 48% in traditional healer; Traditional Birdi Attendants
worst-off households were attended by an (trained and untrained); Wogeishas (traditional
untrained TBA, a neighbour, or a relative. All physiodierapists/bonesetters); holy waters
women in better-offhouseholds were assisted by (church); home treatment. The nearest govern-
a doctor or a nurse during birth. In the worst-off ment healdi centre in Kebele 09 provides the
group, 38% reported having problems after following services.
delivery; 40% of those reported heavy bleeding, Health education
and 20% anaemia. Antenatal care
It must be noted diat a significant proportion Postnatal care
of women in die worst-off and medium groups Family planning
still give birth at home, and diat these groups Vaccination and immunisation
report problems during pregnancy and after Consultation
birdi. These are high-risk deliveries, taking Laboratory
place in overcrowded and insanitary conditions,
attended by ill-equipped and untrained people.
Family planning: The healdi centre provides Leprosy and TB programme
family-planning services free of charge. STD programme.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

However, due to the complexities of the are seriously ill. Distance is the second most
exemption system, and to the fact that, for those important factor for this group. Most cannot
who do have an exemption paper, there are no afford transport. The sick need to go by taxi,
medicines for treatment, many from Kebele 24 which costs about Birr 21.00 (US$ 2.69).
are discouraged from using the facility. The There were a significant number of
health centre is seriously oversubscribed, with a complaints from the worst-off and better-off
doctor:population ratio of 1:197,895. Partic- groups alike about staff attitudes and
ipants complained about the long queues and discrimination at government health facilities.
the preferential treatment given to paying users
Affordability: All focus groups reported that
or those known personally to stafi7guards. Many
diey could not afford to go to government
use home treatment or traditional healers, or
healdi services. This was confirmed by health-
just go without treatment. Women say that all
service providers, including private clinics and
services except the bonesetter, the TBA, and the
drug stores, who said that they sometimes
health centre provide medicine.
treated the very poor for nothing or at reduced
Women are aware of reproductive-health cost. The situation was becoming impossible.
education services at the health centre, but men Even TB treatment was too expensive, despite
are not. It is possible, therefore, that, unless men die fact that it is free, because of transport costs
come for STD treatment, they will not access any and the cost of nutritious food. In the household
reproductive-health education. Given the level survey, 84% of worst-off households reported
of sexual promiscuity, early pregnancies, rape, diat health care was unaffordable, and die
and HIV/AIDS in the area, described by all remaining 16% said it was 'affordable with
participants, it would seem essential that men a struggle' i.e. they had to reduce food
and boys should be reached by health consumption, or had less cash available for
education. The men's group was aware of the school costs. A serious illness in the household
STD clinic at the health centre, but women were was one of the reasons given for dropping out of
not. This may also be an indicator that women school.
do not recognise and treat STDs, and men do.
In theory, a paper giving exemption from
Many men just go to die drug store and treat
user fees, obtained from die Kebele, should
themselves. Women say that in the case of an
provide die patient with free diagnosis and
emergency they go to all health facilities except treatment. In practice, die healdi centre has
die church. Men did not mention emergencies. inadequate medical supplies and diere is no
Health-seeking behaviour and accessibility of medication for treatment. In addition, die
treatment: Women and men will choose to go to Kebele is charging 5.00 Birr per exemption
a government health centre if die complaint is paper (which normally carries no charge), to
serious, but they need a referral to a cover community contributions to a World
government hospital (e.g. for TB). Men believe Bank part-funded project (The Ediiopian Social
diat women prefer traditional healers, while Rehabilitation and Development Fund) for the
they themselves chose to go to die healdi centre. building of a maternity unit in a neighbouring
Women were more particular about matching Kebele. In effect, this means diat die very
die complaint to die service provider. They said poorest are being asked to contribute to
diat it is good to go to hospital when children investments in healdi-care infrastructure which
have diarrhoea and for car accidents. But diey diey are least likely to use, or to forfeit access to
are more confident in traditional healers' ability an exemption form.
to treat hepatitis, almaze (a sometimes fatal skin- People also said that there was a very
rash, caused by die bite of an insect called bureaucratic and time-consuming process to get
almaze), STDs, and tonsillitis. die paper. The poor have a long working day,
Most households in die worst-off group especially poor women, and do not have spare
reported low cost as die main reason for selecting time. Participants dierefore said that it was not
die location of treatment. These households wordi applying for an exemption paper. For
have no money to make a choice. The youdi traditional healdi services, people have to pay
groups, especially die girls, reported having up to Birr 20.00 (US$2.56) for a visit to the
home treatment because dieir mothers could not wogeisha or to have an untrained TBA attend
afford anydiing else. They seek treatment dieir delivery. Sometimes diese services are
elsewhere only when die condition is much provided to very poor households free of charge
worse. Women do not go to die clinic unless diey or at reduced rates.

Appendix 3

Some people reported borrowing money to staff, especially of appropriately qualified staff.
cover health costs (at interest rates of up to 50%), They are aware that they are unable to provide
selling assets like jewellery, furniture, or radios, the sort of service they would wish for.
and necessary possessions such as winter coats Women were concerned about cost, the
and beds. In some cases neighbours made a distance to the health centre, and having access
collection to help someone to get health care. to a 24-hour service. The availability of medicine
Quality of health care: The youth groups was extremely important to all groups. Both
preferred private clinics to government adult groups gave availability of medicine at
services, because they felt they were diagnosed government health facilities a low score. This
properly and listened to. People felt that was also raised as a main problem by health-
government health-service staff have a negative service providers, in terms of both availability
attitude to the poor and do not treat them as well and affordability for the poor.
as they treat the better-off. Finally, waiting time was a crucial aspect of
Young participants said that they were at the quality health-service delivery. All groups gave
mercy of health-centre staff who use re-useable the health centre and government hospitals the
needles. The youth group were very conscious lowest score for waiting time. Given that patients
of the dangers of government and traditional from the poorest households, especially women,
health practitioners using used needles and are brought to a government facility when the
razor blades. condition has deteriorated considerably, a long
There were several criticisms about staff wait can make the difference between life and
attitudes in government health facilities, death.
including their treating poor people 'like dogs' Good diagnosis and trained medical staff
(male participant). The girls' group and the were important to most groups. For this reason,
women also gave the health centre a very low one girl said, it was good to go to a private clinic:
rating for staff attitude to the poor. The health 'because they ask you what is wrong, listen to your
centre is underfunded and has a shortage of heartbeat and respiration'. The men's group

Table 19: Criteria identified for assessing the quality of health-service providers (by
gender and age)

Quality criteria Respondents

Men Women Boys Girls

Cure * * *
Cost * * *
Waiting time * * *
Waiting place in health facility *
Waiting place outside facility *
24-hour service * *
Distance *
Trained medical staff * * * *
Staff attitude * * * *
Good examination *
Availability of medicine * * *
Beds available * *
Cleanliness * * * *
Cleanliness (outside/buildings) * *
Latrine * *
Equipped with medical equipment *
Lab facility available *
(Source: PRAfocus-group discussions)

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

scored the health centre and drug store highest It was interesting diat a higher percentage of
for cures, and traditional treatment lowest. The women household-heads were literate (30% of
women also scored the health centre and worst-off households interviewed), than men
hospital high for cure but included holy waters, household-heads. This may be connected to die
other traditional treatments, and the TBAs literacy campaign during Mengistu's period,
among those with a high score for cure. The when many women and children took
most costly service, and that with the least advantage of literacy classes in the Kebele.
chance of a cure, women said, was that provided
by illegal abortionists. They also thought drug
Availability of primary schooling
stores were too cosdy. Men tend to use the drug
stores and the health centre more, while women The only schools in the Kebele are fee-paying
tend to go to traditional healers and die holy private schools attended by children from
waters more. The reasons are a combination of marginally better-off households widiin and
access to cash, cost, distance, waiting time, and outside the Kebele. The worst-off households
expectation of a cure. cannot afford to send dieir children to diese
schools and have to send diem to government
schools outside the Kebele. The schools most
used by children in this community are Edget
Education Behbret (a government school outside die
In the adult focus groups diere was a strong Kebele), Felege Yordanos (a private fee-paying
appreciation of the value of education, and for school), and Walya community school (also fee-
both girls and boys. In the past it was not as paying). For many households the nearest
strongly appreciated that girls should go to government schools are too far away. Women
school, but things have changed. Some women expressed concern for dieir children of
were keen that education should improve girls' primary-school age walking dirough the highly
opportunities and status, and mothers did not congested area and in die traffic. Hence most of
want their girls to live such a tough life as theirs. the worst-off and medium households in the
Education was broadly linked to access to Kebele do not send their children to school.
employment and to the ability to look after one's
family, including die parents in their old age. Children in school
However, in the household survey, where The Zone 2 Education Office said diat very few
70% of the respondents were women, as many as children in Kebele 24 actually go to school.
33% of respondents from worst-off households There is no government school in die Kebele.
thought there were no advantages to educating They agreed that die government schools in die
boys, and 43% no advantages to educating girls.
neighbouring Kebele were too far away, and
All better-off households believed in the benefit
added that diey are also oversubscribed. In
of educating both girls and boys. Boys and girls
Woreda 21 as a whole diere are not enough
diought diat education could liberate the
school places to accommodate all children of
community from poverty (boys) and help them
primary-school age.
to teach their own children (girls). Both believed
The household survey showed diat out of 59
education would help them in their jobs in the
future, but boys said that diere was a need for children in die worst-off households interviewed,
skills training in addition to schooling to make 41% were not in school. Aldiough die number of
them employable. years in school varied, bodi adult focus groups
reported diat boys stayed longer in school on
average dian girls.
Level of education in the community For children in school, particular difficulties
Levels of education among parents and were reported; diose reporting diem included
appreciation of die value of education for dieir die teachers. Poverty was increasing and demon-
offspring are connected. There were higher strating itself in children's poor diet. Children
levels of illiteracy in die worst-off households reported being hungry in school and lacking
than in die better-off, widi 41% of die male concentration. Girls in particular have heavy
heads of household and 22% of the female heads domestic and income-earning workloads, which
of household illiterate in the worst-off group, interfere widi their performance in school and
while in the better-off households 75% had ability to fulfil homework assignments. Boys
completed Grades 9-12. from die poorest families have difficulties

Appendix 3

because they have to work, in daily labour, Some children and adults reported diat for
hawking, or shoe-shining to supplement the male adolescents in particular the attractions of
family income, in addition to their school work; street life are greater than school, and diey refuse
sometimes the household's increased need for to go. Parents cannot control diem. There were
their labour is a reason for leaving school. reports of young girls who became pregnant and
Older boys are disruptive, and discipline is a left school, some becoming prostitutes, attracted
major problem. The Kebele said that most of the by die allure of high incomes as sex workers. On
boys taking drugs, alcohol, and tobacco are from the other hand, odier girls suffer die fear of being
better-off families. Those from the poorest raped, accosted, or abused by hooligans on die
households are busy earning money for the way to school; diis affects dieir performance and
family. attendance.
Some families simply do not understand the
Reasons for not attending school, and value of education and do not send their
affordability children to school. Odiers cannot manage to
look after, control, and guide their children
The main reasons for not attending school are
because of their long working day. The boys'
low incomes, and the cost of sending all children
group said that they wished diey could have
to school. The cost, even in government schools
more support and guidance from dieir parents,
where parents have to pay a maximum of 10.00
the community, and die government.
Birr (US$ 1.28) as a registration fee, is pro-
hibitive. This is also because children in primary
school in Addis have to wear uniforms at a cost of Quality of existing schools
Birr 50.00 - 60.00 (US$6.40 - 7.69), or one While it is true diat many children do not go to
month's income. Parents in the focus groups school because of low incomes and the
include food, clothing, exercise books, and the household's demands on their labour time, it is
cost of heakh care in the cost of sending a child also true that there are not enough schools to
to school. Sending one child is expensive accommodate all children of primary-school age
enough; it is hard to send four-eight children to anyway. At die same time, die existing schools,
school. Education-service providers agreed that even private ones, are run down and lack basic
education was too expensive for the poorest materials and facilities. The state of some
households, who are in the majority in a Kebele buildings ranges from inadequate to being
like Cherkos. hazardous to the healdi of die children. None of
In Kebele 24 another main reason for non- the schools had adequate sports facilities. Some
attendance is the fact that there is no govern- classrooms in Walya are built widi sheets of iron,
ment school in the Kebele. It is considered by and have up to 105 students in a class. In all
mothers to be too distant, dangerous, and schools there was a lack of desks and chairs, even
congested for children to walk to die other for the teachers. Average class size in one private
Kebele school. Children would also have to cross school was between 60 and 80 children. In
busy roads. government schools die teacher:pupil ratio
The unemployment or death of a parent, or sometimes reaches 1:120. None of die schools
serious illness in die family, affects income has adequate teaching materials, and in all
sufficiendy for a family to withdraw one or more schools children have to share textbooks. In the
children from school. private schools it was reported that one book is
Because of hunger, child-labour obligations, shared between three or four children; in the
and die stress of poverty and living in such a government schools it can be as high as one book
congested and poor environment 'not to six children. The Zone 2 Education Office
conducive to learning', children, in particular also regretted diat there was a lack of teachers'
girls, do not meet the required educational guidebooks in some grades, which certainly
standards school. One of the most common affected the teaching standards.
reasons for leaving is failing a repeat year. Teachers, even in the fee-paying schools, said
Children are not allowed to sit an exam for a that children come to school hungry, which
third time. Some children attend school when affects the quality of education and dieir
diere is enough money, and leave school to find performance. None of the schools provides any
work when household income is too low. This food during the day. In addition girls, in
also affects performance and dieir ability to pass particular, complained about die insanitary
exams and stay in school. conditions and die lack of toilets in schools, and

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

all were concerned about the lack or shortage of Felege Yordanos has a good reputation for
water in school compounds. examination results; however, it was the most
Teachers said that there was a lack of qualified expensive school in the area. Overall, people
teachers, and that some teachers do not even meet thought that the quality of education in the area
the criteria specified by the new education and had deteriorated, largely because of discipline
training policy. Parents and children also noted problems, particularly hooliganism and drinking,
the poor quality of teaching. In addition, the new and because of the deteriorating quality of die
self-contained teaching policy was proving teachers.
problematic for teachers. They are not trained to
teach all subjects from Grades 1 to 4, but this is
now expected of them. Conclusions
Teachers are motivated, but the poor
conditions, low salaries, lack of teaching materials, Health services
and the favouritism that affects access to training The focus groups made many recommen-
are counter-productive. Teachers are finding it dations, summarised in Table 20, to improve the
increasingly difficult to teach unruly young boys health services.
in particular. Some said that it was distressing to
teach children who are obviously suffering from Access, affordability, and quality
poverty and hunger and who had a long day of The following supply-side factors were men-
both school and work outside school hours. tioned by focus groups.
Of course, in terms of quality, examination A lack of sufficient health-care facilities in the
results are important to parents, but in the context community.
of the circumstances and needs discussed above A shortage of appropriately qualified staff.
this issue was lower down the list of quality criteria. A lack of basic equipment.

