RIGHT TO HEALTHCARE IN ETHIOPIA: Then, Now and Tomorrow
G. Amare 12-05-15
The Pre-1991 Ethiopia
The pre-1991 period refers to the political structure where the power of decision-making completely remained in the hands of the central unitary Government. This system didn't encourage the rural majority to actively participate in policy formulation to bring political and socioeconomic developments and improve their living conditions. It failed to recognize their roles in aspects such as need identification, resource allocation, and prioritization.
Until now, the rural population being predominant in proportion, are leading their lives under disadvantaged and unprivileged conditions, facing all kinds of avoidable and preventable socioeconomic problems related to manmade and nature made calamities. They have been unfairly suffered from inequity in healthcare.
Regardless of age, gender, socio-economic or ethnic background, health is considered as the most basic and essential asset.[] Particularly, for people living in poverty, their health may be the only asset on which they depend to exercise their right to other economic and social services.
Right to health is a fundamental human right and human rights are interdependent, indivisible and interrelated. Thus, violating the right to health often impairs other fundamental human rights such as right to education or work. [,,3] The principle of right to health also states that functioning healthcare facilities and services must be available in sufficient quantity and; they must be physically accessible in safe reach for all sections of the population in a non-discriminatory and in an equitable manner.
Right to health, which also contains entitlements to prevention, treatment and control of diseases; access to essential medicines; equal and timely access to basic healthcare services; and participation of the population in health-related decision making,[] is not a new concept. Rather, it was articulated in the 1946 Constitution of the World Health Organization; [] then, the 1948 Universal Declaration of Human Rights also accentuated healthcare as part of the right to an adequate standard of living; [] and this was again recognized as a human right in the 1966 International Covenant on Economic, Social and Cultural Rights which affirmed that right to health is understanding of a life in dignity. []
However, the provision of healthcare service has never been materialized in Ethiopia as a right. Even today, millions of Ethiopians lack access to quality healthcare and health related information; safe drinking water and adequate sanitation; adequate nutrition; and primary education. Majority have been discriminated from enjoying their right to health and discrimination, a key human rights principle, is described as marginalization of specific population groups which is generally at the root of fundamental structural inequalities in society and this, in turn, may make these groups more vulnerable to poverty and ill health.[, ]
Without question, human health is intricate and is not only affected by physiology of the body but also by social structures, culture, politics, and economics.[] The impacts of physiology-biology and chemistry-are, in most instances, beyond one’s control but the effects of culture, politics, and the social structure are within politicians goodwill of politicians i.e. require consistent commitment, undeterred determination, and flexibility to adopt a policy that is formulated with a purposive plan to address the people’s political, economic and social needs.
Mehari E, citing other sources, documented that modern medicine came to Ethiopia during Emperor Libne Dingel (1508-1540). Successive emperors also communicated and established connections with different parts of the world in an effort to handle and treat health problems and sporadic cases of epidemics.
Indisputably, this opened the door of opportunity for modern medicine to enter into Ethiopia and could have served as a prospect to expand healthcare. Nevertheless, the Emperors' level of intellect and consciousness did not allow them to connect the dots and pursue further communications and establish diplomatic relationships to stride forward and formally establish healthcare facilities of their own and provide viable healthcare services to their people.
It was only after Emperor Menelik II (1889-1913) came to power, a great number of missionaries and diplomatic communities came to the country to practice medicine in properly established settings. Emperor Haile Selassie, following the footsteps of Emperor Menelik, showed efforts to expand healthcare services by establishing health facilities though limited to big towns and urban dwellers.
Haile Selassie also established health professional training centers and colleges. Particularly, the establishment of the Gondar Public Health College seemed to have commendable intention when it comes to promoting basic healthcare services and preventive educations to the rural communities. This college existed for some years producing health officers, sanitarians and community nurses that after completing their education used to function as a team in health centers located closer to the rural communities. However, despite its clear intention and relevance to the rural people, the program discontinued to achieve its goals because a shift in government policy disallowed its organic existence.
