Child health problems in Ethiopia 1

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Review article

Child health problems in Ethiopia

EPHA Expert Group

Amha Mekasha1 Frew Lemma1 and Tesfaye Shiferaw1

1. Global situation or child health The world population is growing at an alarming rate and particularly so in the
developing nations. Over 80% of the world's children live in the developing world (1) where child mortality and
morbidity rates are the highest. Each year about 14 million under-five children die from malnutrition and infection,
i.e. , 40,000 daily or 2000 per hour, of which 98 % occur in the developing countries (1). The main causes of mortality
in these countries are diarrhoeal diseases, pneumonia, perinatal and neonatal problems, measles, neonatal tetanus and
malaria (Table 1), over 60% of which are preventable at low cost in these countries (2). In 1980, an estimated five
million children under 5 years of age, died as a consequence of diarrhoeal disease (3). After the introduction of ORT,
a quarter-century ago, over one million young lives are now being saved a year .Still over two million under-five
children in the world's poorest neighborhoods die necessarily every year of diarrhoeal diseases (4)
.
Acute respiratory infections (ARI) are also major causes of mortality among children in developing countries
accounting for over four million deaths per year (4). In 1980 dlere were 2.5 million dead1s due to measles but now
this is reduced to just over one million a year; and the non-fatal cases have also been reduced. Over the same

period, deaths due to neonatal tetanus fell from 1.1 million to less than 600,000 (4). However, they still remain as the
main causes of under five deaths in developing countries. In addition to the above problems, new health problems like
HIV I AIDS and substance abuse are emerging besides the resurgence of the old on such as tuberculosis and malaria.

The survival of children is also increasingly under threats of war and instability in Africa, Asia and Bosnia, famine
and drought in sub- saharan Mrican countries. Child labour and the life on streets for children are increasing in many
countries due to economic recession and migration to the urban areas. Over 100 million 6-11 year-old were not
attending school in 1990, the majority of which were girls (5).

With these problems still prevailing we are approaching the end of the century .The rights of child survival,
development and protection have yet to be implemented. The observance of the Convention is the appropriate solution
to the needs of children. The promises made by the World Summit of Sept. 30,1991 should be translated from papers
to deeds.

It should be noted that eventhough children are defined as those below the age of 18 years, in this section it refers to
children under-five years and/or children under 15 years of age interchangebly, since most of the review materials
address this group.

_______________________________
1
From Jimma Institute of Health Sciences, [Link] 378, Jimma

2. National situation of child health

In 1992 the mid-year total population of Ethiopia was 53 million (6). Children below 15 years of age account for 48%
of the Ethiopian population. Children under 5 years of age constitute about 18% and infants are 3.5% .In general, the
majority of the Ethiopian population is very young with a mean age of approximately 17 years (7). The health of this
large part of the population is featured by high morbidity and mortality. The basic health indicators are as follows (7):
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Table 1: Under - five deaths, developing

countries, 1990
Cause Annual number of child
deaths (thousands)

Diarrhoea 3000

Pneumonia 3560

Measles 880

Whooping cough 360

Neonatal tetanus 560

Tuberculosis 300

Malaria 800

Other peri & neonatal 2470

Others 970

Total 12900

In a community based national survey 38.2% of children (6-59 months) had some type of illness. Diarrhoea and fever
were the most common symptoms reported, affecting 8.5% and 22% of sick children, respectively
(8). It is also estimated that there are about half a million under-five deaths annually in Ethiopia (6). Hospital data
(911) indicate that the major causes of morbidity and mortality are related to infections and malnutrition (Tables 2-5).

Diarrhoeal Diseases
A nation wide survey in the age group 6-59 months revealed that 8.5% had diarrhoea (8). In general, the median
incidence of childhood diarrhoea is 5 episodes/year and mortality rate of 9.2/1000 with 46% of diarrhoea death ratio
(12). Health institution reports from all over Ethiopia also show that diarrhoeal disease
stands among the top 15 causes of hospitalization (5.7 % ) and are also one of the leading causes of new out-patient
visits in both infants and children 1-4 years of age , accounting for 20.1% and 16.9% , respectively (9,10). On the
other hand the ORS use rate is quite low i.e. 22% (12).

Vaccine Preventable Diseases (VPD)

In the developing world of all the under-five causes of death about 16% are due to VPD (6). Tuberculosis is one of
the top ten causes of hospital admission and deaths (9). In a national survey among children of 6-10 years age group
the incidence rate was 77/100000 (12). The BCG coverage by mid 1994 is 50% for infants (12).
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A nation wide survey puts the prevalence rate of measles at 2.2/1000 (12). Recently, epidemics were noted in some
parts of the country. During epidemics the mortality rate may reach 20% (12). Tetanus is identified as
one of the five killers of infants (13). This may be related to harmful cultural practices related to the newborn care and
unsafe delivery practices. The current DPT3 coverage of 38% and TT 17% (12) in accessible areas should be increased
to the safest level. The prevalence rate of pertussis has been put at 3.8/1000 in the rural areas (8). In Ethiopia the polio
lameness incidence rate is 11.511000 population (12). The OPV3 coverage is 38% in accessible areas. Acute
Respiratory Infections (ARI) is an important health problem accounting for over a third of the causes of morbidity and
mortality in Ethiopian children as elsewhere in the developing world. ARI are the leading causes of out-patient visists
in infants and young children (1-4 years) accounting for 27.8 % and 22.3 % , respectively (10). Bronchopneumonia
(7.9%) and lobar pneumonia (0.9%) were the second and the 14th causes of hospital admission, respectively, in
children under 15 years(9). It is estimated
that most children suffer 4-6 episodes per year(14), most of which die mainly as a result of pneumonia. A rural survey
revealed that 4.7% of all the illness were due to whooping cough and other coughs (8).

Parasitic infections
Parasitic infections are among the top ten causes of visits to health institutions for the 1 - 4 year age group (10). The
prevalence of intestinal parasitism is extremely high (15). The rates vary form place to place; in general most of the
children harbour one or more parasites .

Nutritional Disorders
Breast-feeding is one of the determinants of infant survival. In rural surveys virtually all children are breast-fed at birth
and the vast majority continue breastfeeding through the first year of life (8) whereas, the trend in the urban areas is
on the decline. The weaning period is late with a median of 7.1 months (8). Furthermore, weaning diets are deficient
in protein, energy and micronutrients in many parts of the country .

Protein-energy and micro nutrient deficiencies are rampant. Low income, reduced access to quality food, low health
state, high rate of illiteracy of women, high fertility and population growth are among the major problems contributing
to the increased rate of malnutrition. The daily per capita calorie supply is the lowest (73 %) in the world (6). In a
nation wide survey in .the 6-59 months age group, 64.2% were found to be stunted, 8% wasted and 47.7 % underweight
(8). Hospital discharge summary reports of the Ministry of Health in 1982 E.C. indicate that, from the total discharges,
28.3% of them were children under 15 years (10). Out of these PEM accounted for 4.0% and it was also the 61h
leading cause of all hospital deaths with a fatality rate of 151.811000 (9). Stunting was noted to set in earlier suggesting
the importance of the infancy period in the causation. It is also worth to note that a contrasting difference was observed
between urban and rural childrens' nutritional status; the rural children showed markedly worse condition (16).