Table 20: Focus-group recommendations for improvements to health services

Group Group Group Group
Build health centres or clinics in the Kebele. * * * *
Improve efficiency and quality of the service. *
Employment opportunities to earn money & * *
improve nutritional and health status.
Food for work for the youth - e.g. growing *
vegetables - with nutritional benefits.
Improve environmental sanitation. *
Equip existing clinics with medical instruments *
and materials.
Improve quality and quantity of medicine. *
Establish new public pharmacies like the Red Cross. *
Train traditional healers to minimise the harm they *
can cause through lack of awareness.
Government training on sterile blades and needles *
for government and private health centres, traditional
practitioners, and the community.
Means to borrow money for treatment. *
Government should help the poor in the community. *
Government should control addictive plants. *
Guidance and counselling for the youth. * *

Appendix 3

A shortage of sufficient quantities of good- electricity, water, food, andfirewood/keroseneto

quality, most frequently needed medication. cook and heat the house. This puts an enormous
A lack of funds for health education and strain on the poorest households.
reproductive-health education in the
Government health-service providers and
community, targeted at different gender/age
private clinics and drug stores said that only
and occupational groups.
with improvement in the people's economic
A lack of investment in improving water,
status would their health improve.
sanitation, housing and feeder roads;
Health care, both preventative and curative,
improvements in environmental health
is unaffordable for the majority - staying
would contribute to improved overall health
healthy is unaffordable.
status in the community.
Increased incomes would improve nutrition
The private clinics clearly provide an
and increase access to government health
important service and are close to the
services and treatment at private clinics.
community; training, particularly in repro-
The above recommendations, linked to
ductive health and environmental sanitation,
improvements in sanitation, incomes, and
should be extended to private practitioners as
reproductive health, would improve the
well as traditional practitioners.
quality of life, increase access to better
A lack of training and support for traditional nutrition, and reduce the incidence of
practitioners, particularly TBAs and tradi- disease.
tional physiotherapists, who used to play an
Low incomes and labour-intensive work for
important role as community health workers.
small returns mean that there is barely
Until three years ago people used to go to drug
enough money to feed the family, still less to
stores for diagnosis and medication; now drug
contemplate paying for health services and
stores are not allowed to diagnose under new
education for four to eight children.
regulations. A procedure is needed for selec-
Labour-intensive domestic and income-
tion of pharmacies, and quality control, to
generation activities reduce the time available
enable drug stores to provide diagnostic and
to go to health facilities. Women in particular
curative services for the most common diseases.
wait until their condition is serious.
Controls on the origins, expiry dates, and
Unemployment, low incomes, and lack of
quantity of drugs to be taken should be in place.
opportunities for the young in particular
Drug stores are in the community and may be
have resulted in a deterioration in the social
the only source of medical advice close to hand.
fabric, an increase in juvenile delinquency,
Funding: The community is not in a position to and insecurity in the streets with street
contribute cash to the World Bank Social violence and abuse, rape, early pregnancies,
Rehabilitation and Development Fund. At least and girls taking up street trade ('streetism').
70% of the community are classified as 'worst- All focus groups linked improved health and
off, which means low incomes, 90% of income nutrition to employment, incomes, and/or
spent on food, overcrowded housing, and family food-for-work programmes. Young girls in
sizes of at least 10 people. The Kebele has had a particular wanted employment for male youth,
series of NGO, multilateral, and bilateral donors who were described as being disturbed in their
visiting and discussing programmes, with no minds and disruptive in the community.
outcome. The population is increasing, not Sexual promiscuity, early pregnancy, and
through inward migration but through growing large family sizes are a burden on low-income
families. There is no investment in the area, and households, put pressure on the housing
the situation is appalling. The Kebele is very situation, and increase the spread of STDs and
disillusioned by development organisations HIV/AIDS. Reproductive-health education in
which come and go, take their time discussing the community must be a priority.
'and taking photos', and then do nothing.
There must be alternatives to cash- Gendered division of labour and
contribution deals, which could include labour responsibilities
and food for work for different age and gender
Women in the worst-off households suffer a
groups in the community.
particularly heavy burden of responsibility to
Demand-side problems: The difference between find the cash to feed the family each day. They
city life and the rural sites is that in Addis all the have a long working day, including carrying
basic needs have to be paid for every month: rent, heavy loads in domestic and income-earning

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

activities. Their reproductive-health status is involve the youth (both male and female),
poor and characterised by early pregnancy, together with training in masonry, building,
high fertility rates, and deliveries at home, a plumbing, etc., for future employment.
high incidence of anaemia, indicative of a poor
diet, and postnatal heavy bleeding, with little or Education
no medical assistance, all in the context of the
The recommendations made by women and
abysmal sanitary conditions. men to improve the accessibility and quality of
Men suffer unemployment, are reduced to education are summarised in Table 21.
occasional daily labour jobs at low incomes, Access to education: In the household survey
and are said to turn to alcohol. A man's the broad recommendations to improve access
contribution to household income, according to education included adequate food; adequate
to focus-group participants, makes a signif- clothing; availability of sufficient income; well-
icant difference to the welfare of the family. equipped schools, sufficient learning materials
Men need to be re-engaged with family life. and good teachers; free education; and conve-
Investment in employment creation for both nient location. These conditions for improve-
women and men would be invaluable. ment are almost identical to those mentioned by
Investment in water points and sanitation the girls' youth group, and many are included in
would reduce women's and girls' workloads. the recommendations from the PRA.
Programmes to address alcoholism, drug It is absolutely clear that the cost of education
addiction, and tobacco consumption would does not consist solely of registration fees. The
release some cash for food in the household, cost of education is the cost of keeping a child
and reduce multiple, high-risk sexual fed and healthy and providing him/her with a
relations and improve men's health status. uniform and exercise books and pens. It is also
Food-for-work programmes are needed in the cost of replacing the money normally earned
water, sanitation, road building, etc., to by the child in school. It is the opportunity-cost

Table 21: Focus-group recommendations for improvements to education services

Improve the security situation in the area as a whole (crime).

Improve security for both boys and girls.
Take action to reduce harassment of girls.
Clean up the school environment, inc. toilets and water supply.
Need properly constructed classrooms.
Establish sufficient good schools (quantity and quality);
and make them free.
Have capable teachers;
more and better trained teachers.
Follow up families, monitor children's performance.
Create good contact with the teachers.
Government should discuss with us to improve schooling.
Government should provide enough books & teaching materials;
should sell exercise books, pens and pencils at production price on
school premises.
Community has to cooperate with PTA, school, and government to improve
schools and control children.
'About school uniform, it's a good idea, but we can't afford to pay for it.'
Need sports fields/facilities.

Appendix 3

of women's lost income if they have to stay at Adequate instructional materials, facilities,
home and do the domestic tasks normally done and equipment must be made available.
by their daughters while they are trading or In the case of Felege Yordanos: either change
employed in daily labour. These costs in the the market-place or demolish the existing
poorest households have to be multiplied by school and have it rebuilt elsewhere.
four to eight children. Additional classrooms should be constructed,
Education is not affordable. Nor is it available, particularly at Edget Behbret School.
since there are not enough school places and not Reasonably wide playgrounds and sports
enough books and desks and chairs. equipment should be provided.
All of the above cannot be realised by
Quality of education: service providers made
individual efforts nor by the communities
the following recommendations to improve the
themselves. The view of the educational
quality of education.
establishment is diat the government has to
Children should not be hungry. be involved by way of providing land, trained
Teachers' salaries should be improved. teachers, and ample instructional materials
Well-trained teachers must be assigned to and facilities.
schools. Political appointees who have no
interest in teaching and who are academically
and pedagogically incompetent should not be
posted as teachers.

Appendix 4
Case study 2: Yegurassa and Andaje, Delanta Dawunt,
North Wollo

The research site in Peasant Association (PA) 05 buy food. The 'most vulnerable' are mostly
was selected by the Oxfam Regional Office in households where there are no animals at all,
Delanta. It was chosen because Oxfam does not one or more income-earners (men or women)
have a regular commitment to the PA, and no are seriously ill, or where the man has died or
participatory research had been conducted with left to the lowlands, reducing the household's
this community. Although only 15km from potential daily income.
Wogel Tena, the capital of Delanta Dawunt
woreda, the site was a one hour's drive away over Nutrition
rough terrain. The team decided to select two
neighbouring villages, Yegurassa and Andaja, Without harvests there is no food. Over 90% of
within 30 minutes' walk of each other. This income in the most vulnerable and very poor
households is used to buy food. Average income
facilitated logistics during the household inter-
in 70% of these households is less than 50.00
views and service-providers' phase. There were
Birr per month ($US6.40); in another 26%,
about 70-80 households in each village. The
average income is below 100.00 birr per month.
school and church were located in a third village,
As a last resort, animals are sold. The population
Wokote, about 30 minutes' walk from Yegurassa.
of PA 05 has no choice but to fall back on very
basic means of survival, using dung, straw, trees,
and their own physical strength to survive.
Poverty, nutrition, and A crucial feature is that among an estimated
livelihoods 93% of the population in the two villages
researched, more or less 60% eat only twice a
Poverty day. At least one meal, if not both, is likely to be
very insubstantial. Almost one-third eat only
During the mapping, the women and men once a day, and some say that is just a cup of
involved ranked 60 households from die two coffee to keep them going. Almost 50% of
villages (about 40% of the population) according women in the most vulnerable group eat only
to their own poverty criteria. They dismissed the once a day. We know that some do not eat at all.
notion of 'poor', 'medium', and 'better-off There is minimal outside support or
categories. Instead, they ranked the households: intervention. The community remembers the
most vulnerable (13% of households), very poor 1980s, when die Derg's government provided
(80%), and better-off (7%). Well-being is ranked food and clodies when diey had nothing. The
according to livestock ownership, including Ministry of Agriculture's woreda office is
horses and donkeys. Women-headed households involved in development activities, some of
are also ranked in this way. Although livestock are which are co-ordinated and funded through the
viewed as a household asset, it is the men who sell Integrated Food Security Project, a project
the livestock and control the income from the funded by the European Union and overseen by
sale. Livestock ownership is also used by officials Oxfam. Its activities include soil and water
to means-test the population. A household with conservation; pond construction (food for work
sufficient livestock can gain access to agricultural in Yegurassa Gote); capacity-building for
credit, will not be issued with an exemption paper farmers; horticulture; private nurseries; pro-
for health care, and will not receive food aid. vision of tools and pesticides and sprays to the
However, due to persistent harvest failures woreda agricultural office; and, via the woreda
over the past seven years, most households 'have administrative office, roads construction (also a
nodiing'. Gradually, people who were better-off food-for-work programme).
have become as poor as those categorised as However, given the gravity of the current
'very poor', with only one cow and horse, or two situation, the lack of tree cover, the lack of water
sheep, because they have sold their animals to for agriculture or home consumption, and die

Appendix 4

lack of feed for livestock, visible externally shortage of water, and a need for clean water.
driven development activity in Yegurassa, One woman said: 'Why do you think thefliesare all
Andaja, and Wokote villages is minimal. The around us, we are dirty.' One girl explained: 7 can't
project is facilitated through MoA development wash because it's too cold and my hands are already sore
agents, who are responsible for up to 800 from the cold.' Her hands were ingrained with
households (about eight Gotes). Under existing dirt, rough and sore. And people have no clothes
conditions, this is like sifting sand in the to change into when they have washed. It is a
wilderness. highland climate, and the wind is cold. Skin
In many families about 90% of income is problems and scabies are common complaints,
spent on food, and on totally inadequate attributed to hunger and sanitation. Again, there
amounts at that. Families cope by living from is very little being done about the water situation
hand to mouth ('ke idge waddey aff). There were in PA 05. A pond is being dug in Yegurassa as
strong indicators that men, women, and part of a food-for-work programme. It was
children are suffering from malnutrition. Men extraordinary to find people (mosdy men and
said that women and children suffer more. We boys) digging at die hard rock, despite not
heard reports of a high incidence of miscarriage having received their monthly food payment for
attributed to malnutrition (men's group and four mondis. This would be an indication of dire
TBAs reporting). Children complain of hunger need, even if diere were no others.
and stomach pains, and eat one or two small There are no latrines or waste-disposal
meals a day (women's group and children's facilities. People use the open countryside. The
groups reporting). Many children go to school country is open and clean, and there are no
without breakfast or with very little. Most people visible signs of human waste or other rubbish.
are eating 'kolo. Some families are eating guaya, However, most people are dirty and unwashed.
which is a plant that can be 'eaten like njera or The high incidence of diarrhoea was attributed
fried. When we eat it hot, it breaks us.' It is a by men and women to dirty water and flies. The
drought-resistant plant, known to cause per- youth focus groups told us that at school they
manent lameness: 'He became lame because he ate are told about the benefits of washing and
guaya, but we eat it all the same because of lack of staying clean. One mother said: 'They teach her
alternatives' (men's group). Some parents that she should wash with soap and water.' She
reported drinking coffee and going the whole thought this was very good; but, asked whether
day with nothing - giving what little grain there she could buy soap, the woman laughed: 'What
was to the children. do you think ? Of course not!'
They said they 'appeal to the Kebele officials for A doctor at the healdi centre attributed the
assistance to get grain every month in exchangefor our high incidence of diseases to 'poverty, a low level of
labour'. Unfortunately the local food-for-work awareness of health, problem of safe water, even the
programme in Yegurassa had not supplied any tap water is contaminated (in the town), poor personal
food 'payment' in the past four months. It was hygiene and poor environmental sanitation'. The
finally distributed during the research week woreda has a sanitation officer, but the depart-
(February 1999), a few days before the major ment is understaffed and under-resourced.
'Kebre Ba'al religious festival. The grain was According to health-centre staff, diere are no
used up to prepare for the visitors coming from funds at all for environmental sanitation work,
surrounding villages to the festival. particularly for work in schools and prisons.
The men said that there was little left to do The staff undertake diis work without a budget.
but pray. While the research was going on, they
were waiting every day for the rain to come, so Livelihoods
they could plant seeds: 'God is almighty, he saves
us. Our coping strategy depends upon God. We go to 'The people have difficulties to find their earning
church and pray.' The rain never came. unless they exchange something: goat, sheep, cow
dung, firewood.'
With the main livelihood base (livestock and
Water and sanitation crop production) eroded, men and women, widi
The women collect water from local springs, of a significant contribution from their children,
which three were highlighted in the mapping: have shifted to daily, labour-intensive activities,
Gurassa Tana, Tiburay spring in Andaja village, widi minimal returns. Even those who still have
and Ambo spring, which is far away. One of the some livestock 'are even worse off, because they have
main problems raised by the focus groups was a to worry about their feed' (women's group). The

