No child should have fewer chances to survive than others because of where they were born.
Yet despite impressive national gains in health outcomes in Ethiopia over recent decades, children in the Afar Region are over five times more likely to be stunted than in Addis Ababa[1], and less than 20% of children under five received all basic immunisations, compared to 83% in the capital[2]. Children growing up in Afar are three times less likely to survive to the age of five than in Addis Ababa[3] – the highest under-five mortality rate in the country.
The difficult reality for pastoralist communities
“Most communities in Afar Region are pastoralists and they are largely dependent on livestock rearing. However, because of the recurrent drought and lack of rain in the area most communities lost their animals and were unable to feed their children”, explained Hassen Ibrahim, a nurse from Elidaar Health Centre. She recalled that when a child named Mohamed first came to the clinic suffering from acute malnutrition, he could barely move his body due to the bedsores he had developed.
When Habib, 7-months old at the time, stopped breastfeeding and started vomiting due to malnutrition, his 21-year-old mum Amina wanted to take him to the health facility - but didn’t have any money to pay for transport. Eventually, when Habib deteriorated, she walked three hours from her village to the nearest health facility to have Habib treated.
Mohamed and Habib were able to recover. Unfortunately, many other children do not.
The health system cannot cope
Recurrent droughts and conflicts have resulted in the displacement of children and their communities. Families on the move lose access to food, water, security, and health services.
The health system in the region is barely able to cope with the needs of settled communities and is in no state to address the additional needs of displaced or nomadic communities. Inadequate health facilities, a shortage of qualified health workers and frequent vaccine and medicine stock outs are serious challenges in Afar Region.
Weak infrastructure, lack of electricity, fuel, and social services, make this a challenging environment to work in, whilst low salaries for health workers make it difficult to attract doctors, nurses, midwives and health extension workers.
Afar health budget
Adequate public health investments could reduce these challenges faced by health providers and communities in Afar. To better understand the health financing gap, Save the Children analysed the federal, regional and district health budget allocations, from 2013 to 2018. We found that:
· The Regional health allocation stagnated at around 7%; health expenditure was around $4.78 per person each year.
· Two-thirds of Afar’s total budget relied on federal subsidies. Yet, Afar didn’t benefit as much as wealthier regions which were prioritised. For example, Oromia is getting 34% of the federal government subside whilst Afar only 3%[4].
· Due to the lack of qualified staff at the district level, the district health office did not manage its budget. A separate office managed health resources and often repurposed them to different activities other than health.
· The health needs of the most vulnerable, women and children, were not prioritised in the health budget planning process, as women and children were not consulted in budgeting decisions.
Working together can make the difference
We used our findings to urge the federal and Afar regional government to increase allocations for primary healthcare. We appealed for improved governance and leadership and for the government to select qualified health managers and staff in district health offices.
We shared our findings with government decision-makers at federal, regional and district levels, donors and development partners and used our budget analysis at critical moments during the government budgeting cycle.
The Federal Ministry of Health asked Save the Children to organise a learning session for them on public financing and Universal Health Coverage whilst Afar regional state MPs and the pastoralist and budget standing committees invited us to share our budget findings. A knowledge gap among decision makers had been filled.
We trained community members, including significant numbers of women, who formed social accountability groups and regularly assessed the performance of health facilities. There were strong correlations between the gaps identified by the community and the funding shortfalls highlighted in our budget analysis. We shared the community’s findings with district health planning and budgeting officials, who used this information to push for increased health allocations with the Regional Council.
The Deputy Head of Afar Regional Health Bureau became a champion for increased funding to primary healthcare. When the COVID-19 crisis struck, they joined Islamic Supreme Court and clan leaders, community champions and child survival ambassadors trained by Save the Children, to publicly urge the government to financially sustain routine immunisation throughout the pandemic.
How things changed
In 2020/2021, the tide turned. The Regional Council almost doubled health allocations, from 7.4% to 13.2%, the highest share of the Regional budget ever. Allocations were made public and shared with the whole community. At the federal level, health financing rose from the 8th to the 4th highest budget share.
The Finance and Economic Development Bureau Deputy Head said:
“Investing in health is not just a choice but a strategic approach. We learnt from your advocacy and media activity that COVID-19 exposed our collective failure, caused by limited investment in health system strengthening”.
Increased recruitment of qualified staff at the district level means that district health offices can now manage their own resources effectively to better respond to local health needs and challenges.
Change is possible, but only continuous monitoring and vigilance can sustain it
The world will not achieve Universal Health Coverage until inequities in public financing are addressed; budget advocacy helps us do just that. It is a language that politicians understand. It fosters collaboration across different administrative levels and between the government and the community. It gives credibility to community demands and enables decision-makers to make evidence-based decisions.
Save the Children will continue to support women and the wider community in Afar Region, including working with child parliaments, to use budget analysis to advocate for maintaining existing allocations and to ensure that resources are spent effectively and will reach the most impacted children and their communities.
[1] Ethiopia MDHS 2019 https://www.ephi.gov.et/images/Mini-Demographic-and-Health-Survey-Key-Indicators-2019.pdf
[2] Ethiopia MDHS 2019 https://www.ephi.gov.et/images/Mini-Demographic-and-Health-Survey-Key-Indicators-2019.pdf
[3] Ethiopia DHS 2016, https://dhsprogram.com/pubs/pdf/FR328/FR328.pdf
[4] CEPHEUS Research &Analytics, Ethiopia’s 2020-21 budget
