The main cause of many of Ethiopia's health problems is the relative isolation of large segments of the population from the modern sector. Additionally, widespread illiteracy prevents the dissemination of information on modern health practices. A shortage of trained personnel and insufficient funding also hampers the equitable distribution of health services. Moreover, most health institutions were concentrated in urban centers prior to 1974 and were concerned with curative rather than preventive medicine.

Western medicine came to Ethiopia during the last quarter of the nineteenth century with the arrival of missionary doctors, nurses, and midwives. But there was little progress on measures to cope with the acute and endemic diseases that debilitated large segments of the population until the government established its Ministry of Public Health in 1948. The World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the United States Agency for International Development (AID) provided technical and financial assistance to eliminate the sources of health problems.

In addition to establishing hospitals, health centers, and outpatient clinics, the government initiated programs to train Ethiopian health care personnel so that they could supplement the private institutions that existed in a few major urban centers. The few government campaigns that exhorted the people to cooperate in the fight against disease and unhealthful living conditions were mainly directed at the urban population.

By the mid-1970s, the number of modern medical facilities had increased relatively slowly--particularly in rural areas, where at least 80 percent of the people still did not have access to techniques or services that would improve health conditions. Forty-six percent of the hospital beds were concentrated in Addis Ababa, Asmera, Dire Dawa, and Harer. In the absence of modern medical services, the rural population continued to rely on traditional folk medicine. According to official statistics, in 1983/84 there were 546 physicians in the country to serve a population of 42 million, a ratio of roughly one physician per 77,000 people, one of the worst ratios in the world. Less than 40 percent of the population was within reach of modern health services.

As in most developing countries in the early 1990s, Ethiopia's main health problems were communicable diseases caused by poor sanitation and malnutrition and exacerbated by the shortage of trained manpower and health facilities. Mortality and morbidity data were based primarily on health facility records, which may not reflect the real incidence of disease in the population. According to such records, the leading causes of hospital deaths were dysentery and gastroenteritis (11 percent), tuberculosis (11 percent), pneumonia (11 percent), malnutrition and anemia (7 percent), liver diseases including hepatitis (6 percent), tetanus (3 percent), and malaria (3 percent). The leading causes of outpatient morbidity in children under age five were upper respiratory illnesses, diarrhea, eye infections including trachoma, skin infections, malnutrition, and fevers. Nearly 60 percent of childhood morbidity was preventable. The leading causes of adult morbidity were dysentery and gastrointestinal infections, malaria, parasitic worms, skin and eye diseases, venereal diseases, rheumatism, malnutrition, fevers, upper respiratory tract infections, and tuberculosis. These diseases were endemic and quite widespread, reflecting the fact that Ethiopians had no access to modern health care.

Tuberculosis still affected much of the population despite efforts to immunize as many people as possible. Venereal diseases, particularly syphilis and gonorrhea, were prevalent in towns and cities, where prostitution contributed to the problem. The high prevalence of worms and other intestinal parasites indicated poor sanitary facilities and education and the fact that potable water was available to less than 14 percent of the population. Tapeworm infection was common because of the popular practice of eating raw or partially cooked meat.

Schistosomiasis, leprosy, and yellow fever were serious health hazards in certain regions of the country. Schistosomiasis, a disease caused by a parasite transmitted from snails to humans through the medium of water, occurred mainly in the northern part of the highlands, in the western lowlands, and in Eritrea and Harerge. Leprosy was common in Harerge and Gojam and in areas bordering Sudan and Kenya. The incidence of typhoid, whooping cough, rabies, cholera, and other diseases had diminished in the 1970s because of school immunization programs, but serious outbreaks still plagued many rural areas. Frequent famine made health conditions even worse.

Smallpox has been stamped out in Ethiopia, the last outbreak having occurred among the nomadic population in the late 1970s. Malaria, which is endemic in 70 percent of the country, was once a scourge in areas below 1,500 meters elevation. Its threat had declined considerably as a result of government efforts supported by WHO and AID, but occasional seasonal outbreaks were common. The most recent occurrence was in 1989, and the outbreak was largely the result of heavy rain, unusually high temperatures, and the settling of peasants in new locations. There was also a report of a meningitis epidemic in southern and western Ethiopia in 1989, even though the government had taken preventive measures by vaccinating 1.6 million people. The logistics involved in reaching the 70 percent of Ethiopians who lived more than three days' walk from a health center with refrigerated vaccines and penicillin prevented the medical authorities from arresting the epidemic.