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

selling price for cattle has dropped by 65%. The bar work. It is not without risks: 'Last month there
men said, 'We get our food by purchasing, and the were five deaths. All five had gone to the lowlands in
money comes from selling wood, grass, cow dung, search of jobs but came back with yellow malaria and
casual labour working as livestock tending', the latter died. There are another ten or more who have returned
largely by girls and boys, some as young as four from the lowlands sick and are in bed waiting to die,' a
and five years old. TTBA told us. In a society where it is important
Now, according to the household survey, 29% to have a man who can bring in additional
of men and 12% of women are engaged in food- income and represent the family in public
for-work or daily labour activities. Another 57% decisions and claim access to resources, women
of men were involved in collecting, left behind with children can become even
transporting, and selling items such as firewood worse off. When income diminishes and
and grass (large bales of which are used for women's burden increases, the need to increase
thatching roofs). In a third of the households the contribution of children's labour arises and
interviewed, women also collect, transport, and often results in their leaving school. It is an
sell firewood, often as one of several income-
essential survival strategy for the family as a
earning activities. Men, women, and children go
whole. One girl said: 'If our fathers could grow
down the steep slopes of the gorge and cut
crops, we could go to schoolfull-time.'
firewood to carry and sell in the market (one
day's work = 3.00 birr). It is a hazardous
occupation, and there are fatal accidents. Child labour
Collecting and selling cow dung for fuel has Girls' and boys' labour - looking after animals,
become a key source of daily income, with 71% collecting and selling firewood (boys and girls),
of women reporting it (two days' work = 2.00 collecting dung for the market (girls), and
birr ($US 0.26) for a large basketful). This used domestic work (girls) - is central to daily life.
to be one of women's income-earning activities The drought and consequent reduced agri-
to bridge food shortages until a harvest, but now cultural activity has reduced the need for boys'
it appears to have become a more regular main labour in agriculture. Boys instead have to
source of income for many households. Women contribute their labour to daily income-earning
also collect, transport, and weave sheep's wool, activities such as collecting firewood. The
38% of women, all from the most vulnerable or
heaviest burden is, however, still borne by girls,
very poor households, reporting it (10 balls of
although boys' labour time also interferes with
wool: eight days' work = 2.00 - 3.00 birr); and
their school attendance.
they weave baskets for sale, 25% of women from
all poverty categories reporting it.
Some men cut and strip young eucalyptus
saplings to sell in the market and share the Health
returns. They are conscious of the fact that they
The main health problems identified by men were
are in effect destroying the environment to
typhoid fever, diarrhoea, mogne bagegne, and
survive: 'We are all struggling selling wood, dung
pregnancy and associated problems; by women:
and wool. We are now tired and the eucalyptus is also
mogne bagegne, scabies, headache and nausea,
lost', but they have no choice.
rheumatic pains, ear aches (from insect in the ear),
The men's focus group discussed the
and heavy menstrual bleeding. The main heakh
implications of drought and the Global 2000
problems suffered by youth and children, as iden-
credit scheme.' We getfertilisers and improved seeds
on a credit basis. After the crops were destroyed, we
tified by girls, were diarrhoea, scabies, and
were forced to pay the credit. We sell our animals and
accidents (e.g. when collectingfirewood);by boys:
goods, which takes us into more poverty. Those who typhoid fever, mogne bagegne, scabies, and
could not pay are taken to prison, which means more abdominal pains. The traditional healers and the
worse situation than three years ago.' A TBA said, health centre identified more or less the same
'The credit scheme is provided without the appropriate main health problems. The traditional healers
education. We are being imprisoned, as we cannot were concerned by the extent of illness in the
afford to pay on time. Because of the drought people community and attributed it very much to poverty
cannot keep their promises.' and hunger. They said that people come widi
A small but ever-increasing number of men stomach problems when they eat something after
migrate to the lowlands in search of work. Some being hungry for too long. Women said 'Many
young girls are also sent to the lowlands to do people die because they cannot afford health treatment.'

Appendix 4

Reproductive health When in need, women and men sell assets or

Harmful traditional practices such as female and borrow or ask neighbours for help in order to
male circumcision (genital mutilation) are still cover health costs. Men, and women heads of
widely practised. According to all focus groups household, rent out dieir land in exchange for
and education-service providers interviewed, cash or crops in order to cover costs. However,
early marriage was one of the main reasons why for better-off farmers (mostly men), die drought
girls leave school. Early pregnancy is common. has reduced the attractiveness of renting land.
In none of the households interviewed did Some men leave the area in search of work as
women go to the health centre to give birth; 89% casual labourers, with the intention of sending
gave birth at home, 4% at a TBA's, and 7% at a money to pay for health costs.
relative's. The health centre in Wogel Tena is a Families 'cope' widi education costs and
three-hour walk away. Women and girls expe- healdi care during bad times by simply
riencing obstructed birth or other irregularities wididrawing their children from school, and
are likely to die, according to the health-centre staying at home without treatment, respectively.
doctor. The hospital in Dessie is a four-hour They say that many are dying as a result. Some of
drive away from Wogel Tena, and few can afford die traditional healers are providing treatment
the transport. free of charge, because people cannot pay.
All focus groups were aware of HIV/AIDS Finally, die MCH outreach programme
and said that young people were dying from it. stopped eight mondis ago, when UNICEF's
programme came to an end. Children born in
Access to health-service providers die past eight mondis did not even have one dose
There is one health centre in Wogel Tena, a of antigens. There is litde chance diat infants
three-hour walk from the site. The doctor: under one year will complete dieir full doses.
population ratio is 1:161,966. Most households
use traditional healers or go to holy waters at the
church in Wokote. They largely cannot afford Education
the government health services, which are too
far away. Very few have access to an exemption There is one elementary school in Wokote: Tana
paper: 'At present the PA doesn't provide us with a Elementary School, Grades 1-6. To complete
paper, because we are all poor and are all asking for primary education (Grades 7-8), children have
the paper' (women's group). The PA leaders to walk for diree hours to die Wogel Tena
confirmed that 'the woreda office has told the PA Elementary School. Consequendy very few
that anyone with livestock, even one hen, is not eligible children complete school, and most who do are
for an exemption paper, so they [the PA] are unable to boys. The women said diat girls are in danger of
issue exemption papers to most of the people. People becoming pregnant if diey go to the town.
cannot afford the fees at the health centre, so they don't There is hunger and disease, and clodiing is
go.' The PA leaders had gone to the woreda inadequate. An estimated 60% of the children in
health office explaining the situation in January die community do not attend school. In
(Tir). They had had no reply. They know that addition, among diose who attend, absenteeism
the woreda has no budget. was a major problem highlighted by Wokote
The health centre is under-resourced. teachers. Boys miss one day per week on
Seventy-five per cent of its patients are 'free', and average, and girls two days per week, because of
most come from the town of Wogel Tena. The demands on dieir labour. Class sizes vary
doctor at the health centre said: 'Most cannot enormously. In Wokote Grade 1 is a group of
afford, the situation has deteriorated as they have become over 253. The number drops offto 14 in Grade 6.
poorer and poorer.' Ninety-three per cent of house- In the woreda as a whole, attendance numbers
holds interviewed said health services were drop from 4739 students in Grade 1 to 427 in
'unaffordable'. Of the rural population, it is mosdy Grade 8. For die past diree years the woreda
men who come to die health centre. The health education office has been pursuing a policy of
centre said that women and children do not come increasing school enrolment. Parents said they
for treatment until diey are seriously ill; they go were forced' to send dieir children to school. In
to holy waters first, believing diey can find cures, die woreda as a whole, 58% of primary-school
especially for particular diseases like scabies. The children are boys and 42% girls. The boys' group
girls' group also said diat better-off people were said diey thought diat more girls should attend
favoured, so they did not like die healdi centre: school. A major reason for girls' low attendance
'They do not care for weaker people.' was domestic work and early marriage.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

The woreda education office confirmed what girls. They also said that girls were not as
the community told us: 'Large proportions of interested as boys in education, and that parents
children, and about more than half of girls, do not do not encourage them enough. The girls also
attend school. The reasons are poverty and repeated said that they have problems when menstruating.
famine, early marriage, and parents' unwillingness to They miss school and cannot explain the reason
send children to school.' to the male teachers. All told, girls have particular
Although in the focus groups both women and problems which are not managed, and they
men were in favour of educating both boys and themselves feel discriminated against. Boys
girls, 57% of very poor households interviewed attending the Wogel Tena primary school
did not see the value of educating girls, and 14% (Grades 7-8), on the other hand, feel that boys
did not see the value of educating boys. In the from the urban areas are favoured by the
households interviewed, 70% of adults were teachers, and they are discriminated against.
illiterate themselves. The men's group, however, The men's group thought that their school in
said that there had been a change in attitudes: Wokote had more difficulties than the school in
'Before a few years parents wanted their boys to work in
Wogel Tena, because it is physically so far from
agriculture and girls to work at home with their mothers.
the woreda authorities in town. They believed
Now they have understood the value of education for
both boys and girls. But poverty arising from natural
that problems could be dealt with more easily by
calamity since 1991 is now the obstacle.' Despite the schools in town. The research, however, shows
great optimism vested in the value of education, that both rural and urban schools have very
the men's group expressed a very serious doubt: similar problems. They both need maintenance,
There is also dissatisfaction among parents, because have inadequate playing facilities, no water or
those who have completed grade 12from our community toilets, and lack teaching materials, textbooks,
could not get jobs, or continue their education beyond desks, and chairs, and the classrooms are
grade 12.' overcrowded. Yet diere are some rural/urban
More or less 70% of the local population earn differences. The repetition rate in Wogel Tena is
less than 50.00 Birr ($US6.4) per month; 96% lower, and children in rural Wokote are on
earn less than 100.00 Birr ($12.80) per month. average two years behind their peers in the town.
In these families, 75-92% of income is spent on
food. Children are too hungry to go to school
and have inadequate clothing. In theory Conclusions and
schooling is free, but parents included food, recommendations
clothes, and exercise books in the cost of
schooling. They cannot afford these items. The 'If we get clothing, food and adequate medical care, we
Education Office in Wogel Tena is fully aware of would be most comfortable' (women's focus group).
the situation, and said that education was 'too The following section lists aspirations expressed
expensive, especially for poor people'. by the community, disaggregated by gender
The schools lack textbooks (one book to eight and generation.
pupils), chairs, desks, water, toilets, and teaching
materials. The buildings require substantial Women's aspirations and
maintenance work, and there are no sports or recommendations
recreational facilities. There is a budget of
300.00 Birr per year for medicines for the 24 Livelihoods
schools in the woreda. The schools receive
teachers' salaries and very little else. They grow Make better roads for vehicles to pass.
grass and some vegetables to sell towards their Establish a new market.
income. Basically, the schools are under- Build a grinding mill near the school.
resourced, and there is no external funding to Deal with cattle diseases.
improve the situation even marginally. NGOs should give us skills to be productive.
In Wokote there are no women teachers or Establish food-for-work programmes.
staff. Women from the community were clearly Hopes: to harvest barley as they used to
less informed about the school than men are. before.
There were no women in the school committee.
All education-service providers said that boys do
better than girls in school, and put this down to Provision of food rationing until the situation
early marriage and the labour demands made on improves.

Appendix 4

Water and sanitation Provide free exercise books and pens.

Help to meet needs for clothing food and
Install tap water near the primary school.
Health School should farm land with assistance from
local NGOs and provide free lunch to
Have a health station located near the school
in Wokote. children from vulnerable and very poor
Have clothing, food, and adequate medical households.
Free treatment, especially for women and Girls' aspirations and recommendations
Medicines: 'The government is what we have next Livelihoods
to God'.
Food-for-work programmes.
'We want the government to realise that even if we
have a health centre with equipment, we are dyingHealth and sanitation
of illness.'
Stop medicines being sold off by the health
Education centre (to private pharmacies).
Establish a school for Grades 7-8 near the Need medication to cure scabies.
existing primary school. The government should stop favouring the
Provide free exercise books and pens.. people who can pay.
'We don't need a new health centre, we want the
Men's aspirations and recommendations services at the existing one improved.'
Need adult education at the Kebele for our
Livelihoods parents in birth spacing, preparing nutritious
food, and clean preparation of food, personal
Construct a road to Wogel Tena ('We have
and house hygiene.
already contributed 5.00 Birr').
Establish a system of irrigation to make farm- Education
ing possible.
Establish provision of free seeds and fertiliser. Enough clothes.
Establish food for work programmes. Enough grain.
Rain and harvests, 'so we would go to school
Nutrition instead of collecting dung andfirewoodto sell'.
Establish provision of food rationing until the Grinding mills 'so that children don't have to
situation improves. grind'.
Domestic servants so we would not have to do
Water and sanitation domestic work and we could go to school'.
Solve the shortage of water problem ('Oxfam
already been helping with water'). Boys' aspirations and recommendations
Install tap water near the primary school.
'We need clothes and soap.' Health
Health Have a health station located nearby, prefer-
ably well equipped.
NGOs to open clinics in nearby villages.
Construct a clinic in the area with help from Have a health centre with qualified staff.
the community. Medicines
Have a health station located near the school To have research conducted into existing
in Wokote. traditional medicines, their application and
Establish provision of free treatment. effectiveness, and to make them available to
the public.
Education Need adult education on circumcision and
Establish a school for Grades 7-8 near the family planning for parents.
existing primary school. Need lessons in literacy centres and to
Need a government policy to assist and strengthen the health-education service at
support children from very poor households. the health centre.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Education Tackling contributors to poverty