Vitamin A deficiency leads not only to blindness but also to sharply increased risk of illness, poor growth and early
death. A nation wide survey consisting of children from six months to six years old revealed 4.8% and 1 % prevalence
of conjunctival xerosis and Bitot's spots, respectively. Both signs of deficiency status were more prevalent in cropping
and pastoral agroecological zones compared with cash crop and 'ensete' zones (17).

Rickets is a disease of paradox in a country within the tropics. There are no data on the extent of the problem. However,
it is a common problem at health institutions. The problem clearly reflects the virtual absence of health promotion in
the health care delivery system. It is among the few preventable diseases with little or no expense or labour.

Iodine deficiency disease is prevalent in Ethiopia. Goiter survey conducted in all regions of Ethiopia, (except Tigray),
showed that the prevalence of gross goitre among school chidlren was 30.6% and that of visible goitre was 1.6%.
More girls had goitre than boys. The prevalence of goitre was higher in children living at higher attitudes than those
at lower attitudes. It is estimated that there are 59% cretins and 176,000 show some degree of developmental and
neurological function impairment (17).

HIV/AIDS
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As many mothers get infected with HIV many babies are delivered infected; most develop the disease and die early in
life. Parental infection leads not only to HIV transmission but also AIDS orphans. In the report of April 1994, among
the total reported cases 1.69% were children (18). The orphaned girls join the pool of the high risk groups because of
destitution completing a vicious circle of disease transmission.

Disabilities
An overall 2.3 % disability rate was reported in the under 15 years children during the 1983 census. Blindness (40.42
% ), physical disability (11.33%) and hearing disability (7.28%). In general the disabilities were higher among the
rural children (19). Child abuse and neglect There is lack of systematicallycolleteddata on child abuse and neglect in
Ethiopia. However there are events and/or practices such as excessive child discipline by parents or guardians, child
abduction, child abondonrnent, use of children as means of begging, child prostitution, child labour, etc. which need
an indepth study of occurrence and determinants (20).

Adolescent Health Problems

Adolescence is characterized by rapid biological and psychological turmoil. Risk- taking behaviours are the
component of the psychological development in this age group. Most high school students have been found to have
started sexual intercourse, consequently some get pregnant (21). Health institution data indicate most of the STDs are
among this age group. Further more, because of the high correlation with HIV infection the reservoir appears to be
massive. From the report of 1994 of the total HIV cases 4.18% were students and 5.58% between 15 -19 yrs age group
(18). Among the high school students in south western Ethiopia 40% practice unprotected sexual intercourse (22).
Surveys at schools have shown that use of khat ( catha edulis Forsk) is common mostly in association with cigarette
smoking (23,24). Poly-drug abuse are not uncommon.

Use of alcohol is also a very common phenomenon. About a decade ago the problem of petrol and gasoline inhalation
has been described to be on the increase (25). Over the recent years, the demonstration of drugs convicts on the media
are the ominous signs of the spread, in particular among the young. The extent of the problem is not yet determined
but it is a threat to the well-being of the young.

Maternal Health
The center of challenge of the health of the child is within the household. Child care is mostly the role of the woman.
It would be incomplete to deal with issues of children without that of the mother. Ethiopian women work at home
and out, especially in the rural areas. The illiteracy rate of Ethiopian women is exceedingly high. Elsewhere,
education of the mother has been consistantly found to reduce birth weight which cosequently lowers child death
rates.

In Addis Ababa women were found to eat less than 60% of the calories and 70% of the protein recommended by WHO
(26). Over 40% of pregnant women are anaemic (27). Both of the above conditions have been demonstrated to result
in intrauterine growth retardation and fetal deaths (26).

Traditional practices
A survey in rural Ethiopia has shown that during illness self-care and resorting to traditional healers were 9.2% and
5.1%, respectively (28). There are many kinds of traditional practices in this culturally rich country. It is of paramount
importance to promote the useful ones and discourage the harmful practices. Application of dung to that: fresh
umblical stump leading to neonatal tetanus, removal of milk teeth to throat diarrhoea and uvelectomy to treat sore
throat, are among the more harmful practices claiming the lives of many.
Table 2: top 20 Diagnoses of 1-4 Year New Out-patients, Ethiopia
(IN BRACKETS ARE %)
1. Acute Upper Respiratory Infection 45193(10.3)

2. Gastro-Enteritis & Colitis 32063(7.3)

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3. Infections of skin & subcutaneous tissue 30671(7.0)

4. *Other Helminths 22566(5.2)

5. Ascariasis 21972(5.0)

6. Bronchopneumonia 20349(4.7)

7. Hypertrophy of tonsils & adeno 18321(4.2)

8. *Other Malaria 17411(4.0)

9. Otitis Media & Mastoiditis 17073(3.9)

10. Gastro-Enteritis & Colitis 16980(3.9)

11. *Inflammatory Disease of Eye 16630(3.8)

12. Amoebiasis 11899(2.7)

13. *All other Infective & Parasitic Disease 11002(2.5)

14. Lobar Pneumonia 8563(2.0)

15. Pyrexia of unknown origin (fever) 8517(1.9)

16. *All other diseases of skin 8072(1.8)

17. *Other dysentery 7447(1.7)

18. Acute Bronchitis 5947(1.4)

19. Bacillary Dysentery 5654(1.3)

20. *Other Diseases & Conditions of the Eye 5215(1.2)

All ther diagnoses 105789(24.2)

Total 437143(100)
Source: Ref 10
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Table 3: Number and percentage distribution of top 15 diagnoses by age, Ethiopia, 1982 E.C. (1989/90 G.C.) For children under 15 years.