Acquired immune deficiency syndrome (AIDS) was a growing problem in Ethiopia. In 1985 the Ministry of Health reported the country's first AIDS case. In subsequent years, the government sponsored numerous AIDS studies and surveys. For example, in 1988 the country's AIDS Control and Prevention Office conducted a study in twenty-four towns and discovered that an average of 17 percent of the people in each town tested positive for the human immunodeficiency virus (HIV), the precursor of full-blown AIDS. A similar survey in Addis Ababa showed that 24 percent tested positive.

In 1990 Mengistu Mihret, head of the Surveillance and Research Coordination Department of the AIDS Control and Prevention Office, indicated that AIDS was spreading more rapidly in heavily traveled areas. According to the Ministry of Health, there were two AIDS patients in the country in 1986, seventeen in 1987, eighty-five in 1988, 188 in 1989, and 355 as of mid-1990. Despite this dramatic growth rate, the number of reported AIDS cases in Ethiopia was lower than in many other African countries. However, the difference likely reflected the comparatively small amount of resources being devoted to the study of AIDS.

Starting in 1975, the regime embarked on the formulation of a new health policy emphasizing disease prevention and control, rural health services, and promotion of community involvement and self-reliance in health activities. The ground for the new policy was broken during the student zemecha of 1975/76, which introduced peasants to the need for improved health standards. In 1983 the government drew up a ten-year health perspective plan that was incorporated into the ten-year economic development plan launched in September 1984. The goal of this plan was the provision of health services to 80 percent of the population by 1993/94. To achieve such a goal would have required an increase of over 10 percent in annual budget allocations, which was unrealistic in view of fiscal constraints.

The regime decentralized health care administration to the local level in keeping with its objective of community involvement in health matters. Regional Ministry of Health offices gave assistance in technical matters, but peasant associations and kebeles had considerable autonomy in educating people on health matters and in constructing health facilities in outlying areas. Starting in 1981, a hierarchy of community health services, health stations, health centers, rural hospitals, regional hospitals, and central referral hospitals were supposed to provide health care. By the late 1980s, however, these facilities were available to only a small fraction of the country's population.

At the bottom of the health-care pyramid was the community health service, designed to give every 1,000 people access to a community health agent, someone with three months of training in environmental sanitation and the treatment of simple diseases. In addition to the community health agent, there was a traditional birth attendant, with one month of training in prenatal and postnatal care and safe delivery practices. As of 1988, only about a quarter of the population was being served by a community health agent or a traditional birth attendant. Both categories were made up of volunteers chosen by the community and were supported by health assistants.

Health assistants were full-time Ministry of Health workers with eighteen months of training, based at health stations ultimately to be provided at the rate of one health station per 10,000 population. Each health station was ultimately to be staffed by three health assistants. Ten health stations were supervised by one health center, which was designed to provide services for a 100,000-person segment of the population. The Regional Health Department supervised health centers. Rural hospitals with an average of seventy-five beds and general regional hospitals with 100 to 250 beds provided referral services for health centers. The six central referral hospitals were organized to provide care in all important specialties, train health professionals, and conduct research. There were a few specialized hospitals for leprosy and tuberculosis, but overall the lack of funds meant emphasis on building health centers and health stations rather than hospitals.

Trained medical personnel were also in short supply. As noted previously, the ratio of citizens to physicians was one of the worst in the world. Of 4,000 positions for nurses, only half were filled, and half of all health stations were staffed by only one health assistant instead of the planned three. There were two medical schools--in Addis Ababa and Gonder--and one school of pharmacy, all managed by Addis Ababa University. The Gonder medical school also trained nurses and sanitation and laboratory technicians. The Ministry of Health ran three nursing schools and eleven schools for health assistants. Missionaries also ran two such schools. The regime increased the number of nurses to 385 and health assistants to 650 annually, but the health budget could not support this many new graduates. The quality of graduates had also not kept pace with the quantity of graduates.

Since 1974 there have been modest improvements in national expenditures on public health. Between 1970 and 1975, the government spent about 5 percent of its total budget on health programs. From 1975 to 1978, annual expenditures varied between 5.5 and 6.6 percent of outlays, and for the 1982-88 period total expenditures on the Ministry of Health were about 4 percent of total government expenditures. This was a low figure but comparable to that for other low-income African countries. Moreover, much of the real increases of 7 to 8 percent in the health budget went to salaries.

A number of countries were generous in helping Ethiopia meet its health care needs. Cuba, the Soviet Union, and a number of East European countries provided medical assistance. In early 1980, nearly 300 Cuban medical technicians, including more than 100 physicians, supported local efforts to resolve public health problems. Western aid for long-term development of Ethiopia's health sector was modest, averaging about US$10 million annually, the lowest per capita assistance in sub-Saharan Africa. The main Western donors included Italy and Sweden. International organizations, namely UNICEF, WHO, and the United Nations Population Fund, also extended assistance.

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Source: U.S. Library of Congress