Increase the number of girls attending and gender inequities
Teachers should care about all students. In theory, if the contributors to poverty and lack
Provide water and sanitation in school. of purchasing power (in an economy which
Improved quality of teaching. requires cash to pay for basic needs and services)
are tackled, then women and men could better
Provision of schools nearby.
access health services for themselves and their
Remove poverty, to increase attendance.
children. They could also cover die basic
Provide food and health care to increase
requirements necessary to enable their children
attendance. to attend school. The contributors to poverty
Clergymen ('debtera') should be trained to include three broad domains: natural; external:
stop their evil practices on some students. international, government, and NGO policy
and planning; and internal: cultural factors.
What could the community do?
People are painfully conscious of their poverty The 'natural' domain
and suffering. Women talked about men who The hostile weather conditions over the past
have no clothing in which to go out and do daily seven years have contributed to repeated lost
work, and who have no energy: 'Due to frost their harvests. As a result, traditional share-cropping
feet are not able to move, some ofthem sit and die.' Men relations have broken down, and there is no food
talked about women's problems: 'Due to drought and no income from the sale of crops. In
effect, our women are malnourished and give birth to addition, livestock ownership has been depleted,
unhealthy children.' The only thing the commu- and traditional shareholding arrangements
nity can do is to continue die struggle to survive. have broken down. Because of die complete
The men say that die community can do nothing dependency of diese highland communities on
more than diat. The woreda education office crop production and livestock, women and men
confirmed that die community could not, for have few resources to fall back on.
example, contribute to the costs of improving It is not possible to influence nature, but it is
education, 'because the community is very poor'. possible to develop support strategies, combined
widi a strengdiening of women's and men's
capacity to cope under tiiese circumstances. This
Recommendations: potential for requires a substantial increase in financial and
action human resources. At die moment, however,
certain government initiatives, such as the
Despite the very negative findings of the survey, agricultural credit programme, exacerbate die
die meeting with the PA administration situation, and tiireaten individual households'
demonstrated that there are key social very survival. Equally, diere is a general lack of
institutions (run by men) which manage some external intervention to strengtiien women's
parts of community life, and provide channels of and men's resolve and ability to manage under
such adverse conditions.
communication to institutions outside the
community. These include die church, die
Kerray, and the PA (in which two out of 69 External: international, government, and
officials are women). In die Kerray and PA, NGO policy and planning
household heads are members representing Loss of crops and catde, together widi lack of
their families. Women are dierefore members government intervention or NGO back-up,
only if diey are widows or divorced. The fact diat leaves people destitute, widi no means to eat,
men dominate all institutions is traditional, send dieir children to school, or treat increasing
rather dian rational, given the degree to which incidences of illness.
men in the focus group openly recognised
women's contribution and problems. Livelihoods and food security
Future initiatives should be taken with Agricultural credit: 'Even if the government gave
existing social institutions, increasing the seed to help us, the land could not give grain'
representation of all gender and age interests (women's focus group). The government has
and needs. provided grain seed on credit, die repayment of

Appendix 4

Table 22: Institutions in the community with potential for action

Institution Function Management Membership

Church Centre of life. Church committee of Men and women in

Teaches religious instruction. priests: all men the community; men
Blesses the fields. play a more decisive
Cures illnesses. role.
Settles disputes.

'Kerray Informal savings association for weddings, Heads of households Men and women
funerals, and religious festivals. (men or women)
One or two 'Kerray in each Gote. represent the families

'Kerray Meets to plan very large festivals. Each 'kerray has elected Only men, no women
Abatoch Solves serious crime - theft or murder. Elders; five of these Elders.
Holds court and punishes culprit. Elders form the 'Kerray
Most severe punishment is banishment Abatoch of PA 05.
from Kerray = banishment from church.
No links to woreda admin or courts and
system of justice.

Peasant Link between community and Has its own 69 members, 2 of

Association development or local government. management structure. whom are women.
NGOs & government work with
community through PA.
Has organisational structure down to each
PA is an animator and disseminator of

Service co- Is dysfunctional. For the time being Probably heads of

operative Was set up to sell essentials to the none, but would be household men or
community. elected by the women.
Obviously important to the community. community.

Elementary Deals with problems in the school; School staff; Men;

school Animates community to improve school PA representatives; Men;
committee (fencing etc). Community. Men.
Organises farming of school land to
contribute to school funds.

(Source: Meeting with PA 05 Administration)

which has created more problems. The PA has credit defaults, which are inevitable in drought-
sought to resolve this at the woreda agricultural prone regions like north Wollo.
office, without much success. The exertion to
Food aid: 'Because of the drought the government
repay agricultural credit further exacerbates a should provide us with grain. The previous government
very precarious existence for many households. provided clothing, blankets and since the land was not
Livestock, which were used as collateral, have producing they settled us somewhere else.' B o t h t h e
been sold to buy food. Some men have left for the men's and women's groups referred to the fact
lowlands to work to repay the credit, while diat the previous government had provided
women and children survive on even less daily food aid and clothing. The methodology used in
income. Through advocacy at national level with the early warning system, inter-related as it is
the Ministry of Agriculture, and capacity- with pre-harvest crop assessments and the
building at woreda and PA levels, action should Global 2000 agricultural credit initiative,
be taken to resolve the immediate dilemma and potentially creates a conflict of interests for
to develop strategies for future agricultural- Ministry of Agriculture personnel. As a result it

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

appears that the woreda and zone agricultural diat women and girls have to spend on domestic
and DPPC offices cannot agree on food-aid work. This would increase the time available for
requirement figures. The woreda office is afraid schooling, and potentially increase time
that the figures are greatly underestimated: 'In available for involvement in other activities -
the past three to four years the people have tried to exist both income-earning initiatives, and, for
in different ways and now have no alternatives to assist example, work widi die PA or school committee.
themselves - the only alternative is to migrate south,' Women's workloads impede them from going
said one very worried official. They estimated to the healdi centre before an illness becomes
that 60% of PA 05 was in need of food aid too serious.
(February 1999). They say that even die food-
for-work and employment-generating activities Health services
cannot help die people, as the problem has been The staff at the woreda department of healdi
going on for too long. Any food-for-work and personnel at the health centre are aware of
programme should be sure to make food die enormous health problems diat die people
'payments' each month. Men working at the of Delanta have to face. They state that die poor
pond-construction project in Yegurassa have no access to healdi services, that die budget
complained diey had not received their food in for treatment is low, and that outreach services
payment for their labour for the past four are not sustained.
months. More food-for-work initiatives should Infrastructure and transport: The Woreda
be taken to respond to needs expressed by Healdi Department said diat two clinics and five
women and men in the community. These could healdi posts have been constructed in die past
include water provision and road construction. five years. The main problem is a shortage of staff
In addition, men are aware of the fact that they and resources. Only two of die new health posts
are depleting environmental resources in order are actually functioning. The staff would like to
to survive. Research into appropriate tree provide free basic healdi services dirough an
species and tree planting should be taking place increased number of healdi institutions 'at the door
on a large scale. (For example, it is known in the step of the poor'. They also wish for government
community that eucalyptus drains die soil of provision of additional relief drugs, supplied
nutrients, which is why they do not plant it along free, to improve curative services to die poor. The
the fields.) EU funding and the Oxfam healdi centre desperately needs transport, in
programme include these activities. However, particular an ambulance, and a generator to
dieir contributions are simply not enough. maintain a permanent source of electricity.
Veterinary services: The PA representatives said Curative and outreach services: It is clear diat
diat the MoA provides veterinary services. The the rural population does not have access to
women's group said diat they need help to cure curative services. Since die UNICEF funds for
catde diseases. During die cold season, and vaccine and antenatal outreach services
during die extreme heavy rains, they need help stopped, people have had no access to basic
to resolve problems widi livestock. On die basis of MCH services either. The reproductive-healdi
experience of previous re-stocking programmes, status of women and girls is life-threateningly
it is recommended diat action should be taken to serious. MCH outreach services are required, as
assist households to increase dieir livestock are antenatal outreach services, in conjunction
resources again, once appropriate conditions widi TBA training and support. The
prevail. Gender implications of livestock schoolteachers are potential allies in community
ownership, and also die food-security impli- awareness-raising on the subjects of early
cations, should be taken into account so diat marriage, early pregnancy, and general sexual-
women can also benefit from any such initiative. healdi matters for boys and girls. There is a need
for at least one woman teacher who can act as an
Other livelihood sources: At least 70% of die advocate for girls and provide diem with sexual-
adult population in die villages interviewed were healdi education. To diis end also die school
illiterate. Women in particular were looking to and PA should be encouraged to create a gender
the NGO community to provide training balance on die school committee. Women are
opportunities to broaden livelihood options. too overworked to take active community roles;
Reducing domestic workloads: Provision of this should be discussed and solutions found. If
accessible clean water and establishment of die PA administration is to be a partner in
grinding mills would reduce die amount of time improving outreach services, increasing

Appendix 4

women's representation and action is essential. be found, working together with women and
The health centre also needs an increase in men in the community, the school, the woreda
supplies of the most frequently required basic office, and the NGO community. If the reason
medications. for non-attendance is lack of food, clothing, and
exercise books, a source of subvention in the
Support and training for health staff: The
interim must be identified. If the reason is early
existing health infrastructure in the woreda is
marriage or child labour, then more complex
not adequately staffed or resourced. There is no
adequate budget for supervision and training, solutions need to be discussed.
which would enable motivated health workers Repairing and equipping the existing school:
in the remote rural areas to perform their duties The Tana Elementary School, Wokote, is the
more efficiently. Both the woreda and the only school available for Andaja, Yegorasa, and
health-centre staff said that they had asked several other neighbouring villages. It was
Oxfam GB to supply an ambulance. They established during the Derg period, and now
wished Oxfam would have some input on the the building has grown so old that it is about to
woreda health sector, as it has on the agriculture fall down. The following measures are
sector of the woreda. Staff at both the woreda necessary: repairs to the existing school; the
department of health and the health centre provision of adequate furniture - benches,
strongly feel that the woreda health department chairs, and tables - for teachers and students,
should be able to utilise part of the income and sufficient textbooks for all subjects and
generated from service fees to fill the gaps that teachers' guides; improvements to the quality of
are not covered by the budget or by other teachers, by providing in-service teacher
sources such as UNICEF and IDA funds. education programme to all teachers and not to
the political cadres only; the provision of clean
Education and safe water and toilets.
Child labour: One of the main reasons why
children do not attend school is that their labour Upgrading the existing school: The Tana
is essential to their family's income. Girls do Elementary School provides primary education
domestic work to enable their mothers to collect up to Grade 6 only, two grades short of a
and sell cow dung and firewood. Boys who complete primary education. It is necessary to
collect firewood and grasses, and girls who upgrade the school to Grade 8, so that as many
collect cow dung and firewood, contribute to the children as possible can finish elementary
family income. When most incomes are as low as schooling.
50-100 Birr per month, the need is indisputable. Constructing a new school: The Tana
Children will be released for school from these Elementary School is too far away for many
responsibilities when women's and men's children, who have to walk for one and a half or
productivity and income increase sufficiently to nearly two hours to school. Participants in the
cover the basic costs of living. The demand on mapping session (both women and men)
girls' labour time is greater than on boys', recommended that a new school should be built
because of time-consuming domestic work and in another Got (village), providing for Grades
the burden of labour on women, which girls are 1-10, and ultimately Grades 11-12.
expected to relieve. When domestic work is
lightened, or shared beyond the female
members of the household, girls will have more Internal: cultural factors
time to go to school and do homework.
Early marriage, early pregnancy: Both girls and
Cost of schooling: Although primary education boys said that they have sex education in school.
is free, parents still face unaffordable costs of However, 90% of respondents to the household
items such as food, clothing, exercise books, and questionnaire did not use family-planning
pens. Some children leave school because their methods. Protected sex is not widespread among
family cannot afford to buy exercise books. adults, and is therefore unlikely to be practised
Some families send only one or two children, by teenagers. Girls risk becoming pregnant from
because they cannot afford the books for all the as early as 12 or 13, either through relationships
children. Most households have a problem entered voluntarily or through forced relations
feeding their children, and most start the day in early marriage arrangements. Girls are
without breakfast or with just a handful of married as early as 10 years. The practice
roasted barley grains ('kolo). A solution needs to appears to be quite common and was mentioned

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

by most focus groups, and by traditional and the government health workers who were
government providers of health and education interviewed. The National Policy on Women in
services. Not only do early marriage and early Ethiopia discourages both early marriage and
pregnancy put an end to girls' schooling, but female genital mutilation. A more intensive
early pregnancy also poses a life-threatening education and awareness-raising programme
health risk to young girls. The woreda and local needs to be initiated with women and men, and
elementary-school staff believe that more should girls and boys, and with traditional circumcisers
be done to reverse such harmful traditional and birth attendants in the community. The local
practices. According to the men's group, the schools and the health posts and health centre
school already tries to educate the community. could be actively engaged in such a programme.
However, the practice continues to be Young girls and women risk death in childbirth
widespread. More needs to be done to protect as a result of both practices.
young girls from early marriage and to give them
The issue of male circumcision was not
choices in education and future partners.
specifically addressed. It appears to be an
Female and male circumcision (genital accepted practice. However, there may be
mutilation): All children are circumcised at a physical and social consequences. Certainly the
young age. Although women and girls generally intervention is not practised in the most hygienic
did not believe that female genital mutilation was environment. In some countries, such as Egypt,
harmful, some girls knew that it could cause the implications of the practice for men's sexual
problems in childbirth. This was confirmed by health is being explored and challenged.