Rank Diagnosis Number Percent

All Diagnoses 38836 100.0

1 Tuberculosis of respiratory system 15175 39.1

2 Bronchopneumonia 3055 7.9

3 Falciparum malaria (S.T) 1797 4.6

4 Gastro-enteritis and colitis 1614 4.2

(age 4 weeks to 2 years)

5 Other accidental causes 909 2.3

6 Marasmus 809 2.1

7 Knwashiorkor 721 1.9

8 Other Menningitis 649 1.7

(except meningococcal)

9 Gastroenteritis and colitis 598 1.5

(age 2 yars and over)

10 Homicide and injury 546 1.4

11 Meningococcal infections 460 1.2

12 Infections of skin and 423 1.1

subcutaneous tissue

13 Unspecified Malaria 393 1.0

14 Lobar Pneumonia 376 0.9

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15 Pyrexia of unknown origin 355 0.9

Total of the above 27880 71.8

Source: Ref 9

Table 4: Top 20 Diagnoses of Under-One year New Out-patients, Ethiopia

1. Acute Upper Respiratory Infections 41619 (16.1)

2. Gastro-Enteritis & Colitis 40317 (15.6)

3. Hypertrophy of Tonsils & Adenoids 19701 (7.6)

4. Infections of skin & Subcutaneous Tissue 18484 (7.2)

5. *Inflammatory Disease of Eye 13538 (5.2)

6. Bronchopneumonia 12888 (5.0)

7. Otitis Media & Mastoiditis 8310 (3.2)

8. *Other Helminths 7030 (2.7)

9. *Other Malaria 6200 (2.4)

10. Lobar Pneumonia 5507 (2.1)

11. Ascariasis 5453 (2.1)

12. Pyrexia of Unknown Origin (Fever) 4933 (1.9)

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13. *Other Dysentery 4873 (1.9)

14. Observation without need 4502 (1.7)

for furether medical care

15. *All other Diseases of skin 4455 (1.7)

16. *Other Diseases & conditions of the Eye 4277 (1.7)

17. Amoebiasis 3716 (1.4)

18. Acute Bronchitis 3506 (1.4)

19. Influenza 3148 (1.2)

20. Bacillary Dysentery 3130 (1.2)

All other diagnoses 42621 (16.5)

Total 258310 (100)

Source: Ref 10
Table 5: Mortality by diagnosis among 1815 admissions in the paediatric ward, Jemma Hospital, May 1992 to March 1993.

Primary Diagnosis No. of No. of % mortality % of Deaths

Admissions Deaths

Pneumonia 553 45 8.1 32.4

Gastroenteritis 200 22 11.0 15.8

Tuberculosis 172 13 7.6 9.4

(all forms)

Bacillary 44 10 22.7 7.2

dysentery

5
Meningococcal 41 12.2 3.6
infection

5
Malaria 65 7.7 3.6

4
Neonatal 27 14.8 2.9
diseases

Others 713 35 4.9 26.2

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Total 1815 139 7.6 100

Source: Ref 11

3. Review of the extent of child health problems in the regions (zones) of Ethiopia.

I. Background
The relatively large proportion of children, and the high Infant & Under-five Mortality rate in Ethiopia reflect that this
vulnerable population group is of high priority, particularly in need of appropriate and accessible health care services.

Due to varying health service accessibility, level of utilization, etc. , some of the basic indicators differ among regions.
For instance Infant Mortality Rate (IMR) shows differences among regions. Gondar, Wellega, Shewa, and Sjdamo
had lower IMRs, while Arsi, Gojjam, Illubabor, and Wollo had higher IMRs. The worst IMRs were observed in Gamu
Gofa, Keffa, Hararge and Bale. None of these IMRs is within an acceptable level (29). Fertilityalso varies by region
and residence. TFR ranges from 5.1 children per woman in Wollo to 9 in Bale. In Arsi, Bale, Gamo Gofa and Hararghe,
the difference between rural and urban fertility is significant (29).

The National population density is 47 persons per sq. km. Shewa is the most densly populated with an estimated 120
persons per sq. km. and Bale is the least populated with approximately 14.5 persons per sq. km. (29). Regarding the
proportion of urban-rural population there is considerable regional variation, that is, 7.7 % in Gamo Gofa and 28.2%
in Showa. Urban settings have high growth rate (5.4%) than the total population (3.2%) (29).

In the previous section, an overview of the major childhood health problems have been described. Even though
regional (zonal) level data are scanty and not disaggregated, this part of the review would attempt to present the extent
of the problem in the various regions and zones of the country .

II. Major causes of childhood morbidity, disability, and mortality in the regions. I.
Nutritional disorders.
A. Protein-Energy Malnutrition (PEM)
Up to 1983, wastage in rural Ethiopia was between 5-10%. By late 1983, it increased to 15-20% in parts of Wollo,
North Shewa and Hararge. In 1984, it further increased to 30 % in Bale and Sidamo (29). Child malnutrition in Bale,
Kaffa, Gojam Region which perennially produce food surpluses, was found to be higher than the national average
(29). At present, within those regions relatively unaffected by drought, it is estimated that about one third of rural
children are chronically malnourished and nearly one-half are underweight (29).

The 1992 rural nutrition survey revealed that stunting affected most of the northern parts of Ethiopia, namely Gondar,
Gojam, Wollo and Tigray and also Showa, Sidamo and Illubabor located in the southern part of the central plateau.
Tigray and Gondar, in northern Ethiopia, were again most affected by wasting plus underweight and regions of the
western plateau and extreme south (Sidamo, North Omo, Borena) were also more affected by wasting and underweight
(30).

B. Micronutrient Deficiencies
Anaemia: In 1982, anaemia was the main cause of death recorded in Illubabor hospital (16.3%) and contributed to
many deaths in Gondar (6.9%), Sidamo (2.7%), and Wollo (2.4%) (29). In the Paediatrics ward of Jimma Hospital,
among 1730 patients with secondary diagnoses, anaemia (6.6%) was the most commonly diagnosed ailment (II). A
relatively high incidence of anaemia prevalence was reported from farming cooperatives in Gondar.

Vitamin A Deficiency: Studies showed prevalence rates of Bitot's spot as high as 6% in Gondar and an avarage
prevalence of Bitot's spot to be approximately 1.5%, with higher prevalences in Addis Ababa and lower in Harar,
Jimma, Eritrea and Axum (29). Two studies were done in southwestern Ethiopia among children six months to six
years old. The first revealed 6.9% prevalence of Night Blindness (XN) and Bitot's spot of 4.6% in Agaro town. This
study also documented a significant association (P < 0.05) between nutritional status, family income, and the
 Child health problems in Ethiopia 10
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prevalence of xerophthalmia (31) .The second study was done in Jimma town which revealed 1.2% prevalence of
Bitot's spots and a significant association between conjuctival xerosis and PEM (32).

Blinding malnutrition was reported from 17 villages in Arsi among children six months to six years of age (33). In this
area Vitamin A deficiency of as high as 28.3% was found, but the overall prevalence of xerophthalmia was 10.9%
(Bitot's pots prevalence of .8%) (33). Reports of eye clinics showed that among new out-patients under six years old,
the rate of xerophthalmia for Bale was 11.9%, Wollega 0.8%, and Shewa 0.3%, with an average of 4.5% (34). A 5.9%
rate of xerophthalmia in Gamu Gofa (Gardula) was reported. DeSole reported hyperendemic Vitamin A deficiency in
wheat farming areas of Bale & Arsi, i.e. average prevalence of 5.0% for Bitot's spots, 0.8% for corneal xerosis &
ulceration and 0.5% for corneal scar (17), In Tigray and Gondar, vitamin A intake was less than 40 % of the
requirements and in young children of Arsi pastoralists less than 30% (17).

