"The Amount of Input Allocated to Health Is Very Minimal Compared With Problem Magnitude"

Tayitu 14th Tayitu 14th

interview

Mengistu Asnake (PhD) was born and attended primary and secondary education in Addis Ababa. He later went to Gondar to study medicine. He served in Hararghe, eastern part of the nation, for a couple of years before he started his masters education in public health. He worked with more public institutions and later shifted to Pathfinder International first as a programme officer and since the last couple of years as a Country Representative. The Ethiopian Herald had an interview with him on issues related to health and his private life.

Excerpts:

Herald: Let’s begin with introducing yourself to our esteemed readers.

Dr. Mengistu: I was born and grown up in Addis Ababa. I attended my elementary and secondary education here in Addis in public schools. After that I joined the then Gondar College of Medical Sciences, which was under Addis Ababa University. I attended medical education there for six years. After graduation I was assigned to work in a rural hospital in the then Haraghe. The hospital had only 60 beds at the time when I was working there. I served there for about two and half years before I joined my graduate studies in public health. I joined the community health department of Addis Ababa University, now named after the school of public health, to do my graduate studies and our time for graduate studies was not completely like in the school. In the first semester you have theoretical education and then you go out in the field being assigned as trainee district health manager. I was in the eastern part of the country at a place called Garamuleta to serve as a district health manager. Throughout the whole training time although there was time that I was back to the school to do some theoretical training, presentation and defending, I was mainly in the field doing actual on the job training and practical activities there. Graduating my master degree in public health, I was assigned as a programme manager again within the Ministry of Health in Harar. I was the head of the regional health office for more than a year before I joined the All African Leprosy Rehabilitation and Training Centre (ALERT) to work as a clinical medical officer in the areas of leprosy, tuberculosis and others. I worked there for about three years. My duty was mainly focused on integrating both programmes within the public sector. Then I got a new employment in a non governmental organization to work in a child health area. I worked for about two and half years in Hawassa and other areas of the southern region. After the project had phased out, I got a chance to join Pathfinder as a programme officer for a few years and prior to the last couple of years I was serving as the Deputy Country Representative and during the last two years I am serving as the Country Representative for Pathfinder International.

Herald: As a professional working in the area of public health for many years, what do you think are the main obstacles in the effort to minimize maternal mortality in Ethiopia?

Dr. Mengistu: Looking at the data in Ethiopia in terms of maternal mortality, in terms of rate and number there is a decline from year to year. But in general when you look at it the decline is not to the level of satisfaction of most of us. We should make it decline more and more. We can not say maternal mortality is not huge problem but we should not consider improvement is not there. There is an improvement but the way it is improving is not at the expected level. Of course, even a single mother should not die. But we are talking about rates which are huge number but even a single mother should not die. Looking at what are the most important reasons for maternal death most of it is happening in relation to pregnancy or its outcomes. The most important part of it is women are not getting the necessary skilled birth attendance.

There is an improvement in the past few years but few years back it was only less than ten percent of women were getting skilled birth attendance. That means a professional assisted them during labor and their delivery is also assisted by trained personnel. About 90 per cent of the women, a few years back, were delivering at home without getting any assistance of skilled service providers. If any problem happens those women may enter easily into complications and even die without getting any support. We usually refer to the challenges as the three delays. The first one is to make a decision in terms of a women in a family needs to seek care in the health facility. That is the first decision. There are a lot of traditional and cultural issues that impede this decision. For instance, if you tell to somebody to go and attend a health center for delivery they may tell you the last two or three deliveries were at home and there is no need to go there. That primarily relates to the level of awareness at the community level. Any delivery can be accompanied by a certain risk. They need to go to a health facility during that moment. The second delay is, once we make the decision, related to coming from home to the health center. This in turn is tied with our transport facility and their level of income which are the major barriers. A woman may go to labor during the agricultural season, a time when everyone is engaged in work she rarely gets anyone who can take her to a health center. Once they make decision and get the transport after they reach to the facility the quality of care or the delay at the facility in terms of getting the service right away or having the right person to do those services is the third delay. Tackling all these three delays is the very important thing. In terms of creating awareness the government is doing a lot of things specifically via the health extension program which is making a major progress from this point of view. You might have heard the recent motto which says “no woman should die giving life.” So, everyone should give birth at a health facility. This type of messages, when they are told repeatedly, they may bring a lot of change. Another important area is the government is supplying ambulances in each district for pregnant and other women to be transported to the nearby health center. At community level also a lot of encouraging works are being done. For instance, in most communities what in medical terms we call a stretcher was mostly termed in Amharic as Kareza. This word does not have a good impression. Most people in the rural area feel a man taken to a hospital via kareza may not come back. So nobody wants to carried by it as it is compounded by wrong perception. Some communities, after having a mutual discussion, have decided to not to call it with its usual name, rather decided to call it a traditional ambulance. This has changed the previous bad impression about using it to go to a health facility. The other important thing is youth and other members of the community are organized to take women to the health centers when needed. This makes a big difference in terms of transporting the women. In some places the level of skilled professionals is also improving. Some places have even started to report their village is a zero home delivery village. Providing training in terms of those skills is very important. Most of them may have taken training in the schools but they need to strengthen it. The delivery rate at health facilities in the past was ten percent but now with more and more people coming for delivery at the health centers, training the service providers with the necessary competency training would become more easier. As you stated, yes there is still a challenge but there are promising progresses in terms of improving the service of maternal health in the country.

Herald: Since the last few decades, various kinds of birth controls have been introduced to our country. Given the ever increasing population growth and the social, cultural and religious barriers, can we say that these controls are effective in creating a health society in terms of reproductive health?