Appendix 5
Case study 3: Ali Roba, Metta, Eastern Hararge

Background had been killed on die road two weeks before die
research team passed dirough.
Ali Roba, the research site, is located in Metta
woreda, Eastern Hararge. The majority of the The site selected for research
population are Oromo. Metta borders Deder,
Ali Roba, a village some 40km from Deder and
where the Oxfam regional office is located, and
12km from Chelenko, was selected by die Oxfam
has recently been created a woreda in its own
regional office. It is part of an active PA, whose
right. The vast majority of people are Muslims.
Chairman assisted die team diroughout die ten-
There is a minority Christian population. It is a
day stay. Some households in die village had
fertile highland region, which has been of late benefited from Oxfam's Integrated
increasingly given over to growing 'chat, an Development Programme (1993-1996), which
addictive stimulant used by a majority of the male was now in a consolidation phase in partnership
population, and a smaller number of women. witii die Ministry of Agriculture (MoA). The
This mass addiction has serious implications for MoA's development agent also assisted die team.
the socio-economic potential in the region and Oxfam interventions included water supply, soil
the health status of men in particular. Apart from and water conservation and re-afforestation, and
sales on die local market, 'chat is supplied across credit groups for petty trade (mosdy women)
die border into Djibouti and Somalia, and farther and livestock ownership, in particular oxen
to Yemen. Fluctuations in die market price for (mostly men). There was also a modern bee-
'chat affect household food security. keeping project. The credit programme for
Chelenko town, 12km from die site, is die women traders was very popular, as was die oxen
capital of Metta woreda. There is a bustling local credit scheme.
market selling livestock, grains, vegetables, fruits,
Oxfam's involvement in die village gave the
household goods, clodi, and 'chat. The vast
team a very positive opening. The women were
majority of traders are women, many trading in
reluctant to begin with, particularly as diey were
'chat. The population of Metta woreda is 172,803, responsible for feeding dieir families from dieir
96% of diem living in rural areas. There are daily income from trade. However, by die end of
roughly equal numbers of males and females in the PRA, the women were singing and dancing
the woreda, and out-migration did not appear to and dianking die team for coming. They had
be a major feature, although some men migrate to learned a lot about themselves by going dirough
Dire Dawa and Harar in search of work. this process.
The region was subjected to the Derg regime's
programme of villagisation. Ownership of pro-
ductive assets such as land and livestock was Number of people involved in the research
affected. Households were organised into Peasant There was a total of 82 participants in die focus
Associations (PAs) for die purpose of die co- groups: two groups of 12 men; two groups of 12
operative organisation ofagricultural production. women; two single-sex youdi groups of 12, aged
Men and boys were conscripted into die army, 10-18 years; and one group of 10 PA leaders,
and some women lost dieir husbands in the civil including one woman, die Chairwoman of die
war diat was waged during Mengistu's time. It is women's wing. In addition, 35 households par-
in die front line, bordering widi Somalia in die ticipated in one-to-one interviews, and 30 were
east. While die community in die research site was selected for analysis, including eight men and 22
hoping for a quiet life, diere was an awareness of women. More women dian men were inter-
die potential for instability due to extremist viewed, since die process included an in-deptii
Oromo Liberation Movements operating in die section on women's reproductive-healdi issues as
region. The road leadingfromAddis to Deder was well as livelihoods, incomes and expenditure,
not safe to travel after 4.00 p.m., and two travellers general healdi problems, and education.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

A total of 13 professionals in the education shortage of teachers. It could be expanded to teach

service were interviewed, all men except one students up to Grade 8.' (Women)
woman teacher. These included the Acting Head Security: Worried about 'peace and the safety of
of the Woreda Education Office; the Director our children'. (Men)
and two teachers, and six members of the PTA at 111 health: 'If you are healthy you can even work as
Dudela 3 Elementary School in Ali Roba; and the a daily labourer and earn some money.' (Women)
Director of Chelenko Elementary school. Death of spouse: 'Loss of partner is a problem for
A total of eight health professionals (all men) work on the farm.' (Women)
were interviewed. These included the Health Grinding mill: 'We travel a long distance to get
Service Director of Chelenko Clinic (a health our grain milled. It takes around two hours' round
assistant); the Sanitarian for Metta Woreda; the trip.' (Women)
Head of the Woreda Health Bureau; the
The men's group explained that for the
Manager of the Woreda Environmental Healdi
majority of households, i.e. the worst-off, the
Department; the General Surgeon and the head
main problem was 'to secure their daily bread'.
nurse at Deder hospital; and two nurses at
They said that poorer women, often widows,
Chelenko health centre. A total of six traditional
were 'worried tofindfood for theirfamily and always
practitioners were interviewed, including a
toil, they search for firewood because they only have
(male) Sheik herbalist; two (female) TBAs; one
very small plots of land.' Women said that 'the
(female) TBA who had been trained 15 years
problems affect women more. Health problems as well
previously; a male Herbalist; and a drug-store
as other problems affect mostly women.'
owner and traditional health practitioner in
Chelenko (male).
Difficult months
At the time of the research, March 1999, the
Poverty, nutrition, and livelihoods women and men in Ali Roba reported that the
region had been suffering from drought, so there
Women and men identified the following were low incomes and no food. The price for 'chat
problems. had dropped significandy, further diminishing
the ability to buy food. May to August (Ginbot to
Agriculture: 'Our crop was damaged byflood.We Nehasse) were reported as the most difficult
lost its harvest and have nothing during this year.' months in the year. While men reported high
(Men) incomes from harvests in July, the women's
Land: 'Shortage of land for cultivation.' (Men) group and 35% of the worst-off household-heads
'Land deterioration and lack of money to buy interviewed (75% of whom were female) reported
inputs.' (Men) diat July was die worst mondi for income. This
Water: Shortage of potable water. (Men and substantiates men's argument that they are in
women) control of the main family income.
Irrigation: 'We were digging this spring to get
some water for irrigation. We need help to dig the
stones out.' (Men) Poverty ranking
Food: 'Due to hunger we could not send our The adult focus groups were asked to identify
children to school.' (Men). Can't afford to follow criteria for distinguishing the well-being and
nutrition advice for their children. (Women) poverty of different households. They classified
'Chat: Depression in the market, and worst-off households as those with large
increasing taxes on 'chat, seriously affecting families (seven children); or where the spouse,
incomes and ability to purchase food. (Men) especially the husband, is dead; where women
Health centre: 'We do not have health centre to have to bring up children alone; where the
take our children for treatment, or to go to when we mother might have land, but no male help to
get sick, even if we have the money.' (Men) 'We can't produce; or she has no livestock; or she is old,
get money immediately to take our children to the sick, or disabled. Men in 'worst-off households
health centre. By the time we bring the money, the were described as 'chat traders or sellers of
children have died, or become worthless.' (Women) firewood; or they did daily labour on other's
Medication: The high cost of medication. land. Their land may be too small; they may not
(Men) produce 'chat; or they may have to share a small
School: School in the village has Grades 1-4 area of land with a father or son. They may have
only. (Men) 'It has enough rooms but has a to resort to share-cropping.

Appendix 5

Medium-poor households were defined as Access to resources and communications

those able to send children to school. The head The nearest healdi centre is in Chelenko: 'one
works as a daily labourer, or has land and sells hour's walk for a healthy person, four hours'walk for
'chat or firewood; might be a salaried a sick one'. The nearest hospital is 40km away in
businessman; or might have a small amount of Deder.
land, and 'he and his wife are strong enough to work'. There is one elementary school in the village,
Better-off households were defined as those which caters for Grades 1-4. None of the
that owned enough land and could grow 'chat focus-group participants had a child in the
and/or have sufficient livestock. elementary school in Chelenko, which covers
Grades 5-8.
Factors contributing to increasing poverty There is no market in the village; the nearest
The drought: it has affected the production is in Chelenko.
of 'chat, grains, and vegetables, and food There is a small 'suk' with basic provisions,
security. including some basic medicines.
There is piped water, installed by the
Losing access to land, especially 'chat land.
community with Oxfam assistance.
Becoming a widow, losing a husband's labour
There are no phones or easy access to
(especially ploughing).
transport. Most people walk.
Becoming a widower, losing women's labour,
There are mosques in and around the village
losing trading income, and losing a carer for
for the majority Muslim population, but no
the household and children.
church for Christians.
Serious health problems which require
Women, especially widows, had less access
selling assets or borrowing money to seek
within the village to credit for healdi costs and
education dian men did. Men widi 'chat fields
Being hungry and physically weak, not
had die greatest chance of borrowing, but now
having the strength to work.
die 'chat market has dropped in value, even
Changes in market prices, e.g. the price of 'chat farmers said it was difficult to borrow.
'chat had decreased. 'Now this hope we lost, nobody lends to the poor.'

Signs of increasing poverty Social relations

Breakdown in social customs: sharing food and
inviting neighbours does not happen any more The team gained a strong impression diat women
(women reporting). and girls in Oromo society were seriously
Land distribution: high incidence of'accidents' oppressed. Men control the main source of
arising from violent disputes widiin families household income and land. They are repre-
over land (men and health-service providers sented in key organisations which potentially
reporting). influence die socio-economic and religious lives of
Impact of 'chat: few used to chew it in Haile die whole community. These include die school
Selassie's time. Addiction has gradually committee, die mosque, die Koran school, and die
increased until virtually all males over 15 are Peasant Association. There was no doubt, how-
ever, diat for die household economy to function,
chewing 'chat (old man reporting, heakh-
men need women and dieir skills and con-
service providers' comments, and team
tribution, and women need men's. Women's well-
being drops more dramatically dian men's on die
Women increasing dieir petty trading in
deadi or serious illness of dieir spouses, since it is
addition to their over-stretched burden in only men who can plough die land, and it is men
domestic labour and agriculture. Dependency who inherit and defend land. There is a serious
of families on incomes of 3.00 - 5.00 Birr from shortage of land, because of population growdi,
women's 'chat trade. die inheritance system, and die land-distribution
Low incomes and increasing market prices for policies diat have been implemented in die region.
food commodities. Land is of such crucial importance to survival in
The healdi and education service providers die absence of odier important sources of liveli-
were unanimously agreed that the cost of hood diat one of die main health problems
education and health care was too high for the reported was accidental injury as a result of feuds
majority, who were in die worst-off households. between male family members over land.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

This was the only site where there were several Livestock: Women said that in medium-poor
corroborated reports of physical violence - by households they fatten oxen to sellfor a better price'.
men against brothers and fathers over land, by They also 'rear sheep for sale in difficult times'.
men against wives, and by women and men Money from the sale of livestock 'we use for
against children. There were reports of children schooling, health, etc'. Although women may also
being regularly whipped and beaten in order to be feeding die animals, men generally decide on
ensure that they grow up properly. Violence was and control the sale of livestock.
attributed to the effects of'chat addiction: when
Men's trading: Aldiough some men are petty
du immediate effect wears off, addicts become
traders like the women, men are more likely to
increasingly unpredictable and aggressive. be trading the higher-value items, and in larger
quantities. They oversee the sale of livestock and
Livelihoods crops. In the market in Chelenko, men were
This is a subsistence-agriculture economy, involved in wholesale trading of charcoal and
dependent on the productivity and contribution grains.
of all household members of all ages. Men's Bee-keeping: 'Ato Selama Husen, one of the very
productivity is influenced by dieir addiction to worst-off earns about 30.00 birr a month from his
'chat. It appears that there is a significant onus beehives.' Improved bee-keeping and training is
on women to provide, particularly in the most one of Oxfam's projects in die area.
difficult months.
It is important to understand the gender/age Daily labour: 'Poor men go to far places and do daily
division of labour and its connection with the labour to generate income for the family.'
physical and mental burdens which women and Women's work
girls in particular bear, especially in the context
of their reproductive-health status. Their Agriculture: 'We help our husbands on their farmland,
workload, their physical healdi, and their weeding and other farm activities.' They are also
gender-based reduced access to resources involved in hoeing, watering, weeding, husking,
relative to men's seriously undermine their and collecting and piling straw for animal feed.
ability to maintain the health and welfare of They said diat diey also bring hodja (local tea
their children, who are visibly undernourished, made widi milk) and food, and sing and dance in
dirty, and poorly. Boys' and girls' significant the fields to encourage the men in their work.
contribution to the household economy reduces
Horticulture: 'We grow vegetables and fruit which
time available for school and potentially affects
we sell in the market to earn money and supplement our
their health status. family diet (especially with sweet potato).'
There were many products being sold in the
market in Chelenko. These included shoes, Porterage: A large part of women's work
clothes and traditional shemma (second-hand involved carrying. TBAs linked women's heavy
and new), grains, spices, yam, potato, mango, porterage to complaints of pain in the uterus
banana, lemon, onion, garlic, vegetables, (umbilical hernia). At harvest time, 'Women carry
handicrafts including pottery and baskets, the harvest in a 'debo' [a work group]'. 'Women carry
firewood and charcoal, seeds, tobacco and the soil from the fertile land to the crop land to make
coffee leaves for hodja tea, and coffee. Many the soil more fertile.' 'Women irrigate the crops and
items are produced by the rural population and carry them to market.' During ploughing time,
sold by a large proportion of women and girls, 'The woman prepares hodja andfood before she leaves
and by some men and boys. to trade in the market. Shefeeds the animals, and ifthe
husband needs help, she carries the plough to the field
Men's work for him.'
Agriculture: 'Maize, sorghum, barley, potato, yam, Petty trade: About 10-20 women have formed
sweet potato and 'chat are grown by men. Livestockforan association ('ekub') in which one woman takes
dairy production and oxen fattening for sale is done by the milk produced by all of diem to market. She
men.' Men are responsible for ploughing and can use the income immediately. Instead of
preparing die land, including women's going to market widi a cup of milk every day and
vegetable plots. Men did not recognise women's earning one or two birr, each woman goes widi
contribution to agriculture; diey said, 'Men do it'. 20 cups every 20 days or so, and earns a larger
However, women gave detailed descriptions of sum. Women also sell vegetables and 'njera for
their work in agriculture. those who need to buy'.

Appendix 5

Men sell the 'chat crop if they have a donkey sale of livestock as a source of income, and only
or if a customer comes to the field, 'otherwise when then as a secondary source. In the focus groups
the husband is harvesting ['chat], the woman carries it it emerged that livestock is sold only when there
on her back to the market'. Many women are 'chat is a specific need; men said that they fatten and
traders: 'Women work hard to keep their families. A sell once a year on a Muslim holiday.
[woman] 'chat trader wakes up around 5.00 a.m. to go With regard to decision-making on
to another village. She buys 'chat and travels back to expenditures, the men said: 'All expenditures are
Chelenko to sell. There are times when the women get decided by joint discussion, but most of the time men
back around 10.00 p.m.' Small children are left decide.' T h e n they said: 'The money is kept by the
with older sisters. In the household survey, women.' Women said: 'Purchasing cattle is men's
77% of women from the poorest households decision', while 'Purchase of household items like
reported being engaged in 'chat trade or selling food, kerosene, school materials is decided by women.'
firewood. In the household survey the majority of worst-
off households reported that men control the
Daily labour: 'Able bodied, healthy women travel to income, even if women earned it. In the
small towns to earn an income from daily labour.' medium households, women were reported to
They carry and fetch water, clean and wash for have proportionately greater control over
households in town. income than in the worst-off group.
Domestic work: Women and girls are respon- In this region, men lie and sit around
sible for cooking, cleaning, collecting water and chewing 'chat, smoking tobacco, and drinking
firewood, and caring for children and the sick. hodja for much of die day. There are seasons
They also organise children, both boys and girls, when they are active in agriculture; otherwise in
to help. More girls than boys miss school as a general women manage the day-to-day needs of
result. the household.
In the worst-off group, 30% reported earning
Children's work
less than 50.00 Birr per month (US$6.40), even in
Children's contribution to the household econ-
good times. The women estimated that on
omy is essential and taken for granted. They also
average poorer women might earn 2.00 to 5.00
need to learn these tasks for adulthood, which,
Birr (US$ 0.25 - 0.64) per day, for a family of six.
especially for girls, starts all too early.
One woman explained: 'My husband is sick. We
Agriculture and livestock: The women said: don't earn an incomefrom land because he can not work
'Boys help theirfathers digging (hoeing) and weeding. on the land. I earn money by trading. With this sort of
They also look after the animals.' 'Girls also look after business I get nothing. The average is 3.00 -5.00 Birr
animals.' per day.'
A slighdy better-off woman said: 7 have a
Domestic labour: The girls help in the house, they
husband. We work together on the land. We get around
collect water, cook and clean the house. They collect
3 quintals per year. However, I do not sit around the
firewood and wash clothes.' In fact, 'some boys do
whole day waitingfor the crop. I go and sell 'chat in the
girls' work and some girls do boys' work, it depends' -
market. learn 3.00-10.00 Birr [US$ 0.38-1.28] per
on how many boys and girls there are in the
day. There are days when I do not earn any money.
family and how old they are.
There are days when I even lose the capital I spent on
Petty trading: In Chelenko market, boys were the 'chat.'
buying quantities of bread rolls to sell at a 75% The lowest-income month for 43% of
mark-up. One boy interviewed was paying for his households in the survey was July, followed by
schooling this way. Efitu, a young girl trading to August. During these bad months, 60% of worst-
support her family, was selling milk at 2.90 Birr off households reported incomes of less than
per litre. 50.00 Birr ($US 6.40), and at least a third of
these households are single-parent families. In
Incomes and expenditures medium households which have a small 'chat
plot, 71% reported earning less dian 100.00 Birr
The household-survey data confirmed that sales ($US 12.80) per month.
of 'chat and other crops were the main sources
of income. In 50% of the worst-off households
and 71% of the medium households, the main Food security
source of income was from 'chat sales. Only 5% At the time of the research, this community was
of the household-survey respondents reported under stress, as a result of poor harvests due to