Iodine deficiency diseases: Very low or zero rates of goitre were observed both in school children and household
members of Alemaya, Jijiga, Awash and Yabello, while high prevalence rates were observed in both groups in areas
such as Gondar, Debarck, Tis-Abay and Felegeneway, in northern Ethiopia (29). A goitre assessment survey was
conducted in a peasant association located on a hill around the outskirts of Jimma Town. The study showed that the
prevalence of goitre was 30.8% in the general population. The prevalence in the age- group 0-9 years was 27.5 % and
in 10-19 years group 32.4% (35)..

Rickets: Unhealthy child-care practices such as non-exposure of infants to sunshine and complete covering while
outdoors in fear of evil eye contribute to the occurance of rickets in Etiopian children. In 1963, a survey in Addis
Ababa among 300 children showed that 41% had rickets (36). According to Kloos & Zein, recent observations
indicated that rickets is It:ss preValent in Ethiopia. However, retrospective analysis of childhood admissions between
May 1990 -March 1993 in Jimma hospital indicated that rickets was the second commonest diagnosis (4.5%) observed
as a secondary diagnosis among 1730 children (11).

2. Infection diseases
Community-based rural survey of percieved morbidity in south-western Ethiopia revealed that 65% of those studied
reported illness within 2 weeks prior to the survey. Among the children less than 15 years of age 16.2 % had some
kind of illness. The main symptoms reported by children were fever (22/57), cough (14/57) and diarrhoea (10/57)
(28). In central Ethiopia (Butajira), the rate of reported illness was 5.8 per 100 person years among children below
five years of age. The study also indicated that the mean number of illness episodes per child per year was 2.3, and
children living in lowlands were found to expirience more illness (28).
 Child health problems in Ethiopia 11
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On the other hand, the rural national nutritional survey (1992) revealed that, North and East Shewa and Addis Ababa
were the regions with the lowest illness prevalence (< 22%) while Tigray (61%), [Link] and Metekel > 50%)
had the highest illness prevalences (30).

A three year review of 1815 Paediatric admissions to Jimma Hospital revealed that 64.2% of all admitted cases were
children less than 5 years old. Pneumonia, gastroenterites and tuberculosis were the major causes of admission (11).
Malnutrition was found in nearly half of the admitted cases. The study also found an overall mortality rate of 76 per
1000, with a significantly high mortality in serverly malnourished children (P < 0.05) (11). Major morbidity and
mortality findings of recent community-based and hospital-based studies is displayed in Table 6 and 7.

Eventhough they differ in methodology (denominator, study pop., period of investigation), these findings would
highlight the major causes of childhood morbidity and mortality in the regions.

Table 6: Leading causes of childhood morbidity from different studies

National Rural Percieved Butajira Project Peadiatric Admission
Nutritional Survey Morbidity Analysis

Population: Under 5 children Children <15yrs Children under 5 Children under 15

Area: All region Jimma Zone Central Ethiopia Jimma Hospital

Total No.: UK* 57 UK 1815

Leading Causes Leading Causes Leading Causes Leading Causes

1. Diarrhoea 1. Fever 1. Acute Resp. 1. Resp. disease
2. Fever 2. Cough infection 2. 2. Gastroenteritis
3. Dirrhoea + Vomiting 3. Diarrhoea 3. Tb (all forms)
Diarrhoea
4. Cough 4. Relapsing Fever
5. Vomiting 5. Meningitis
6. Whooping Cough 6. Malaria
7. Malaria 7. Typhoid Fever
8. Edema (Kwash) 8. Skin Infection
9. Measles 9. Bacillary
10. Others Dysentry
10. Others

Total 5.8 per 100

Proportion = 38.2% 16.2% Person years ----

Table 7: Leading Causes of Childhood Mortality of Different Studies

Jimma Hospital Gondar Hospital Butajira Project
Peadiatric Analysis Childhood Deaths

Population: child <14 Children 3 days to 15 yrs Under 5 children

Area: Jimma Hospital Gondar Hospital UK

 Child health problems in Ethiopia 12
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No: 1815 No. 656

Leading Causes
1. Pneumonia (32.4%) 1. P.E.M. (24.5%) 1. ARIs
2. Gastroenteritis (15.8) 2. Bronchopneumonia (12.2) 2. Diarrhoea
3. Tb (all forms) (9.4%) 3. Pyogenic Meningitis (84%) 3. Measles
4. Bacillary Dysentry (7.2%) 4. Septicemia (7.0%)
5. Meningococal Infection (3.6%) 5. Disseminated Tb (6.1%)
6. Malraria (3.6%)
7. Neonatal Tetanus (2.9%)
8. Others (25.2%)

Mortality

Rate 73.6% in U5 children U5MR* = 209/1000

*U5MR = Under-five mortality rate

A. Diarrhoeal Diseases (DDs). The 1992 rural survey indicated a high diarrhoeal burden in Borena (24% ),
followed by Tigray, Metekel & North Omo (16%). Low diarrhoeal burden was observed in North Shewa & Addis
Ababa (30). However, the figure for the under-fives in Jimma town is 23.6%, with 7.7% having persistent
diarrhoea (36). A longitudinal community-based survey in Butajira indicated that acute diarrhea is the second
commonest illness reported (2.4 per 100 person years) and the highest incidence was among children 2 to 6
months old. This study also indicated that in both infancy and children 1-4 years old, diarrhoea was one of the
main causes of death (13). The paediatric admissions' review of Jimma Hospital also show that diarrhoea was the
second leading cause of admission and hospital death, accounting for 11% & 15.8%, respectively (11).

Table 8: Morbidity and Mortality due to Diarrheal Diseases in Elght Administrative Regions
in Children Under-five years, 1984-1986.
Region 2-week Projected No. Mortality rate
Prevalence of cases/year (per 1000)

Arsi 15.5 4.0 10.0

Ababa Ababa 17.4 4.5 4.7

Eritrea 26.2 7.0 27.0

Gondar 23.0 6.2 15.0

Hararg 18.4 5.0 8.3

Kefa 16.9 4.0 7.7

Shewa 16.7 4.0 17.0

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Sidamo 15.6 4.0 6.9

Source: Ministry of Health, 1990

B. Vaccine preventable diseases (VPD).

In 1989 in the southern regions of Ethiopia the mortality rate of tetanus neonatourm was found to be 6.7 per 1000 Live
Births, accounting for 40% of all neonatal deaths and an estimated incidence rate was 8.4 per 1000
Live Births (12). Polio lameness survey conducted in Arsi, Shoa and Sidamo (1983) revealed a prevalence rate of 3.95
per 1000 and the estimated incidence of 11.5 per 1000 population. In Addis Ababa, the prevalence of the residual
effects of poliomyelites in school children was assessed and revealed a 2.7 per 1 000 prevalence rate and an estimated
incidence of 7.8 per 100,000 population (12). The Butajira study indicated that measles was one of the main causes
of death in both infants and children 1-4 years (13). A community- based survey in rural and urban Gondar Regions
reported a higher mortality rate among babies delivered at home (4.5/1000 than those delivered in hospitals (34). A
household survey in Arsi, Shewa and Sidamo revealed a neonatal tetanus mortality rate of 0.86/1000 live births and
estimated the incidence rate to be 4.3/1000 (34).

