Democracy or Dictatorship?

Understanding the effects of governmental centrality on healthcare access/provision in Ethiopia

Prior to my arrival in Ethiopia, I did my research to find locally run health NGOs as I previously did in my last two project countries. Now before that, I had theorized that with Ethiopia being the only African country never colonized, things might be very centralized. Unsurprisingly, my search results didn’t turn up any leads worth following- yes! Organizations like UNICEF, Red Cross and WFP are present but it’s hard to get in or reach people working with such organizations.  With that being the issue, I structured my approach to be mainly one of participant observation. Thus I’d pick locations, live there for extended amounts of time, get to know the locals and the lay of the area in an effort to understand the local health situations.

I started out by spending a week in Addis Ababa visiting the school of public health and other leads to get a sense of population’s health in Ethiopia. I didn’t get much information in Addis because I felt like I was in a pinball machine, people just kept bouncing me around to the next person instead of just giving me the information I need- mind you these were mainly professors who teach public health smh!. However, I did learn about the Ethiopian Health Extension Program which suited the kind of public health approach I was looking for. I decided to head eastward to Dire Dawa and Harar where I got a little bit of a better picture about health in Ethiopia- I wouldn’t generalize and apply what I learned east to all of Ethiopia because each part of the country is significantly different from the other.

In the several visits I paid to the local clinics and health centers, I was able to learn quite a lot about the local health situation. For instance, in a city like Harar, there is one main hospital but supporting it are four smaller health centers and other private owned health centers. As with other parts of Ethiopia, the city of Harar utilizes the help of health extension workers to reach populations who are not within the parameters of the city to have access to health centers or hospitals. I wanted to talk to one of these health extension workers, I couldn’t reach any but I was fortunate to learn about them through locals and some administration officers. So in short, these health extension workers are hired by the government for the purpose of providing services to those removed from the urban areas and prominent society- this includes communities that live as nomads like the Afar people.

Each extension worker is assigned to a particular village or a group of houses which they are responsible for monitoring and making sure the people are living healthy lives. Some of the duties of the health workers include providing immunization, counselling on maternal health and teaching locals how to avoid common illnesses and diseases. In talking to the clinic administrators, I was made aware that some of the typical focus of the extension work revolves around regulating behavior changes. This is because in the east and other parts of the country for example, local populations live and sleep in the same house as their farm animals which makes them prone to all kinds of illnesses. It’s really unfortunate that I didn’t actually get to talk to an extension worker because it would have been great to pick their brains and learn about their motivations. Nevertheless, as I traveled further north to continue my research, it became more obvious how important these workers are in maintaining and providing health access.

One of the advantages of living in the communities is being able to pick up on several heath issues that honestly weren’t being addressed. Two issues that stood out to me the most surrounded poor sanitation and the high rate of physical disabilities. In the case of sanitation, its uncommon to visit certain places in Ethiopia where there aren’t any means of proper waste disposals- both human waste and garbage. What makes it worse is that there are very few garbage receptacles around so many people just through garbage anywhere- consequences being a high rate of cholera and other diarrheal disease. I am still trying to understand the case of physical disabilities because I am aware that Ethiopia is close to being free totally free of polio so there aren’t any new cases. However, there are several people, mainly older people with untreated cases of disabilities who currently live on the streets as beggars. Also in speaking to some locals, I was informed that some of the disabilities are mainly as a result of past wars in Ethiopia- that can be true because I’ve seen people without some limbs who are beggars on the street.

Curiously, I asked around why those with disabilities aren’t receiving any formal help from the government- surely in they can reach and help those in remote areas, they can certainly help those in the immediate cities. Well I mainly got mixed answers, some of them I wished were not true- one local in Lalibela told me that people with disabilities are locally stigmatized as “sinners” and looked down upon. This led to my rethinking of health approaches in Ethiopia because if the ministry of health sets the parameters of health outreach then who takes care of where and those that the government and its resources can’t reach? It’s great that the government regulates the few health related organizations that conduct health programs in the country but I am concerned about the lack of local individuals orchestrating their own health NGOs in the country. I haven’t found any different answers to why most services in Ethiopia are so centralized. National pride aside, what happens if the government can’t control everything? The current population is 87million and rising so what happens to those that don’t have access to government services? While in the north, these questions I had become more prevalent in my observations because in the Afar region, people really live off the map and the closest health services are miles and miles away.

I haven’t fully understood everything there is to know about the health system here- I doubt I will- but I’ll keep my ears to the ground and my eyes open for more observations. I would say that I am very impresses with how much the health system works despite being so centralized. Maybe having too many options isn’t all that good?!

Quick Update/News Flash: I’ve had an ample amount of time to process and analyze what I experienced and learned about health/healthcare in Ethiopia and I am fully convinced that on paper, Ethiopia is a democracy but in reality, it’s a full blown dictatorship. That’s honestly the best way to understand many of the realities that Ethiopians live in and it’s no wonder many Ethiopians often seek asylum in other countries because the realities most people face under the government is kept under wraps and people who talk about it do so at their own risk. Furthermore, to emphasize my point about governmental centrality not being plausible, the country’s hunger crisis is on the rise as the current drought is worsening. Ethiopia is still a beautiful/amazing country and I’ll definitely be going back very soon!

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