It is hardly possible to track formally formulated health policies prior to 1960s. It was in 1963 that Ethiopia had formulated a health policy-adopted through the World Health Organization Initiative-with a framework to expand decentralized basic healthcare services network, with emphasis to providing an integrated preventive and curative services.
The reign of Emperor Haile Selassie was not fortunate enough to widely implement its health policy as it was forcefully unseated from its throne and handed over its power to Derg in 1974, consequent to the public discontent and unrest against the feudal system. Relevantly, I doubt if the system had a genuine commitment and willingness to decentralize power that would allow the local people to participate in decision-making and get involved in the process of policy implementation.
The Derg, after solidifying its power, launched a health policy that addressed the principles of Primary Healthcare (PHC). This policy was very tempting as far as the rural population is concerned. Its basic guiding principle was “Health for All” by the year 2000.
However, the policy did not travel long distance to bear fruit. For one reason, the country had never been politically stable throughout the Dreg’s life time. First, the country underwent through a revolution that was disastrous, and a revolution that took the lives of massive number of finest citizens, with accumulated knowledge and expertise that the country had invested in for years.
Second, the country confronted with wars that were catastrophic and occurred one after the other for several years which consumed the country's meager resources. Wars that left many citizens, from all sides of the war fronts, with posttraumatic stress disorders and injuries, and physical and mental disabilities; and wars that had limited the day to day functions of all available hospitals in inner cities to serving wounded soldiers or otherwise remained on standby waiting for causalities to come from battlefields, closing their doors to the general population.
For the second reason, the policy did not critically evaluate the barriers and enablers useful for successful and fruitful policy implementation. For example, Derg didn't show efforts to bring changes in the centralized administrative structure to acknowledge and encourage the rural communities' role and involvement; and it didn't appreciate the rural majorities right to make decisions on matters pertinent to them. Importantly, there was no sustainable commitment to invest in infrastructure developments. The focus was on war and resources were committed to war.
Apparently and particularly, the rural Ethiopians have been deprived of their equity and timely access to basic healthcare due to factors that included political instability; inconsistent policy direction; environmental and lifestyle factors; and sociocultural barriers; and lack of commitment to improve social services.
Therefore, despite the introduction of modern medicine around 16th century and in spite of the fact that Ethiopia was one of the countries in the world that had adopted primary healthcare as its national strategy since 1976, Ethiopia’s health service trailed way behind the rest of the world. The service remained limited to citizens at urban places, which at present are less than 20% of the population and even in those places, the distribution was not even and did not guarantee any equity and accessibility.
Thus, majority of the population has been suffering from unequal and unjustified delivery of modern health services and hence, they continued to depend on various archaic remedies and religious beliefs: herbal, sorcery, holy-water and harmful traditional practices to cure or alleviate their illnesses or sufferings for centuries. However, readers should be aware of the fact that many people around the globe still use herbals and traditional practices hand-in-hand with the conventional medicine.
So, I am not trying to dismiss the value of herbal remedies and traditional practices. Instead, what I am trying to convey is the fact that majority of the Ethiopians solely depended on herbal remedies, religious beliefs, and traditional practices not by choice but as a necessity and as the only available option to cure or alleviate their illnesses and sufferings.
Some of the practices included but not limited to: (i) bloodletting using “Wagemt”-traditional tool made from a horn and razorblades or sharp stones to mutilate the skin to let the blood flow out; (ii) cauterization (stabbing with a hot iron or a burning thin straw) used to treat illness such as headaches and other throbbing pains; (iii) chewing, drinking, or applying traditional plants claimed to have remedial effects for myriad health problems; and (iv) The practice of “we’ge’sha”: a traditional practice used in place of the modern day orthopedics to fix injuries to bone fractures and joint dislocations of victims using locally made traditional splint.