Retrospective analysis in the Ethio-Sewidish Paediatric Clinic found the incidence of diphteria to be 0.166 per 1000
population (12). In a community-based study in Konso (Gammo Gofa) during a measles epidemic in 1982, mortality
rates between 7.1 and 20.9% were reported for children (34). In Debre Markos Awraja, Gojam region, measles
incidence was 7.5% in unvaccinated children and 0.3% in vaccinated children (34). In Yebu town (Jimma Zone), the
overall prevalence of tuberculosis was found to be 42.8 % , while the rate (excluding those with BCG scar) was 28.4%.
This tuberculin survey also showed 91.3 % PPD test positivity with BCG scar. Among rural elementary school children
the overall prevalence of tuberculosis infection is 28.4 % excluding those with BCG scar (37). In Addis Ababa Hospital
1 % of new patients were with TB (34). In tuberculin conversion study after BCG vacination in infancy and childhood,
45 % of the well nourished and 55% of the malnoureshed children were found to have a positive Mantoux test. In
general, it should be noted that a great deal needs to be done to assess the magnitude of vaccine preventable diseases
in the regions.

c. Acute respiratory infection (ARI)

The majority of cough and whooping cough symptoms reported during a national rural nutritional survey were from
the northern part of Ethiopia (Tigray (14%), Metekel (9.5%) and North Gondar (7.5 % ), while the least were reported
from East Shewa (1.6%) and Sidamo (1.7%) (2). Respiratory diseases were the first cause of hospital admissions
accounting for 40 % of all paedeatric admission to Jimma Hospital over three years period (3) (Table 5).

Table 9: types of Respiratory Minesses at Jemma Hopital, 1993.

Type of Respiratory Diseases Primary Secondary

Diagnosis Diagnosis

1. Pneumonia 553 171

2. Bronchial Asthma 40 -

3. Others (Group, Otitis 24 -

Tonsilopharyngites, etc.)

Total 617 171

Source: Meseret Eshetu, 1993 (11)
 Child health problems in Ethiopia 14
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In addition, pneumonia accounted for 32.4 % of all deaths with 8.1% mortality rate (II). Assessment of childhood
deaths in Gondar Hospital revealed that bronchopneumonia (12.2%) stood 2.U among the 5 primary leading causes of
deaths (38). The Butajira project showed that ARI accounted for half of all reported illnesses in under-fives. ARI was
also one of the major causes of death in this area (13).

3. DISABILITY
Prevalence survey of childhood disability carried out in Dedo (Jimma Zune), southwestern Ethiopia, showed a
prevalence rate of 15% using WHO methodology (39).

D. Intestinal Parasitism (34)

Amoebiasis: In Gondar region, [Link] was reported in 1.5% of a group of 1,203 school children. In 50 farming
communities covering five administrative regions an average of 19% of 1850 school children were infected with
[Link]. On the other hand, among school-aged children in Shewa, 12% were found infected by E. Histolytica.
Among school children in Addis Ababa prevalence rate was 6.5% , while in Deberezeit School children it was 2.2%.

Giardiasis: In the above 50 communities giardiasis prevailed in 11 % , the rate in Shewa was 3 % , and Addis Ababa
and Deberzeit 9% . Taeneasis: In the school children of Gondar 7.11 % had Taneasis. In Addis Ababa, Harar , Alemaya
the rate reached 37% iil school children. Doubled rates of Taneasis in Addis Ababa and Alemaya school children
between 1960s and early 1980s was observed. Lower taneasis prevalence rates were reported from pastoralist
population of Ogaden and Awash Valley. No [Link] was found among school children in two communities of
Illubabor.

Hymenolepiasis: In 20 communities in and around Hararge, 65 cases of [Link] and one case of [Link] was found
among school children. The highest of H. Nana in Ethiopia was 61 % among school children in Kemise town (S.
Wollo) and < 2% of several pastoral nomads in Awash valley were positive. Ascariasis: Distinct geographic
distribution of ascarasis show that between 50% and 75% of the children examined in Kefa, Gojjam, Wellega, and
Gondarwere infected; 10-40% in Wello Tigray, Gamu Gofa, Sidamo, Illubabor,
Showa, Bale and Arsi were infected; and below 10% in semiarid regions of Eriteria and Harargie. In central and
northern highlands rates ranging from 9-98% , were found. Somewhat lower rates were recently reported from
Harargie, with mean prevalence of 19%. In Addis Ababa 50% of children were infected.

Trichuriasis: It commonly occurs together with Ascaris and mainly affects children. In central and northern plateaus
T .Trichuria was found with a mean prevalence of 49% .Bure (Gojjam) had a prevalence of 100% whereas Mendida
(Shewa) was found to be free of trichurasis infection. It is in general lower than Ascaris, but higher rates were found
in the Didessa Vally (Wellega) and in two irrigation schemes in the Awash Vally. In Addis Ababa & Harar infection
rate was consistent with that of Ascariasis.

HookWonn Infection: It is most common in Ethiopia in the 800-1200m. altitudinal zone and in the humid western
lowlands. Highest infection rates were found in lowlands of Illubabor, Keffa and Wollega and lowest rates in both dry
lowland areas of eastern, southern and northern Ethiopian and highland areas. Prevalence rates in Addis Ababa and
other larger towns are low, reflecting influence of the urban physical environment and the greater use of shoes by
urban dwellers.

Strongyloidiasis -It is low in Ethiopia. Nevertheless, rates of up to 44 % have been reported. Infection is low in many
lowland area, including Ogaden and pastoral areas in Awash Valley.

Enterobiasis:- Most surveys reported low E. vermicularis infection rate. Of 569 school children in rural communities
in Gondar Region 5% had E. vermicularis eggs under their fingernails while only 0.5% of them were found to shed
eggs in stools.