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

drought and adverse weather conditions over Coping strategies

the past two to three years. Signs of malnutrition The better-off help the poorest by hiring them to
were visible and were pointed out by work on dieir farms. However, during times
participants in the focus groups. These included of drought there is less work.
diseases such as swollen body and diarrhoea, Trading and daily labour, especially by women.
and a significant incidence of miscarriage There was little agricultural labour for men,
reported by TBAs. due to the drought. Women work in domestic
Meals per day labour in town, in fetching water and
firewood, and cleaning.
The men said: 'Due to the drought we are not sure to
Eating under-ripe food. Some women collect
eat once a day.' In the household interviews it was
and prepare under-ripe sorghum and
reported that in difficult months (including the
vegetables in order to feed their children.
survey period) 43% of boys and 42% of girls, and
Some better-off households sell livestock when
54% of men and 53% of women in worst-off
they are short of cash and to pay for health
households, had one meal per day. In the
care or schooling.
women's focus group, they said: 'We are eating
Borrowing money - aldiough only few reported
once a day, and there are days when we go withoutfood
being able to do so.
for a day or more.' In 71% of households inter- Men are leaving land fallow, and 'we pray to
viewed, a meal consisted of a handful of roasted Allah to solve our problem'.
cereal ('kollo) such as barley or wheat. Women
said of the nutrition advice given by health
workers: 'We know that our children should get
potatoes mixed with onion and eggs, but we can't
afford it.' Some women wished they could give There is a new government health centre,
their own children the milk and eggs that they opened in March 1999, in Chelenko, about
sell in the market to buy grain. 10km from Ali Roba. The hospital is in Deder,
40km away. There are several TBAs and about
Sources of food four herbalists in the village. People also go to
People access food from their own crops and by
the Muslim Sheiks for healing. The government
buying. When they finish their own crop,
health staff said that people come for treatment
women sell 'chat to buy food. The shift from only when the illness is very serious. At Deder
food to 'chat production has reduced the hospital most patients are not exempt from fees.
availability of food from their own farms. Sweet In Chelenko they reported that it was mostly
potato and beans are inter-cropped, and some men who come for curative care and women
sorghum is grown, but little else. From a who come for preventative treatment. These
woman's daily earnings of 3.00-5.00 Birr, little women, however, appear to be largely the
can be bought. In the market in Chelenko at the better-off urban dwellers.
time of the survey, teff was sold at 2.00 Birr per
The government service providers did not list
kilo, sorghum at 1.70 per kilo, and maize at 1.60 women's reproductive-health problems as
per kilo. One day's work may buy one and a half 'main health problems', but the community did.
kilos of teff for a family of six. Many procedures relating to these are carried
Expenditure on food out in the village and/or dealt with outside the
In the household survey it was reported that government health service. Procedures such as
88% of income was spent on food in good tonsilectomy and uvelectomy are also
months and 94% in bad months. In worst-off performed by traditional herbalists.
households, 30% woman-headed, 95% of
income was spent on food in bad months and Causes of health problems
89% in good months. In 97% of all households Health-service providers attributed common
interviewed, difficulty in maintaining adequate health problems to malnutrition, poverty, and
nutrition was reported. The local elementary- poor sanitation. According to men, to Alibaye (a
school teachers confirmed that children did not traditional and modern healer in Chelenko),
get enough food. Both professional and and to nursing staff at the clinic, 'chat was the
traditional health-service providers attributed cause of violent outbursts, resulting in traumatic
most health problems to malnutrition and poor injury, and of impotence. There was also a high
sanitation. incidence of gonorrhoea, on which men consult

Appendix 5

Table 23: The most common health problems identified by the focus groups

Men's Women's Boys' Girls' Govt. health-

group group group group service providers

Paralysis Rheumatic pains

TB TB TB TB, especially pul-


Diarrhoea Amoeba/diarrhoea Intestinal parasites Amoeba/diarrhoea Parasitic diseases,

with blood Diarrhoea With blood schistoma, hook

Scabies Swollen body Kidney problems Skin diseases

Effects of 'chat' Cold/headaches/ Common cold Headaches Respiratory-tract

Fever Coughs infection

Girls' circumcision Measles Girls' circumcision Gonorrhoea

Early pregnancy &
related childbirth

Accidents -oxen Tonsilitis Gastritis Gastritis, ulcers

Violence: fighting Excess bleeding Accidents caused by

& domestic violence (delivery) homicidal injury

Swollen bodies Swollen bodies Malnutrition/

especially children especially children Anemia

Eye diseases

traditional herbalists, because they will not get one of the TBAs, does occur, though it is
treatment at the health centre unless they bring obviously a taboo subject, judging from the
their partners. conflicting reports. The women's group, for
There was insufficient immunisation example, said there was no domestic violence.
coverage. Alibaye said that children die of
measles as a result, and the health assistants in
Effects of health problems on livelihoods
Chelenko and Deder were far from satisfied
with the outreach service. It was under-funded Poor health was reported to lead to reductions in
and poorly staffed. In Ali Roba, women seemed family income; reductions in the number of
to immunise their children if the outreach meals eaten per day, affecting all family
service came, but 50% of infants in the worst-off members; the sacrifice of other activities to look
households had not been vaccinated. Some after the sick; and the inability to plough, if the
women were suspicious and believed that the husband was sick. Keeping up with school was
injection could make their children ill. important to both boys and girls. Some said that
'Paralysis' was mentioned in all focus groups illness kept them away from school. The teachers
and was said to be dealt with by the herbalists. in Ali Roba reported that diarrhoeal diseases in
The men's group attributed it to 'chat, which particular kept children out of school.
'sucks our blood, that is why we represented paralysis by
its leaves'; but the youth groups reported that
everyone suffers from it. Seasonal patterns
The men's group thought that women got TB The surgeon at Deder hospital maintained that
by 'carrying heavy loads and by beatings over the back hospital records of top ten diseases at any point in
and shoulders'. Domestic violence, according to time were more a reflection of the community's

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

access to cash to pay for treatment at different that 'it is not good to circumcise girls'. They wanted
times in the year than a reflection of actual to know more about FGM and its hazards. They
patterns of incidence. There were, however, did not really know why it should be performed,
some distinct patterns, such as border disputes except that it had always been done. Healdi
and resultant traumatic injury, increasing during education advising against FGM has obviously
die dry season when men are irrigating dieir filtered through to Ali Roba. However, aldiough
land. Many problems reportedly occurred the men's group included FGM among one of
throughout the year: women's health problems, the most common health problems, diey said:
parasites, paralysis, scabies, and malnutrition- 'We don't believe anything that is said on the mass
related illnesses such as swollen body in children. media ... about the negative consequences of girls'
The hot dry season, April to June, saw food circumcision'. On the contrary, women said such
shortages, low incomes, and a high prevalence things as: 7 do not know anyone until now who is not
of diarrhoeal diseases, according to the men's circumcised, and who did not have a problem during
group and Alibaye, the healer in Chelenko. He delivery. The TBAs operate with a blade, and there will
said that people have no latrines, and faeces are be excess bleeding.' FGM, according to the surgeon
all over the place, spreading disease. The rainy in Deder hospital, can cause obstructed birdi, a
season also brought a high incidence of ruptured bladder, and incontinence thereafter.
diarrhoea, because of faecal contamination of However, all girls continue to be circumcised,
the drinking water (in Deder). and there were no signs of action to change
attitudes to girls' sexuality and reproductive
The woreda health office reported a higher
rights, nor to eliminate the practice.
incidence of gonorrhoea during the 'chat
harvest season, July and August, when men get Antenatal care: ANC attendance at the old
high on 'chat; some, he said, have a high sexual Chelenko clinic was low and declining. In Ali
drive, others become impotent. Roba, 52% of women in the household
interviews had not used ANC in their last
Reproductive-health issues pregnancy. In the worst-off category, 70% of
Many reproductive-health conditions, rituals, those who had sought ANC had visited the
and problems were dealt with in the village by outreach service when it came. On average,
traditional herbalists or untrained birdi those who attended ANC reported attending
attendants. These included male circumcision, one to three times during their pregnancy.
female genital mutilation, treatments for Almost one-third of women complained of
impotence and gonorrhoea, childbirth, and problems during their most recent pregnancy.
pregnancy-related problems. Women tended to Early marriage, early pregnancy, and child-
use services if diey came as outreach. birth: Early marriage and early pregnancy are
Family planning: Here, as in Somali region, it common. The boys, when asked what healdi
was seen as important to have large families. In education they would like to pass on to dieir
the worst-off households interviewed, 90% said parents, included 'the prevention of early marriage'.
they were not using family planning, mostly The Chairwoman of die women's wing of die PA
because they wanted more children. Only 4% accused die Chairman of die PA and other PA
said they were not aware of family-planning leaders of not doing enough to stop early
methods, and diey were all in the worst-off marriage. She diought the PA and die schools
households. The large number of children was should work closely togedier, particularly to
seen as a problem by men only in the context of persuade parents on diis issue.
land shortage and inheritance rights, and by Not one woman in die household interviews
parents because they could not afford to send so had been attended by a trained medical person
many to school. during her most recent delivery. All had given
birdi at home, 93% widi an untrained traditional
Circumcision: All girls and boys are birth attendant, die remainder widi die one,
circumcised, girls when diey are between 5 and 7 trained, birdi attendant in die village. She,
years, and some later at 12 or 13 years old. The however, has had no training in over 15 years, is
most extreme form of FGM, infibulation, is not supervised, and has no kit. TBAs wanted
practised in Ali Roba. The clitoris is removed, as training and kits and contact widi die healdi
are the labia minora and labia majora. The centre. The healdi centre had a programme to
wound is stitched to leave a tiny opening for train TBAs, but Ali Roba was not included. Given
urine and menstrualflow.The girls' group knew die huge demand, die response is limited, largely

Appendix 5

because of inadequate funds and staffing. Dr and the waiting time. This is crucial, since
Tekolla, surgeon at Deder hospital, confirmed people do not seek treatment until their
that the number of women attended by a medical condition is already very critical. The women
professional in childbirth was negligible. The said: 'People can die waiting.'
main problem reported by women was excess The majority of women reported that the
bleeding after delivery. Women attributed it to untrained TBAs were very dirty. The only birth
poor nutrition, and some, they said, die unless attendant who was respected was the trained
they get some fatty foods. birth attendant.
Government health professionals said that
Quality and affordability of health care there was a shortage of funds and staff for
effective running of the immunisation, FP,
The main criteria that people used for judging ANC, family health, and health-education
quality included cost; cleanliness; availability of
programmes, both on-site and outreach. They
diagnostic and other equipment; the attitude of
believed that outreach was immensely
the medical staff; waiting times; cure rates; and
important, to help them to work more closely
drug availability.
with the community, particularly on the
The government healdi services are too prevention of diseases and on family planning.
expensive for people in Ali Roba. They go only
Generally, men are not targeted by the family
when the problem is severe and if they manage
health programme, FP education, etc. Given
to borrow money. The poorest, and women in
their position of power and control in the
particular, have difficulty in accessing credit. In
community and the enormity of women's
households interviewed, 75% said that health
reproductive-health problems, this may be a
services were unaffordable or only affordable
serious oversight.
with a struggle. For them, the cost of health care
is not just the fees. Women included costs such
as transport and food and accommodation for Source of money for health care
the treatment of TB patients in Deder hospital. Most households reported that people borrowed
Similarly, women could not afford the money if they could, or sold livestock or
'treatment' advised for their malnourished household assets. Not all families were in a
infants. Women's access to good food to feed the position to do any of these: The only option we have
family appeared to be central to maintaining is to wait on a bed to die.' While the women's group
health and to preventing many of the main did not know very much about the exemption
health problems, but they cannot afford to system or how it worked, the men were relatively
adopt the advice that they are given. well informed.
All focus groups, the youth in particular, were
scathing about traditional herbalists and
healers, largely because of the cost and the slim Education
chance of a cure. Boys said they lack the
knowledge and medicine, girls said they make Participants said that there had been a shift in
people crazy and are not effective. opinion about education, especially since the
The women and girls in particular had great Derg's period. In Haile Selassie's time it used
faidi in Alibaye, the traditional and modern- not to be valued at all, and only boys, if anyone at
medicine drug-store owner in Chelenko. all, were sent to school. Now the underlying
However, medication in both government facil- problem was poverty: the lack of income, and
ities and at Alibaye's was too expensive. Several the fact that children's labour is integral to the
women said that they just go to the kiosk in the household economy. Girls were needed for
village to get some painkillers. The government domestic labour and to produce baskets for sale
medical professionals agreed that there was a in the market, boys were needed to look after
shortage of medication. Some of the medication livestock. In the market survey it was noted that
supplied was not required, and some ran out quite a number of traders were school-age girls,
within two months of delivery, leaving the health some of whom were illiterate.
facility with nothing for months. Medication was Children in Ali Roba have three options for
too expensive for most people. elementary schooling: Dudela No. 3 Elementary
The surgeon, Dr Tekolla, also had an School (Grades 1-4) in Ali Roba; Dudela No. 4
excellent reputation with the people. The main (Grades 1^1); and the Chelenko Elementary and
problem with government facilities was the cost Junior Secondary School (Grades 1-8). Most of

