Ethiopia is the country with the highest rates of child and maternal deaths in all of Eastern and Southern Africa. The same applies to protein-energy malnutrition(PEM) and to long-term development retardation of survivors. The problem is deep-rooted in areas of prolonged civil war and drought, where social rehabilitation becomes much more complex due to disruption of social support networks, displacement of populations and environmental degradation.

The health status of women and children in Ethiopia has deteriorated markedly during the last decade. Between 1970 and 1981, infant and child mortality rates were on the decline. Between 1984 and 1991, however, these indicators have steadily deteriorated. The reversal is related to decreased access to health services, persistant famine, increased prevalence of malnutrition and civil war. The situation is illustrated by an Infant Mortality Rate (IMR) of 101.1 per 1000 live births (LB), an Under-Five Mortality Rate (U-5 MR) of 152 per 1000 live births, and Maternal Mortality Rate of 700 per 100,000 live births.

The underlying causes of children's and women's deaths can be attributed to household food insecurity, inadequate environmental sanitation and safe water supply, inadequate access to health services and inadeqate care of children and women. Inadequate care results in improper feeding practices for children and poor dietary habits for women during pregnancy. In Ethiopia, this is usually the result of an excessive maternal work burden and lack of mother's time to take care of the child and herself.

The health infrastructure is very weak. Health coverage, defined as population living within 10 kms from a health facility, is 46%. This means that the majority of the population has no access to modern health services of any kind. The health coverage of women and children is even lower because of overloaded domestic activities, poor female-headed households, social barriers to females travelling outside their community for health care, unavailability of transport, traditional illness beliefs, and lack of effective community-based health services. It is not surprising that only 16% of women receive antenatal care and 15% of children receive health care.

The utilization rate of programmes such as Mother and Child Health/Family Planning (MCH/FP) and Control of Diarrhoeal Diseases (CDD) range from 4 to 38 per cent. The Expanded Programme of Immunization (EPI) coverage by the end of 1990 had increased to 59 per cent for DPT3 in accessible areas. However, DPT3 coverage decreased to 13 % by 1992. This was mainly because only 53% of the health facilities were providing EPI during 1992 and also due to the low utilization of health facilties.

Implementation of current health policies and PHC strategies and programmes is still inadequate despite its initiation some fifteen years ago. This is due to absence of clear conceptualization and policy formulation; lack of real community participation and weak health management. The formulation of new health and drug policies is underway.

Decentralization is the most important positive factor in recent government policy. Regions are given the power to design and implement their own economic and social development programmes, including health. Policies and guidelines are being shaped to facilitate proper implementation of the decentralization process.
 

HOUSEHOLD FOOD SECURITY AND NUTRITION

The nutrition situation in Ethiopia has deteriorated during the last 25 years. The major forms of malnutrition are Protein Energy Malnutrition (PEM), Vitamin A deficiency, and endemic goitre. Among children under 5 years of age, 8% have acute malnutrition (wasting), 64% chronic malnutrition (stunting) and 46.9% are underweight, indicating that approximately 5 million children in the country are malnourished. Iodine deficiency disorders (IDD) , as measured by goitre, have a prevalence of 26%, indicating approximately 12 million people are at a risk of IDD. The number of cretins was projected to be 37,000. Vitamin A deficiency (VAD) is a major public health problem. Low retinol levels in serum are seen in 60% of children 0-6 years of age and affecting aproximately 5 million children in this age group. The 1992 ENI study indicated that all of the children of this age group, 0.87 % (about 73,600) children present Bitot's spot. With the overall increase in malnutrition reported in the country, it is likely that at present even more children are deficient in Vitamin-A. Studies on nutritional anaemia in Ethiopia indicate that its prevalence is not very high: 17.4% among pregnant and lactating women. The study also indicated that 27% of lactating mothers are malnourished (less than 18.4 Body Mass Index). The prevalence of low birth weight babies, an indirect indicator of maternal malnutrition, is 15%.

The nutritional situation of Ethiopian children worsened during the last decade. A comparison of nutrition surveys undertaken in 1983 and 1992 shows that the proportion of underweight children has increased from 37.3% to 46.9%. For this reason malnutrition is one of the main health problems in Ethiopia and a major cause of high under-5 and maternal mortality rates.