Conclusion
Recently, 31% of 569 school children in Gondar had ova, larvae, and/or cyst of [Link], E. vermicularis, T.
Saginata, [Link] and [Link] from fingernail contents. Hence, the various environmental, social and
educational measures must be systematically carried out to reduce the prevalence and intensity of intestinal parasitism
in the intermediate and long term by raising the health consciousness of the population, by creating a more healthy
physical environment and by promoting socio-economic development; particularly in rural areas.
 Child health problems in Ethiopia 15
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4. Adolescent health and HIV/AIDS

A study done among street children in 1976 G.C, showed that most Ethiopian boys and girls start sexual relationships
at the age of 14 and 15 years (40). In 1990, another study documented that 70% of the youth began sexual intercourse
between l4-16 years of age (40). In rural communities, 75% of females get married at the age of 13-15 years. Such
early marriages would not last long, hence females tend to migrate to urban areas and are obliged to work in bars.
Among high-school students in Jimma town 40% reported unprotected sexual intercourse with one or more partner,
while 52.8 % in Gondar had one or more sexual intercourse, with substantial proportion never using condom (22,41).
The majority of Gondar High School Students had their first sexual intercourse before reaching 16 years of age (41).
In Nazareth town, 23% of the 114 men and 34% of the 126 women studied had more than one sexual partner, and 28%
of the men visited prostitutes (42). The aformentioned situations have increased the number of STDs and AIDS among
adolescents, the most economically active population group.

The surveillance report of the National AIDS control programme (ACP) indicate that between 1986-89, 1.8% of all
reported cases were from regional hospitals. During 1989- 1990 this proportion reached 12.4%. Age distribution of
cases revealed that infants accounted for 1.3% , 1-4 years 0.3% , none in 5-14 years, 15-19 years 5%, and 20-29 years
42% .In rural areas, high risk practices for HIV infection and transmission was documented among rural residing
exsoliders, merchants and students. In this study 45-50% reported extramarital sex within 3 years and 25-37% had sex
with urban commercial sex workers (43).

5. Maternal health
Anthropometric measurements of women in reproductive age group in Jimma revealed that 60% of women weighed
more than 40 kgs, 37% between 40-50 kgs and 3% lower than 40 kgs (44). The Body Mass Index (BMI) showed that
11.5% were below the 18.5 kg/m2 cut-off point (44). In Sidamo, on the basis of BMI, 16% of the 226 women studied
were classified as suffering from second or third-degree energy malnutrition (34). A community-based anthropometric
assessment of Oromo, non- pregnant women of child bearing age in eight peasant associations in Jimma Zone found
the mean weight to be 46.9 kgs, with 75% weighing less than 50 kgs. The mean BMI was 19.4 kg/m2 and 35% of the
women had a BMI lower the 18.5 kg/m2 (45).

Anaemia in pregnant woman was assessed in urban (Addis Ababa) and rural (Wolliso) settings. In Wolliso 44 % of
the urban attendants and 57% were found to be within 24% to 36% range, indicating the prevalence
of mild and moderate anaemia (WHO) (46). Low birth weight (LBW) is one of the most important nutritional
indicators in assessment of childhood malnutrition. Estimates of LBW from hospitals ranges from 3% to 17% and 7
% rate was reported from Addis Ababa (34). Community-based study around Jimma Town found a LBW rate of 10.6%
(47), while reports from Jimma Hospital found 14.2% had very LBW rate and 31.4% had LBW. The majority of LBW
were observed in mothers less than 19 years and 20-25 years old (48).

4. Review of policy options, plans and ongoing interventions for child health in Ethiopia.
1. The Problem (Magnitude, Pattern and context)
The review of major indicators on child health in Ethiopia shows that the situation is quite grave(49).

The rates of infant and under-five mortality in Ethiopia are very high. It is estimated that children below five years
of age account for about 50% of total recorded deaths. Sixty percent of the under-five mortalities occur among
infants, half of whom die before the age of one month as a result of high perinatal and neonatal deaths.

There is a high number of childhood 'streetism' in urban centers of Ethiopia resulting from broken homes, poverty,
displacement, rural-urban migration, etc. The estimated prevalence of childhood disability is close to 15% which is
much mgner than that for adults. The practice of child abuse and neglect, though not systematically reported, is
rampant in Ethiopia.

The leading causes of morbidity, mortality and disability in Ethiopian children are malnutrition, diarrhoeal diseases,
vaccine preventable diseases, acute respiratory infections and locally endemic diseases including malaria, tuberculosis,
etc. For Ethiopian mothers, the leading threats to health are associated with pregnancy and childbirth. They also
suffer from malnutrition, anaemia and from locally endemic diseases such as tuberculosis, malaria, etc.

The situation of health and disease of children and mothers in Ethiopia depicts three patterns (50):
 Child health problems in Ethiopia 16
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1. There are interactions among health problems. The leading causes of morbidity and mortality in children are known
to greater extent. But it is important to understand the ways in which these causes interact with one another, often
reinforcing one another .

Thus, malnutrition renders children more susceptible to infectious diseases, such as diarrhoea and respiratory
infections. Diarrhoea and other infections, in turn, exacerbate the malnutrition, and the child can thereby cycle
downward in a deterioration of health.

2. The health problems are interactive with social and economic factors.

3. Ethiopian children and mothers have differential access to PHC and other levels of health services. Such interactions
of the causes of disease/death are more common among children who live in poverty and deprivation. Managing
such disease complexes often requires dealing simultaneously with more than one condition.

Efforts to limit morbidity /morality are often thwarted. For instance, even though 20-25% of under-five mortality
might be due to vaccine preventable diseases, immunizing the children they not decrease mortality by that amount.
Even if protected by immunizations, the children might retain vulnerable to malnutrition and diarrhoea or respiratory
infections.

Conditions affecting Child survival and development are interlinked(29). Those factors which cause high rates of child
death are similar to those which prevent children from developing physically and mentally. Furthermore, the survival
and development of children cannot be separated from the development of women. The women's situation is an integral
part of child health.

The high morbidity and mortality burden in children and the women are the end result of a series of processes operating
at various levels in the Ethiopian society. They are complex and may be addressed in the context of the country's low
level of socio-economic Development(29,51,52).

II. Policy and Plans (53,54,55,56,57,58)

Cognizant of the magnitude, prevailing, emerging and resurging health problems of ctlildren in Ethiopia, the various
sectoral ministries have formulated policies and plans of action.