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

the children who go to school attend the The main reasons for non-attendance or
elementary school in Ali Roba. All participants dropping out of school were given by education-
wanted the grades to be extended at least to service providers as follows: many schools are
Grade 6. No one in the focus groups had a child too far away from where children are living;
attending school in Chelenko: it was just too girls are victims of customs and religion; girls get
distant. There was also a Koran school in the married at an early age; girls are not
village. encouraged to go to school; many parents have
Despite women and men in die focus groups low levels of awareness regarding the value of
saying that education is equally valuable for both education; girls are wanted to help at home;
girls and boys, very few of eidier sex go to school, boys are needed to tend animals; more boys
and proportionately even fewer girls are sent. drop out because they are involved in petty
Education-service providers estimated that about trade, mainly selling 'chat; parents could not
65% of all children do not go to school, and that afford clothing and school supplies; the school
75% of girls do not attend. In the household inter- [in Chelenko] is full to capacity and
views (where 73% of respondents were women), overcrowded. In general there was an
43% said there was no advantage to educating agreement that 'in most cases, the children of the
boys, and 57% no advantage to educating girls. worst-off groups are the main victims'.
There is still a problem of attitude to education, The school PTA said that children did not
particularly among an adult population which is attend school because of parental poverty; the
largely illiterate, or barely literate. shortage of teachers at the school; the lack of
In the worst-off households interviewed, 78% money to buy pens and exercise books; and
of females of school age and above were illiterate, diseases such as diarrhoea.
and 31% of males. While only 24% of males had There was a high drop-out rate reported by
attended elementary education between Grades service providers. The class size in Grade 1 was
1 and 4, a mere 2% of females had. In Dudela typically much larger than that in Grade 4. In
Elementary school in Ali Roba (Grades 1-4), the school in Ali Roba, for example, the 1989
some classes had only 3% girls attending. Grade 1 intake had fallen by 41% over the two
Exposure to education was abysmally low, and years to 1991. The largest number of drop-outs
for women and girls even lower than for their was among boys, linked to the fact that boys
male counterparts. Another issue mentioned make up the larger proportion of children in
was that children start school relatively late. The school. Boys drop out in order to work or trade
average age in Grade 1 was 9 years old. during the worst months of die year.
Teachers said that girls' performance in school The schools suffer from a lack of textbooks:
was worse than boys'. This was attributed to the one book is shared between two to five children.
culture and the fact that girls are brought up to be Teachers do not have teacher's guides, and the
shy and wididrawn and boys to be outgoing. courses translated into Orominya from Amharic
Girls, they said, also had domestic work to do are often too difficult for the students. Some
before and after school. Other factors inhibiting teachers are reportedly under-qualified for die
girls' attendance included early marriage and grades diey are teaching and do not understand
early pregnancy. Early marriage also affected die material either. There are not enough
boys' school attendance, but whereas boys might adequately qualified teachers. Teachers think
enter marriage at 18, girls can get married at 12 that, for the hours they work, the conditions and
or 13 years. The men also reported that girls can die cost of living, their salaries are inadequate.
spend up to three months recovering from FGM; There was a shortage of desks and chairs, and
this will also affect their access to school. no water in school compounds. Many have no
Education was considered to be unaffordable, toilets, though there was one at die school in Ali
particularly for the worst-off households (the Roba. In general, while die demand for services
majority), by participants and service providers. from an increasingly impoverished and growing
The cost of schooling was considered to include population increases, it appears that funding for
die cost of food, clothing, cleanliness, and school education materials, medication, staffing and
materials like exercise books and pens. All this staff training, equipment, and proper sanitation
was unaffordable. One woman said: 'We send only is totally inadequate to cope. Neither die schools
boys to school, because of lack of enough money to send nor die healdi centre receive any cash budget of
both children to school. If we keep girls at home, they dieir own to cover costs. Salaries are paid for by
produce woven baskets, which they take to the market to die woreda offices, and materials and medication
sell. That will enable thefamily to send the boys to school.' are received in kind. The staff who manage diese

Appendix 5

services have no control whatsoever over their they lack access to libraries and entertainment
supply. Assistance from donors has to be applied facilities. A woman teacher said that work was
for through the woreda office, which decides on difficult without child-care support for her two
the distribution of materials among the various small children, and the distance to market
facilities. The UNICEF WIBS programme without transport made provisioning difficult.
provides some school furniture and funds some It has to be said that the research team was
short workshops for teachers, but in the face of enormously impressed by the dedication to
the demand this is a drop in the ocean. their work and to the people that was
Both education and health-care personnel demonstrated by many of the service providers
have a very tough existence in this remote area. interviewed, including the translators from the
They lack training to upgrade themselves and health service and MoA who worked with us.

Appendix 6
Case study 4: Belhare, Jijiga, Somali Region

In Sheik Umer, the men told the researchers: 'If had little left to eat or exchange for food. Oxfam
you had come before the problem, you could have Jijiga had already made requests on behalf of
helped. Now the problem has already cost the lives of the Jijiga DPPB to the Oxfam office in Addis for
our cattle.' The men said there was a need for food aid.
fundamental change: 'We always discuss problems The original site selected for the research was
after they have taken place. There should be some Sheik Umar, a village some 60km east of Jijiga
serious planning to prevent problems.' town. No participatory research (PRA) had
previously been conducted in the site. It is a
recently selected Oxfam project site and has a
Introduction health committee, organised by the Elders and
Oxfam staff. The team spent about a day and a
The woreda ofJijiga is located in Somali Region, half on the site, conducting the mapping (with
bordering Somalia. It is physically and psycho- women and men), ranking, and seasonal
logically remote. The region is accessed by the calendars (separate groups of women and men).
road from Harar between the 'safe' hours of 9.00 On the first day of the research the rains started.
a.m. and 1.00 p.m. At other times, travellers risk On the second day there were torrential rains. It
being accosted by 'shiftas' or bandits from one or took the team three hours to reach the site and
other of the more extremist Somali clans. The four and a half to return to Jijiga. For security
area is associated with contraband trade, includ- reasons it is not advisable to be outside Jijiga
ing the stimulant drug 'chat. The people have town after 5.00 p.m. On the second day the team
suffered drought and war, and signs of the latter returned after 7.00 p.m. It was apparent that
are still visible in the form of derelict tanks seven hours of driving limited the time available
scattered over the wide open plains, or at the for research, and it was agreed that in view of
edge of a village. security problems the team should look for an
The population in the woreda as a whole is alternative site. Belhare village, one of a settle-
248,465, according to the 1994 census, 74% of ment of five villages 10km outside Jijiga town,
whom live in the rural areas. The rural was selected.
population is characterised by nomadic customs The people of Belhare are from the Somali
and traditions; men have control over decision- ethnic group and speak Somali. They are
making and the livestock, and women have the Muslim and have Koran schools in or near the
main responsibility for the family and domestic village. They are not represented by a Peasant
sphere, build houses, and care for the smaller
Association (PA), the lowest local-level
ruminants such as goats and sheep. Men
government administrative body which provides
dominate the clan structures which shape social
a link for development work and provision of
and political relations and alliances. Some
services with local woreda authorities in the
families have now settled in villages and live as
town. The village belongs to a group of four or
agro-pastoralists, tending livestock and growing
five other villages of the same main clan
food crops.
grouping, the 'Akisha', all similarly isolated from
official structures and services. The bulk of this
Sites selected for research report refers to the findings in Belhare village,
The two villages visited for the research in comprising about 170 households. There were
March 1999, Sheik Umar and Belhare, are both five main sub-clans in Belhare: Hrer Adawi,
in Jijiga woreda. They have been settled for over Werro Sengu, Hrer Tukali, Hrer Ali Boch, and
100 years. After a year with litde or no rain, the Werro Hamo. Another four clans in the village
woreda was seriously affected by drought and were Gerri, Charso, Gethe Bursi, and Yebarrhe;
food shortage at the time of the research. In diese are minority clans and are possibly under-
both villages livestock were dying, and people represented and have fewer rights.

Appendix 6

Clan loyalty and affiliations underpin social included 30 interviews: 73% of the respondents
and gender relations and are the source of were women, and women headed 17% of the
tensions which can lead to armed conflict. One households. A significant proportion of
of the most important social institutions questions referred to reproductive health. A
described by the Elders and respected women of total of ten education-service providers were
Belhare was the 'Hodeyashi Nabadota' (see interviewed, including the village Koran school
'Social relations' below). This is a council of teachers, and five elementary-school teachers in
Elders (all men), representing the villages of Jijiga. Five interviews were held with health-
Belhare, Kordere, Musle, Elbehay, and service providers, including two with TBAs, who
'Kaboorelay. The Elders' main function is to were also involved in assisting in female
maintain the peace. The research does not infibulation and the ceremony of cutting a girl,
specifically focus on differentials in access to ready for sexual intercourse on her marriage
resources and representation within and day. Representatives of the Zonal and Regional
between clans and sub-clans, although this is a education and health offices were also
fundamentally important feature. Work in interviewed.
Somali Region requires a solid understanding of
clan structures and dynamics, which influence
access to resources and connections at all levels Poverty, nutrition, and
up to regional government.
Social relations and reproductive health
The team's overall impression of Somali culture Poverty
was of a community whose survival depends on The research took place during March,
staying close and sharing resources. Women and identified by the women in particular as one of
men have very distinct and separate spheres. In the most difficult months each year. This year it
this system men dominate all decision-making. was worse, because of the drought. The last crop
Women are conditioned from childhood to be was harvested over a year ago. The rains needed
retiring and modest, and undertake very specific for ploughing and planting this year's Belg crop
tasks and responsibilities tied closely to were not forthcoming. They had no food crops
reproduction and home-keeping. They also in store or to sell, and the carcasses of dead
contribute their labour to agriculture and animals lay scattered in and around the village.
livestock, but have little or no control over the The drought had completely disrupted the
production output. Having large families is usual rhythm of life and demonstrated to both
considered important, particularly in this women and men how dependent they are on the
subsistence economy, where everyone's labour rain for survival, and how vulnerable they are
contribution counts. without education. The women's group told us:
Girls are circumcised and stitched 'to protect 'All our hope for the better life depends on the rain
them from the boys' and kept on a tight rein. which gives us grass and water for our animals, and
Without circumcision, girls would be called food production for household consumption.' T h e
loose and would never be married. Sexual and men's group said: 'The effect of drought is that
reproductive relations, which are also power animals are dying, and to live we also sell them. Due to
and control relations, impact significantly on the animals' death and no food, we became weak and
wider social and political relations between get dizzy and we too will die. The children's bodies
women and men and impinge on the swell, they get diarrhoea and die or become sick.'
representation of women in local and official Throughout the PRA, both the women's and
institutions, where the distribution of resources men's groups referred to the low educational
and power is centralised. status in the community, which denied them a
source of leadership and the means to define
Number of people involved in the research new strategies to cope with the acute situation
In Belhare 24 men and 24 women, and 12 girls created by the drought and the lack of income-
and 12 boys (10-18 years) participated in the generating alternatives.
PRA, and a further 16 women and men took
part in a group discussion (Venn diagram) on
social institutions. The household survey

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

Table 24: The main problems identified by women and men in Belhare

Main problems Women Men

Transportation/communication * *
Lack of school in the community * *
School in Jijiga too far for our children *
Water: 'all animals including hyena drink with us' *
Lack of health service * *
Lack of ANC *
Lack of help for pregnant women if there is a problem *
Lack of food during pregnancy *
No training for TBAs *
No delivery materials for TBAs *
Two years of drought, no rain *
Animals are dying *
Disease among people is spreading *

(Source: women and men's focus groups)

Access to resources and communications said. Drought had reduced most households to
Belhare has no PA to represent local people the same level of poverty. When better-off
or act as a vehicle for development initiatives households lose their cattle, not only do they
or provide access to health care via become poorer, but those who depended on their
exemption papers. custom lose their source of income too.
There is no clinic; the nearest is 12-15km Men also said that 'lack of education leads to
away. There are no health posts, trained poverty', and that 'health problems make a person
TBAs, or traditional 'bonesetters' (traditional poorer'. T h e women said that 'life is worse than a
physiotherapists who also provide other few years ago. The problems of school, and water, we
therapies) in Belhare itself. The women know from before. But now the drought makes life
placed five TBAs on the village map. worse. There is no food at home for our children and
There is no elementary school; the nearest is us. Most of the people got sick and died.' Both the
12km away. There is a Koran school near the Jijiga Zone Health Bureau and the Region 5
mosque in the village. Education Office confirmed that 'people were
There is no market in Belhare. The villagers becoming poorer and poorer, day by day'.
go to Jijiga to buy and sell their goods.
There are no transportation services. People Livelihoods
just walk wherever they have to go. Food crops like maize and sorghum, and
livestock including cattle, oxen, camel, sheep,
Poverty ranking and some goats, form the basis of the subsistence
The participants identified 80 households for the economy. Men reported that they were largely
ranking, about 47% of the population of Belhare. responsible for crops and livestock, and that men
In 30% of these households, a husband or wife control the sale and income from these activities.
had died. Of these, only four were elderly, 16 They said that older boys worked with them in
were younger men who had died, and three were the fields, and women brought the tea. In the
younger women, leaving growing families household interviews, 71% reported that men
behind. control the main source of income, and two-
Wealth was ranked according to the number of thirds that men either control or share control of
livestock; the worst-off households, the majority, the household's secondary income (often
have no livestock left at all. Shocks such as the loss women's income) with women.
of a crop, the death of animals, and the death of a According to women's reports, however,
spouse all made a household poorer, the men women were very much involved in agricultural