Again, there is one important point that readers should be well informed. This writing is neither in any way undermining the historical use of bloodletting nor denying its applications in today's medical practice. It is very important to point out that bloodletting has been utilized in medical practice for various indications since the ancient times. However, by the late 1800s new treatments and technologies had largely edged out bloodletting and the medical community seriously questioned the merits of this practice because it killed far more people than it cured and studies discredited its use.[,,, ] As a matter of fact, excessive blood loss due to bloodletting was implicated for the death of two world renowned individuals, America’s first president George Washington and King Charles II of England.[] This writing lacks documented information about numbers of people that may have lost their lives due to excessive blood loss associated with the practice of bloodletting in Ethiopia.
Relevant to mention, in ancient times, bloodletting was used to treat and prevent almost every illness. However, today’s modern bloodletting therapy is coming back to be used only to treat a few specific medical conditions of which medical research has proven the benefits: bloodletting could be used with periodic phlebotomy to maintain ferritin levels at a reasonable level so as to minimize further iron deposition; to reduce the red blood cell mass; to decrease the chance of dangerous clots; and to improve cholesterol, blood pressure, and blood glucose levels for people suffering from metabolic syndrome.[]
The consciousness of the majority of the Ethiopians as to what causes illness has been also nothing but a punishment from almighty God for wrong doings and committing sins and so they used to leave their illness untreated until the cure comes from God through consistent and unyielding prayers.
It may seem difficult to believe but it is a documented fact that was aired on television that communities in one part of Ethiopia have a primitive belief that bleeding that occurs during a child birth brings a curse on the family and for this reason they let the woman to give birth in isolated places without any attendance or help from others, in a bush and around a river far from their village. The woman would only be reunited to the family after she became clean of the blood and if she is lucky to give a safe birth without any complications and without losing her life.
Thus, the healthcare service of the past day Ethiopia was both painful and nerve-wracking to recall. It has been painful to hear and read about Ethiopia being the least among the sub-Saharan countries. Until recently, the conventional healthcare parameters- including infant and maternal mortality; life expectancy; morbidity and mortality from communicable diseases; and malnutrition-witnessed Ethiopia to be among the most disadvantaged nations in the world.
Despite the introduction of modern medicine to Ethiopia centuries ago, Ethiopia has not been in a position to provide basic healthcare to majority, estimated to be over 80% of its population residing in rural places and experienced all the worst sufferings on earth-by natural cause and or manmade ones. They experienced all kinds of avoidable social problems: hunger, war, illiteracy, and death due to communicable and preventable health problems. They were living in a country that was labeled as an example to define famine in a worldwide known dictionary, serving as a source of embarrassment to many who got the chance to travel out of the country for different reasons.
So, what went wrong in the past day Ethiopia? The answer to this question is wide open for research and right now, I don’t have concrete answer. But, one thing is certain. Ethiopia has made a backward journey that reversed its history of civilization. Look at the Axum obelisks; look at the Fasiledes Castle; and look at the Rock-Hewn Churches at Labella, which are all ancient but exceptionally attractive and amazing works that are still standing to witness Ethiopia’s early history of civilization.
For sure, there were lights of civilization in the hands and minds of forerunner Ethiopians. However, a blackout replaced those lights of civilization, covered the eyes of descendants and led them to live in darkness for centuries. I think, Ethiopia had made a U-turn at a wrong driveway and drove to a destination where its history of civilization was conquered by histories of war and famine which is aching to recall.
Though, it is not easy to forget about how and why this happened it is not worthy to dwell on it. Now it is only history and history is good only if it helps us: (i) learn from our mistakes and failures; (ii) make plans for future progresses; and (iii) ultimately, get back to the right driveway that will lead us to civilization. As they said, “It’s no use crying over spilled milk” so better to leave it behind and move on with the fresh run.
Stay tuned for the final Part (4)
Vienna Declaration and Programme of Action (A/CONF.157/23), adopted by the World Conference on Human Rights, held in Vienna, 14–25 June 1993.
American Public Health Association. Constitution of the World Health Organization. Am J Public Health Nations Health. Nov 1946; 36(11): 1315–1323.
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