1. Ethiopia, a signatory to the Alma Ata Declaration in 1978 is committed to the implementation of Primary
Health Care as the strategy for health development.
2. The Transitional Government of Ethiopia has adopted and ratified the convention on the rights of the child
on December 9,1991. Following its ratification by the Council of Representatives, the convention has become part of
the legal system of the country by proclamation No. 1011992 and was published in the Negarit Gazette on January
30,1992. It empowers the Ministry of Labour and Social Affairs to undertake all acts necessary for the implementation
of the convention.
3. To facilitate the task of addressing the vast economic and social problems, the TGE has enunciated the
following major policies during1992 -1994. a) New Economic Policy
b) Health Policy
c) National Population Policy
d) National Policy on Ethiopian Women
e) National Social Policy
f) Education and Training Policy
g) National Disaster Prevention and Management strategy
4. The aims enunciated in the Health, Population, Women, Education and Social policies, in particular, are
compatible with those provided in the convention on the rights of the child and Primary Health Care (PHC).
5. The Ethiopian government is committed to the realization of the provisions of the convention on the rights of the
child subject to the objective realities of the country. Its commitment is reflected first and foremost, by
the ratification of the convention and its incorporation into the country's legislation. It is also shown by the efforts
made to prepare a National Program of Action (NPA) for children and women (1994-2000). Furthermore a
proclamation (No 102/1994) to ratify the standard basic cooperation agreement between the TGE and UNICEF was
enacted on 29 August, 1994
 Child health problems in Ethiopia 17
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6. The draft NPA was formulated taking the specific realities and capacities of the society into account, hence the
goals set are less ambitious than the global goals set by the summit.
7. The operationalization of the NP A is envisaged to be undertaken as part and parcel of the National Development
plan, to be executed through existing governmental institutional structures and community organizations.
8. The main problems hampering the implementation of the convention on the rights of the child in Ethiopia lie in
the poor socio- economic condition of the country, and the lack of adequate and effective implementation
mechanisms.
9. The Health policy of the TGE incorporates the following major principles.-
a) Democratization and decentralization of the health service system
b) Development of the preventive components of health care
c) Assurance of accessibility of health care for all segments of the population, and
d) Promotion of the participation of the private sector and NGOs in health care. Child Health is one of the
priority areas in the health policy.
10. The strategies which are given special emphasis within the health policy framework are:-
a) Democratization and decentralization of the health system
b) Intersectoral collaboration
c) Health Education
d) Promotion of Family health Services
11. The operational strategies of the health sector elaborated in the draft NP A is similar to that of the strategies
of the health policy. In both cases, the PHC approach which constitutes curative, preventive, promotive and
rehabilitative health care with focus on women and children, is taken as the relevant strategy for Ethiopia.
12. To ensure the implementation and monitoring of child health programs (Expanded Program on
Immunization, Control of Diarrhoeal Diseases, Acute Respiratory Infections, Growth Monitoring, Adolescent Health),
a Child Health team is designated in the department of Family Health of the MOH. In accordance with the guiding
principle of decentralization and democratization, the MOH is responsible f(>r
issuing policies, setting national targets and monitoring implementation of programs. The regional health bureaus are
responsible for planning, implementation and monitoring of health programs in their respective region in order to
achieve the national targets.

The NP A has set the following goals for the improvement of child Health in Ethiopia by the year 2000 (53,59).

1. Reduction of infant and under-five mortality rates from the current 101 and 152/1000 Live births respectively, by
50%.
2. Reduction of MMR (from the current 700/100,000 LB to 420/100,000 LB).
3. Reduction in morbidity, mortality and disability caused by the six child hood diseases through immunization of at
least 80% of children under one year of age.
4. Elimination of Neonatal Tetanus via immunization of at least 80% of pregnant women with Tr2 and through the
promotion of hygienic and safe delivery practices.
5. Significant reduction in the number of polio cases as a step towards achieving the goal of eradicating polio.
6. Reduction by 95% of deaths caused by measles and a 90% reduction of measles cases. 7. Reduction in the current
diarrhoea- associated mortality rate (9.2/100 cases) by 50%.
8. Reduction in mortality from Acute Respiratory infection in children under 5 by 30% 9.
Reduction in severe and moderate malnutrition in children under 5 by 50%.
10. Provision of safe, adequate and reliable water supply services to at least 35% of the population.

III. Ongoing Interventions (59)

1. Expanded programme on Immunization (BPI)
This program was launched in 1980 with the aim of attaining a 10 % increase in coverage per year so as to gain
universal coverage by 1990.

The objectives of EPI are to reduce morbidity, mortality and disability in children from the 6 diseases. The strategies
adopted are, static, outreach and mobile. As part of the program, several managerial training courses have been
conducted involving different levels of health personnel. In view of several constraints including access, logistics,
community mobilization, management, etc the coverage remains one of the lowest to date (28%).
2. Control of Diarrhoeal Diseases (CDD)
 Child health problems in Ethiopia 18
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The objectives of the CDD program are the reduction of diarrhoeal mortality and morbidity. The primary strategy for
reduction of mortality due to diarrhoea in. Under-five children is effective case management. Morbidity reduction
strategies are actions towards hygiene, clean water supply and sanitation, nutrition and immunization.

Few surveys indicated that ORS use rate is 22% and non-treatment rate at 64%. The program has conducted several
high and mid-level health professionals training courses on the management of CDD.

The National CDD program became fully operational since 1983. Limited information suggests that these are
important variations in mother's knowledge and practices in all the three major components of home case management,
continued feeding, increased fluids and timely referral. The program lacks cohesive and systematic communications
strategy to ensure the improvements in knowledge and the changes in behaviour at household level. Furthermore, the
CDDP dors not seems to have been accorded sufficient importance as a key public health intervention.

3. Control of Acute Respiratory Infections (ARI)

The ARI program was launched on pilot basis in 1990. The primary objective of the program is to reduce mortality
from ARIs, especially pneumonia and secondarily, to reduce the severity and complications of ARIs and encourage
the rationale use of antimicrobials and utilization of immunization services.

To enhance the program, physicians and nurses were trained on case management practices. Training was also given
for trainers of the future.

The major constraints in the way of expanding the ARI program are insufficient training on proper diagnoses and case
management, and the limited supply of drugs.

4. Growth Monitoring (GM)

Despite integration of OM and promotion in MCH activities in health units since 1988, these activities are not being
adequately performed. Most of the time, they are reduced to weighing and charting of children. Outreach and
community-based approaches are limited. Mothers' knowledge on child growth has been found very low in some
surveys. The practices such as unhealthy traditional, improper weaning, etc are rampant.

5. Although there are variations of thought on the provision of day-care for children, there are a good number of them
particularly in urban areas. Information on the practice, standards of care and the health status are scanty.

6. Available information on the state of health of students and school health service as a whole are scanty. In Ethiopia
the overall responsibility of school health is that of Ministry of Education with some technical support from MOH.

7. Services for adolescent health are just starting in the form of generating advocacy from government and
communities.
IV. Considerations to Achieve Optimum and sustainable child Health Care in Ethiopia

1 Epidemiological (51,60)
1.1 The leading causes of infant and child deaths are known. But it is of paramount importance to
understand the ways in which those causes interact with one another, so that interventions for simultaneous
action could be projected.
1.2 In order to focus priorities on the most appropriate interventions for local child health problems and
to target health services, reliable epidemiological information is needed. The health units that collect, collate,
compile and transmit health related data should know the denominator and what changes are taking place in
the catchment area. This is of importance not only for forward planning but setting priorities and use of
resources.
1.3 Innovative techniques have been evolved in Epidemiology in recent times. The techniques are quick,
easy and readily helpful to assess, analyze and act on health problems particularly in maternal and child
health. The innovative techniques of rapid epidemiologic assessment are:-