Appendix 6

activities, as were girls. Women were also households averaged six family members. But
involved in tending livestock and looking for women in Belhare did classify 'many small
food for animals during the dry season. children to feed, especially during the drought'
Although both women and men milk the cows, it as a factor which could contribute to increased
was women in Belhare who reported organising poverty.
themselves into groups for the collection and sale A strong indicator that this community has
of milk in exchange for grain. (In Sheik Umer, few alternative sources of income was the
men - not women - sold milk and milk products. extraordinary proportion of households which
Men said the market was too far for women to go. reported household members 'doing nothing'
However, women heads of household go to the during the worst mondis. In worst-off
market in Hartshek.) households, for example, 43% of men, 33% of
Women and girls were largely responsible for women, 95% of girls, and 95% of boys were
all domestic work, including building and reported to have no income-generating coping
maintaining their houses, collecting fuel and strategies to deal with die very bad months in
water, food processing and preparation, and the year.
child care. With marriage and childbirth at 15
not uncommon, girls are forced into adult Food security
responsibilities at an early age.
Men reported the months of April and May Overall, 70% of respondents reported a
and from November to January as the most dependence on the market for their staple foods.
labour-intensive months for agriculture. In In worst-off households, 90% of income is spent
normal years, low food availability was reported on food during bad mondis, when incomes were
from April through to September. The worst reported to be $3.58 per mondi. A lower
months for livestock disease and fodder proportion of average incomes was spent on
shortage were February and March. food in good months, when many households,
among them even the very poor, had access to
some food from dieir own harvest, or in the form
Incomes of exchange widi and gifts from relatives and
Women and men differed in their assessments of neighbours.
the times of the year for higher incomes. Women The laws of supply and demand, however,
clearly had little access to incomes from mean that grain prices go up when the poor can
agriculture. They reported a slight increase in least afford it. A market survey conducted by the
income from August to January, when there is team in Jijiga showed diat the price of wheat had
usually an increase in milk production. Men's increased from 180.00 Birr per quintal to
highest-income months were in the post-harvest 240.00 Birr in diree months, owing to a
months of February and March, income which shortage since the drought. The grain prices
they spent on agricultural inputs, renting from petty traders had increased 100%. At the
machinery, and buying 'chat and tea to same time, for those needing to sell smaller
invigorate them for the next round of work in livestock to buy food, there had been a
the fields. These months were reported by downward shift in die prices because of a glut in
women to be hard, low-income months. In the the market.
household survey, where 73% of respondents Household food consumption has dropped:
were women, March was identified as the worst 100% of households interviewed reported that
month in the year for income. This was so in 38% they were having difficulty in maintaining
of worst-off, 29% of medium, and 50% of better- adequate nutrition for the whole family, because
off households; 38% of worst-off households of the drought. At least 52% of all households
reported all year as being bad. During the worst reported that dieir children were suffering from
months in the year and it can be assumed that, malnutrition. The number of children aged
for many, the past year had mosdy been bad - 1-15 years in all households totalled 128. Of
83% of all households reported earning less dian these, 27% were reported to be suffering the
50.00 Birr per month ($6.40). However, some symptoms of malnutrition. In die under-five
reported that they were living on nothing, by category, a total of 46 in die households
begging from neighbours. interviewed, 35% were suffering from the
Households are relatively large. In Somali symptoms diat participants associated widi
society, having many children is still seen as a malnutrition. The figures show more boys dian
sign of wealdi. In the 'worst-off category, girls suffering from malnutrition.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

In quite a number of the 80 households of traditional treatment'. The men's and women's
ranked, the youngest child was aged 8 years and groups also said that 'the husband decides about
above. This possibly indicates a high incidence spending money on health'. ' We call a holy person who
of infant mortality, and/or of malnutrition- knows the Koran to pray for Allah. There is no
related miscarriage. The men's focus group traditional medicine.'
reported that 'the main problems are diarrhoea, TB, In general, participants in the research from
constipation and getting very weak'. They said that die community, and health-service providers,
'the children's bodies swell, they get diarrhoea and die attributed most health problems to poverty
or become very sick. The problems got worse over the resulting from die drought. All prevalent diseases
last three years due to total absence of rain.' were linked to die lack of adequate nourishment,
According to men, 'Children and women are most and to drinking dirty contaminated water. The
threatened by the problem.' most common illnesses included diarrhoea,
One of the TBAs interviewed in Belhare, also diarrhoea with blood and vomiting, cough,
responsible for cutting young girls/women on cough and fever, malnutrition, parasites and
their marriage day, confirmed the increased worms and abdominal swelling, anaemia,
number of starvation-related illnesses and excessive bleeding at childbirth, measles, and eye
deaths: 'In the last two years lots ofpeople have died, infections. The clinic in El-hamar 12km away
when compared with other times. It is because of provided a very similar profile of die most
starvation.' common illnesses. The problems are widespread.
Medecins sans Frontieres Belgium is running
a pilot TB programme in Jijiga within the
Water and sanitation
National TB and Leprosy Control Programme.
The community had no access to clean water: It estimates that 90% of the population is
they use open sources, which they share with infected with TB (in die sense of having been
livestock and wild animals. The women said that exposed to it and having their own immunity to
'when there was rain, the first dirty water [stagnant] it), 'but only get sick when they are malnourished, get
was washed out and we could get the clean water. But measles, malaria, whooping cough, or HIV/AIDS'. It
now there is no rain, there is a shortage of water to wash estimated that about 20% of TB patients were
away the dirty water.' In the household survey, HIV-positive, and that 40% of patients admitted
100% of households reported collecting water to the hospital in Jijiga were HIV-positive.
from an open pond, well, or spring for During the research, the team came to die
household consumption. It is mosdy women and conclusion diat die concept of sickness in a
girls who collect water. Men and boys from the community whose healdi status is very poor,
worst-off and medium households sometimes and which has litde or no access to medical
collect water in the dry season, when long treatment, is quite different from that of diose
distances are involved in the search for water. who have regular and easy access to health care.
Fatuma Arebe, for example, a household-survey
respondent, was visibly unwell. She was
Health starving; she and her children all had bloody
diarrhoea. Yet she said diat she considered
There is no clinic within 12km of Belhare. herself sick only if she was in bed, and she was
People reported going to the hospital in Jijiga not in bed yet. She did not believe you could find
only when their problem was really serious. The a 'free' healdi service anywhere.
household survey and all focus groups indicated Widiout a PA, no one in Belhare or die
strongly that in fact most people stayed at home surrounding villages has access to exemption
and prayed to Allah. A few used traditional papers. Only a minority in this community, die
healers, but recourse to them, apart from for few remaining better-off households, can
circumcision and childbirth, appeared relatively 'choose' where they want to go for healdi care.
less common than, for example, in Delanta. We repeatedly heard diat people just 'get sick and
Men appear to be the key decision-makers die'. The boys' group summed up die situation:
regarding health-care choices, especially if Those who have money go to Jijiga hospital. The rest
money is involved. While the girls' focus group simply stay home and pray for Allah. However, it is
said that both mothers and fathers decide on only a few who go to Jijiga or visit traditional healers.'
health treatment, the boys were very clear that The women's group said: 'We don't know the
'the father decides if the treatment requires hospital quality [of govt. services], because we don't go to
management; otherwise the mother decides in the case hospital since we have no money.'

Appendix 6

Those who had used the hospital felt of dry rations they were given as incentives by MSF
discriminated against because of their poverty, Belgium was discontinued.' TBAs generally
dirt, and illiteracy. The men said that the receive no payment from their clients: 7 am not
reception of rural patients was not good: 'They paid a cent. In fact I come home and wash my hands
like to treat those coming from town, considering them and soiled dress with my own soap. I even walk all the
as cleaner.' According to one male participant, way tojijiga to buy pain-relieving medicines.'
' The poor can only wish.' The cost of treatment and There is a high fertility rate in this community.
medicine is so high that unless poor people have Having many children is traditionally welcomed,
some relatives to support them, they simply do and women start having children from the age of
not go anywhere to get treatment. 15 years or younger. Some women, therefore,
The cost of health is also the cost of staying responded that even if there were family-
healthy, or of regaining health through good planning support, they would not use it. Others
nutrition with medical supervision. Both reported not using family planning due to lack of
require assets in livestock, crops and/or cash, knowledge or lack of services.
and depend on healthy livelihoods. The men's Women reported not being able to accept
group recounted the story of Mohamed Farah: hospitalisation of sick children because there
'He was sick with diarrhoea last year, and he got was no one to care for their small children at
anaemia, he did not get treatment. Finally he sold his home. The demands of child care, in addition to
cow and was admitted to hospital for two months'
all the other daily domestic responsibilities, are
treatment. It was good treatment, but he is hungry, he
also most likely to add to a woman's reluctance
is still weak and hungry.'
to prioritise her own health-care needs - partic-
The problem of mental health is rarely ularly reproductive-health problems, since
addressed in rural communities. There were these are taboo.
some extreme cases cited, including a woman
In Sheik Umer, the men said that women
who had three mentally ill children 'tied up at
were suffering from malnutrition, and 'unless it
home'. But there were more common signs of
is brought by Allah, women do not have other
mental discomfort pervading all sites in all age
problems'. They considered women's gynae-
groups, linked to a strong sense of insecurity
cological problems as 'Allah's or God's will for
about the future, a fear of starvation, a sense of
women'. They said, The women do not talk about
failure, especially among men, and a sense of
real fear and sadness among women when faced gynaecological problems. They are shy. Even if they
with crying, hungry children. are sick they do not tell men about their diseases,
because there are no health-care institutions. They are
afraid to talk about these problems.'
Women's reproductive health
Women's reproductive-health status is defined Health-service provision
by the fact that they are subjected to the most
severe form of female genital mutilation at the The Health Bureau reported: 'There is high
age of 9-12 years. The report contains a detailed shortage of equipment, even of materials as
description of the procedure, and subsequent inexpensive as pairs of scissors. The hospital has only
procedures to open the girl at marriage and one microscope, which can only operate when there's
during childbirth. In this context it is even more electricity. There's a shortage of dressing materials,
deplorable that girls and women do not have operation and delivery sets. The shortage of equipment
access to ANC, nor to any medically qualified has been exacerbated because old ones became out of
person during childbirth. use and there is no replacement.'
All women and girls deliver at home: 100% of According to the Zone Health Bureau, There
respondents replied that the place of their most is no essential drugs policy. There is severe shortage of
recent delivery was at home. In 93% of drugs in the hospital, health centre and clinics except
households interviewed, an untrained TBA for niclosomidl and vermox. There is high demand for
attended the most recent birth. It was telling antibiotics, anti-pain and infusions, which we are
that, when women were asked questions about extremely short of. These problems could be solved
poverty during the focus-group discussion, they if the clinic staff were involved in planning and
started talking about the problems they budgeting with the Zonal Department of
experience during pregnancy and childbirth. Health. There is a delay in the release of the
The health assistant at the El-Hamar clinic budget in general. The budget has continued to
said that they had no links with TBAs: The link decline, except the hospital budget, despite the
we had with TBAs was discontinued when the supply continuing increase in the number of patients.

Access to Health and Education Services in Ethiopia: Supply, Demand, and Government Policy

The El-Hamar clinic has no knowledge of the fathers noting the need for them to be kept apart
budget allocation; in fact, they were puzzled from strange boys and men.
that they had faced some drug shortage that In effect, 79% of boys/men in the poorest
year for the first time in the three years. The households were illiterate, and 98% of
clinic is involved in the planning activities and girls/women; the illiteracy is disempowering and
not in the drawing up and allocating of the isolates them from the formal government and
budget. This is the responsibility of the zonal non-government administrative and service-
health department. providing structures. 'No one is educated among us
At El-Hamar clinic there was reported to be who could lead us,' the men's group declared. Both
a significant shortage of funds on practically women and men thought that if their children
every budget line: drugs, medical equipment, were educated they could represent their
stationery, cleaning materials, and even linen to problems to the appropriate authorities when
supply health professionals with the they were older: 'If our children [boys and girls] were
appropriate working uniform. The head of the educated, we would not be like this.' All focus groups
clinic reported that staff at the clinic have been also linked education with access to jobs, largely
obliged to use their own bars of soap and in government employment.
powdered soap to wash the reusable syringes Although there were mostly positive
and surgical instruments. responses about education during the focus-
The zonal deputy head also mentioned that group discussions, the household survey
the World Food Programme provides food showed that there was some resistance. At least
supplements at times (supplementary feeding 50% of all respondents (mostly women) did not
programmes for children). However, he see the advantage of educating either boys or
resented the fact that the 'donation' generally girls. The youth groups said that many of their
arrives within a few days of the expiry date on parents did not appreciate the value of
the food item. education. The men said that' Women do not think
about health and education. They only think about how
to get food and how to survive.' They said: 'Women
Immunisation do not even know the Koran, they have no time and are
In all, 40 of the 48 under-fives (83 %) had no afraid to learn. There is no separate place [from men]
access to any type of immunisation. An for them [to learn the Koran]. They just care for the
additional 10%, five children, have defaulted, house, for the children and husband.'
not because mothers did not want to continue, Access to food, clean water, clothing, and
but because the service was no longer there. income was identified by the adult focus groups
Considering die prevalence of measles and TB as necessary to sending children to school.
in the area, in the context of prevailing levels of Children's labour is an integral part of the
malnutrition the importance of immunisation to household economy. During peak agricultural
protect this very high-risk and most vulnerable seasons, demands on boys' labour increase, thus
group cannot be over-emphasised. One potentially compromising their access to school.
epidemic of measles could have a disastrous Throughout the year, women need their
effect, if introduced into this fertile atmosphere daughters to help them at home and in their
of unprotected and malnourished children. productive work. In any case, with such large
families, the men said that a family might be able
to send only two out of five or seven children to
Education school. Most girls marry and have children
early, and this would also interfere with their
When asked what actions their families could take completing school.
to respond to lack of income and production, the In the region as a whole it was estimated that
women said: 'There is nothing they could do becauseno up to 88% of children were not attending school.
one is educated in this area.' Only five boys from the One of the reasons given was the lack of
whole village go to school in Jijiga, 12km away. classrooms and schools to accommodate all the
More boys tfian girls attend Koran school. The children. The elementary school visited in Jijiga
women said: 'Our children tell us what is in the Koran experienced similar problems to those found in
after learning their lesson. The boys come home to tell the other sites: lack of textbooks and teaching
their sisters and mother about it.' All lessons are in materials, lack of chairs and desks, no furniture
Arabic, and literacy and numeracy are not taught. for teachers, no water or toilet facilities, lack of
The education of girls is controversial, some sports facilities, overcrowded classrooms, etc.

Appendix 6

Teachers lacked motivation, because of low marriage, certainly inhibit girls from gaining
salaries. There were also problems in attracting equal access to a complete elementary education.
teachers who could work and live in such remote Education-service providers felt that the
areas. Lacking transport, the local authorities potential quality of education was seriously
were unable to provide the supervision and compromised by the lack of necessary materials,
support necessary. equipment, and infrastructure. Teachers'
The 1994 rural population census for Somali dissatisfaction and the condition of poverty and
region showed that girls/women made up 26% of hunger in which children currendy find
those currently attending school, and 21% of themselves did not help. For children in and
those who recorded having attended school in around Jijiga, the Regional Education Bureau
the past. The process of socialisation, the burden said diat education 'is too expensive especially for
of domestic and productive work, the expressed those who have many children'. At the time of the
need to maintain a separate space for girls, research they reported that 'drought compels that
together with circumcision practices and early schools are closed down'.