The immediate causes of malnutrition in Ethiopia are low food intake and a high prevalence of infection, which exert a synergistic effect on undernutrition ad mortality.. The underlying causes are related to inadequate household access to food, health services, clean water and sanitation facilities and inadequate care of women and children. With a 3.2% of annual population growth and the agricultural growth rate at only 0.5%, food inadequacy at the national level is a major problem. In general 90% of rural households are food insecure. The majority of rural households are affected by either chronic or transitory food shortages and urban household are using more than 80% of household income to acquire less than 71 per cent of daily caloric requirements.

The country experienced drought and civil conflict over the past decade. War ravaged the country for over 30 years, which led to the massive displacement of people.The crop situation deteriorated seriously in the country and exposed people to malnutrition, increased susceptibility to diseases and to death. The war ended in 1991, and the FAO/WFP November/December 1992 assessment, recorded and improved prouction at 6.9 million metric tons in 1992. The national food deficit in 1993 is estimated at 739,000 metric tons.

Recent developments, such as the explicit commitment of the Government to prioritize the social sector, the process of decentralization, promotion of community and women's participation in agriculture production, promotion of credit facilities, extension services, and income generation for women are expected to provide a unique opportunity to alleviate the nutrition problem in the country.
 

WATER SUPPLY AND SANITATION

In 1992, only 19% of the total population and 20% of the rural population were estimated to have access to potable water. According to the National Programme of Action (NPA) specification, adequate water supply is defined as 20 litres per capita per day made available within a range of one-half to two kilometers from the dwelling. However, in most rural areas of Ethiopia, depending on seasonality and location of source and availability of water, the reality is as low as 3-4 litres per capita per day.

The effects of lack of sufficient quantities of water critically impair the ability of most rural population to engage in appropriate personal, food and environment hygienic practices which would greatly assist in stemming the tide of infectious diseases.

Recent information obtained from the Water Supply and Sewage Authority (WSSA) on water quality related problems in Ethiopia indicates exceptionally high fluoride contents in water obtained from wells in central, southern and western regions. The most frequenty reported problem is dental and skeletal fluorosis in the Rift Valley Regions. High mineral contents (sulphates, nitrates, chlorides, etc) were reported in the eastern and northwestern regions. High salinity was reported in the well fields of the Afar Triangle.

Contamination of water sources is the causal factor for all water-borne , water-washed and water-related diseases. It is difficult to quantify morbidity and mortality related to contaminated water because of the lack of an effective and sensitive monitoring and surveillance system for the general population. No countrywide baseline surveys have been conducted to date.

There are also a number of water-related problems ( water-washed or water-based) which are of serious health concerns. Bilharzia is known to exist in many regions of the country while guinea worm, for which an active case search programme has been initiated in 1992, is already known to be prevalent in two regions. Onchocerciasis and malaria are examples of diseases which plague different areas of the country.

It should be noted that Ethiopia is endowed with vast water resources. There are 14 major river basins in the country. A Water Resources Commission (WRC) publication, The Opportunities and Challenges of Water Resource Development in Ethiopia, 1987, indicates that the total annual surface run off from these basins is estimated at 104.4 billion m3. Over 95% of this run off drains to neighbouring countries through the major trans-boundary rivers. Annual rainfall in the country ranges from less than 200mm in the southeastern lowlands to more than 2000 mm in the western highlands.Although a comprehensive national groundwater resources study has not been conducted, some surveys suggest that the groundwater potential in many parts of the country is high.

Less than 12% of the total population uses laterines. Sanitation is defined only by accessibility to a laterine without consideration as to the status of such a facility, as well as the determination of its us.

Existing school curricula are weak in health/hygiene education. The subject is not taught on its own, but rather incorporated with other subjects and not given the priority it deserves. Also, most schools are without water and sanitaton facilities. Thus and important and easily accessible population remains jeopardized.

In Ethiopia the woman and the girl-child, by virtue of their traditional domestic fuctions are the main water carriers and those in frequent contact with contaminated water. This exposes them to infections of diseases such as guinea worm and schistosomiasis. Even though quantified information is not available, they are therefore the most vulnerable to water-related diseases, which according to WHO estimates (Women and the IDWSSD, 1985), are accountable for 80% of all morbidity in the developing world. Considering that about 88% of rural population and about 20% of urban dwellers in Ethiopia have no access to protected water sources, it is clear that the health and the well being of the population in general, and that of women and children in particular is at a great risk.