1) Prevalence rates of maternal and child mortality

2) Prevalence of disability
3) Methods of Surveillance and monitoring
4) Indicators of risk and health status
 Child health problems in Ethiopia 19
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5) Sampling methods
6) The 'indirect' Health interview Techniques
7) Ethnographic surveys
Using these Techniques, Regional, Zonal and Woreda Health Departments may produce data required for planning,
prioritising, target setting and monitoring and evaluation within a short time and with less cost. A desirable option is
to train front line health workers in the application of the techniques.
1.4 A good deal of research and many programs are aimed at food security. In the area of health, considerable
research has been done linking nutrition and infections. But in the area of 'care', there is lack of
information in terms of having good assessments of caring practices related to nutrition in our
communities.
1.5 To monitor progress in child health, it is important to avoid "the fallacy of the average".
Average levels of immunization coverage, ORT use rate, U5MR, may mask serious disparities among boys and
girls, ethnic groups, regions, woredas, economic strata etc. Therefore disaggregating health information and focusing
action on specific groups is necessary 2 Technological(51,52)
2.1 Today, the technology and the knowledge are available to deal with many of the causes of disease and death in
infants and children: 1) Effective Vaccines
2) Antibiotics for respiratory infections
3) Contraceptive techniques
4) Oral Rehydration Therapy
5) Food and Nutrition Technologies 6) Facts For Life Messages
7) Social Mobilization Technologies

2.2 The problems lie with application necessitating efforts to reach the population segments.

3 Organizational (50,61,62)
3.1 To bring better health for children in our circumstances, efforts need to be centered at household
and community level. At this level, key health decisions are made on a daily basis. Households affect health
through the food they produce or buy, their source and treatment of drinking water, self care practices, use
of traditional healers, purchases from private pharmacies, and as clients of privately and publicly provided
health services. The health system should focus on household capacity for health and conceive of health
services as support to households.
3.2 Integration of services Child health is dependent upon a continuity between preconception nutrition,
a healthy pregnancy, a safe delivery and the satisfactory establishment of lactation. Services should be
integrated not only on vertical and horizontal dimensions but across time also.
3.3 Development of PHC that has the potential for incorporating the five cardinal principles: 1)
Universal coverage, with care according to need (or risk)
2) Effective, Affordable, accessible,
culturallyacceptable
3) Promotive, preventive, curative, rehabilitative
4) Community participation so as to promote
self-reliance
5) Interaction with other sectors of development.
.4
3.4 Realization of a shift from 'intervention' to 'involvement'. It should be recognized that there is a
conventional wisdom in every community, and that people are able to think and act constructively in
identifying and solving their own problems, the emphasis in health care is shifting from intervention to
community involvement.
3.5 The Health sector should be supported by skilful, transparent and strategic management so that it is
able to provide optimum care for the population.
3.6 The Health sector problems that need to be addressed: 1) Scarce resources are being used
inefficiently
2) In the public health care people often face uncaring and inadequately trained staff, long waiting times, inconvenient
working hours and they lack confidentiality or privacy.
3) In the private sector, people are at risk of financial exploitation with no safeguards against potentially dangerous
treatment
3.7 Health institutions, structures and systems need to deal with issues of efficiency, access, cost
containment and responsiveness to public demand
 Child health problems in Ethiopia 20
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3.8 There is a growing body of knowledge about the relative merits of user charges, community
financing, insurance, etc to raise cash for the health services
3.9 Governmental and Non-governmental health organizations should attempt to work for equity, avoid
duplication of efforts and waste of scarce resources for health care in general and child health in particular.
4) Social-Political-Economic complex (50,55,61,62)
4.1 Health development to be considered as an essential component of social and economic
development and not merely as a humanitarian issue.
4.2 One of the most important lessons of the past few decades is that respectable levels of human
development have been achieved in low economy countries that have the right priorities. e.g. Sri Lanka,
Democratic Rep. Korea, Viet Nam and Egypt.

The point is that human progress need not await national economic prosperity; political will to improve peoples' lives
can work miracles even in the midst poverty and under development.

4.3 Culture and Tradition (55) The Ethiopian population exhibits variation and diversity in
ethnicity/nationality , language, culture and religion. These variations have important influence on
perceptions and concepts of health and disease, and practices which may have positive or negative influences
on health including child health. Therefore assessments, analysis and action towards improving child health
need to consider these issues.
4.4 Realistic social mobilization, decentralization of services and implementation of policies should be
carried out.
4.5 Policy statements, however good they may be, do not generate good results of their own accord. The
statements need to be perceived, accepted and understood by all concerned for implementation
4.6 The Economic environment that enables households to improve their own health should be created
including poverty reduction schemes, improving the status of women, investment in education, etc.

Conclusion
Childhood deaths account for nearly 50% of all deaths in developing countries including Ethiopia. Although initial
reductions in mortality can often be achieved through the existing health technology, it is now recognized that
sustained reductions in infant and childhood mortalities could be achieved more effectively through programs that
address the biomedical, socio-economic, cultural, political and environmental determinants. The design and
implementation of Child Health programs that include socio-economic development and behavioral change require
the collaborative efforts of planners, service providers and researchers.

5. Some Areas in which the Ethiopian Public Health Association (EPHA) may play its advocacy roles to
improve Child Health in Ethiopia.
1. Definition of public health
" The science and art of preventing disease, prolonging life and promoting health through organized efforts of society
"(63)

It is concerned primarily with health and disease in populations, complementing clinical medicine with its concern for
the health of individual patients.

Its chief responsibilities are monitoring the health of a population, the identification of its health needs, the fostering
of policies which promote health, and the evaluation of health services.

2. The objective of Ethiopian public health association

The Objective of EPHA is the advancement of measures for the promotion of health, prevention of diseases, care of
the sick and rehabilitation of the disabled by various strategies including policy recommendations, advancing research,
establishing forum of communication, etc.(64)

3. Some activities EPHA may undertake to improve and advance Child Health in Ethiopia(65)
1. Develop mechanisms /explore ways to dissolve institutional and sectoral barriers for child health care.
2. Propose resolution in support of the world summit for children which has been ratified by the TGE urging
government, Non- government Organizations communities etc to implement it.
 Child health problems in Ethiopia 21
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3. Formulate strategies to adopt smoke free work places and residential areas in Ethiopia. 4. Develop ways to formulate
and enact Public Health legislation in Ethiopia
5. New approaches and strategies should be developed by the public health profession, so that international
goals such as HFA/2000, Safe Motherhood and Baby Friendly Hospital Initiative, convention on the rights of the
child, etc can be implemented.
6. Develop strategies for extending the benefits of Health Science Technology to children to prevent the
proliferation of diseases, strengthen Capacity, spur sustainable development, slow population growth, ease stress on
the environment, etc.
7. Establish a Clearinghouse of Child Health information. This would enable professionals from across the
country to access important information on health and disease state of children in Ethiopia 8. The Association should
collaborate with the Other sister associations or societies for assessment, analysis and action on child health problems.

9. The EPHA should set up sections within the association for M CH, Policy, Planning and Evaluation of Health
Services.

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