In addition to the health risk to which the whole family would be exposed as a result of using the water obtained from unprotected sources, the effect of the hard physical labour on the well-being of women and young girls, who are usually undernourished, is obvious.

For the average rural Ethiopian woman, roughly an extra 170 calories per hour will be expended while walking to the water point and 210 calories per hour will be expended returning with a full pot. Distance to the source, rugged terrain, the heavy weight of water containers (often 50-80% of female body weight) and adverse or aggressive seasons which further distance the source and dictate longer hours for collection are all major problems related to water availability.

The provision of safe water supply at short distances will reduce the drudgery to which mothers and their young daughters are subjected. Mothers will thus have more time to care for their children and will also have the opportunity to engage in more productive work or in other social activities. Young girls will also have time to devote to school and studies.

Bacteria and parasites in human faeces are inadvertently passed to food and water through a lack of hand washing after defecation, especially when anal cleansing is done with objects other thaan paper and are not disposed off properly. Even though breast feeding is the most healthy child nutrition practice, womenwho breast feed their children withour proper personal hygiene/washing can accidently contaminate their children, thus causing diarrhoea.

Thus their involvement in water supply and sanitation projects is no longer subject to question. By advocating for the empowerment of rural women and facilitating their hygiene education, it is expected that they will play a decisive role in the planning, implementation, monitoring, operation, and maintenance phases of all water supply and sanitation projects.

Environmental degradation is an immediate concern with grave implications for the provision of water and sanitation, severely impairing the natural condition of the country and resulting in a forest coverage of under 3% in1990. Each year, one billion tons of top soil is washed away, while over 3000 hectares of the previously fertile highlands can no longer support crops. Large areas will be bare rock by the year 2000.
 

BASIC EDUCATION

Education is directly or indirectly the instrument of the political system in power in a country. During the last twenty years, the Education sector in Ethiopia has been characterized by a continuous process of adjustment or readjustment, orientation and reorientation due to changes in policies, plans and modesof implementation caused by a series of man-made and natural disasters.

The sectoral mandate of the Ministry of Education is defined in Proclamation No. 41/1993. Those parts that are related to basic education include- formulation of the country's education policies and strategies; devising and facilitating the implementation of ways and means of expanding education throughout the country; maintaining the country's educational standard; determining the curriculum offered to senior secondary school and higher education institutions and training institutions of similar status; providing assistance to Regional Self-Government in the preparation of curriculum at elementary and junior secondary schools; determining the qualification of the teaching staff at each level of education; preparation of national examinations for promotion of students from onelevel to a higher one and for various recruitment; ensuring the availability of educational materials and textbooks in adequate quality and quantity; preparing and implementing objects designed to improve the quality and to enhance the expansion of education; encouraging and giving technical assistance to regions in the preparation and implementation of projects; in cooperation with appropriate organs, devising ways and means of providing special assistance, in rendering educational services to minority nationalities, women, children, and adults; providing technical and professional assistance to regions with a view to promoting their capacities of implementation and collecting, compiling and disseminating information on education.

Until 1991/92 the education sector was managed by a vertically organized system directed by a central body- the Ministry of Education- with branch offices in the administrative regions and awarajas(provinces). The Ministry was responsible for the formulation of policies, for planning, for allocating of internal and external resources, for employment and deployment of personnel and for monitoring and supervising of the implementation of the programmes. The regional and awaraja offices were the implementing mechanisms for the decisions and orders of the central body. An effort was made to decentralize educational management, at the school level throughout the country, by establishing school management committees. With the issuance of the Proclamation No. 7/1992 establishing National/Regional Self Governments by the TGE, curriculum development and the material and textbooks preparation and use of local languages for instructional purposes for early childhood care and development education and for primary and junior secondary education are decentralized. However, the regional educational bureaus do not have and will not have institutional capacity to undertake these activities in the near future. Therefore they will continue to depend on the central bodies such as the Institute of Curriculum.

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