Dr. Mengistu: We need to start with the use the word itself. For us, we put it as family planning. It refers to the whole issue that individuals need to plan their families. For the purpose of health, the issue of spaced birth is key because if a woman gives birth every years she will not be even to feed the one who was born a year before properly before giving birth to the next one. It is when we look at it in this way that the whole issue of birth control comes in to focus. The other important issue is there are women who want to have children but who are not getting them. The issue of infertility is also part of family planning. At the beginning of the 20th century, the Ethiopian population was about 11 million. It took us 24 years to double and reach 24 million. But if you look at the next doubling times, from 1960 to 1990 the population doubled, which means with in only 30 years. Our growth rate was higher during those periods. Looking at the recent figures from different demographic sources, as the base was big, even though you have more control mechanisms, the annual growth rate may be lower but the increase in population is still huge. So, we should look at it not in terms of limiting the number but also in terms of several other issues. The issue is whether the population growth is in equilibrium with our economic growth and other social needs like education or employment or not. Even we have to see it from the point of view of environmental protection. Looking at the past few years, there is a huge improvement in terms of changes in fertility rate. If you look at the Ethiopian fertility rate it came down from almost an average seven children per woman to the last one four children per woman. Change in fertility even with 0.1 is a great change. When we see the family planning use, it was less than ten per cent some years back. At present it has reached around 40 per cent. This shows the level of awareness is increasing. In terms of the effects cultural, religious and other issues, we need to see it exactly. Is it really the religion or somebody’s perceived thoughts about that religion that influences the issue of birth control use?. If you read the religious books, either Christian or Muslim, there is no way where you can find out that it is against the family planning related services. What makes the difference is the way people interpret it. For instance, the bible says multiply, replicate and fill the world but it did not say to fill the world a with all the poverty and hunger that we see in the world or with people who have several children and who are starved and facing so many problems. When we talk to religious leaders, mainly those living in the community, you can clearly see the problem and that makes it easier to change. We have a program with which we work with both the Christian and Muslim leaders and it has brought considerable changes. If it was religion, there would be other very religious countries who have a better family planning and population size as compared to us. As a health professional, if I go and say to the people the bible is not saying this or that, nobody will listen to me. But they will surely listen to the religious leaders. It is the level of awareness and some of the beliefs which were there for years that matter.

Herald: You are president of the world federation of public health associations. During your presidency you vowed to focus and work more on the health of women and children. To what extent did you make that practical?

Dr. Mengistu: The federation is a global body of professional national public health associations. The presidency is a voluntary responsibility. The association is doing a lot of things. There are different working groups which are looking at issues like environment, tobacco control, public health education and oral health. I am working towards forming a group that also looks on women and children health. As a federation we are working towards more and more of the issues related to global social needs. For me, maternal and child health issue are part of my daily work. We do a lot of work in terms building the capacity of the public health sector to make the whole issue of maternal and child health better than what we see now. We will be making a four and half years programme learned lesson workshop next Tuesday. We are seeing a relative decline in maternal and child mortality. But we need to work more.

Herald: The health sector in general consumes too much finance every year. But the change on the ground is not as such significant as compared to the huge amount of expenditure made every year. What do you think is the problem?

Dr. Mengistu: I may agree on some of it and disagree on major things. The amount of resource put into the health sector either globally or at national level, for me it is very low as compared to the demand. When you compare it to the problem, it is like a drop in the ocean. Sometimes with the amount of money that you have you want to reach to more people. So, equity is very important. There are ethical considerations that you can not say I can serve only these people and I will not serve the others. The demand side is higher than the supply side. In Africa, according to the Abuja Deceleration governments have agreed to allocate 15 percent of their budget for health. But only few countries have reached that level. If you put that level of resource to health most of it may be used for having the infrastructure and what is needed for the software part to use the infrastructure may not be available. You may have for instance a very good hospital built somewhere but not well functioning due to the missing elements in it. For me, it is not a matter of cost effectiveness rather the outcome it produces is very important. To fill the gap, involving the private sector in terms of health insurance is one option. You may not benefit right away but others may benefit from it. “Obviously, the amount of input allocated to health is very minimal compared with the magnitude of the problem.”As you said, we also need need to check whether the investment is going to the right direction. Instead of establishing a support mechanism for people who face some diseases, I may incline into a community programs that could reach millions of people. We put more resources into the lower level of the health system which includes prevention and primary curative systems. In so doing, we minimize the number of people coming to the higher level.

Herald: In relation to your private life, tell us the most challenging moment in your life and how you managed to overcome it?

Dr. Mengistu: Life has a lot of challenges and it may be difficult to trace the most challenging one. I usually tell people that one of my challenges while working in the clinic is identifying the disease, knowing what the treatment is but not getting the treatment because it is not there. You know that if that person gets the treatment, he will be cured. But if there is no treatment, he may even die. Having the knowledge and lacking what is needed to make that knowledge practical is one of the challenges. For instance, when I was practicing medicine in the eastern part of the country, I was having a young person with diabetes who simply went into comma in the hospital because we have finished all our stocks of insulin. For that specific moment we were able to get one from somebody who privately put a reserve for himself. After I went out from the area I always asked about that young person. Unfortunately, one day I heard he died due to absence of insulin in that hospital. So, such a situation where you have the knowledge to help someone but lack the treatment is very challenging.

Herald: What is your life principle?

Dr. Mengistu: The basic principle is I usually do not want to say no. The word ‘no’ probably may mean to me, it is creating helplessness on people’s lives. I like to help people to the level I can. I am not sure I am successful on that but I feel very happy when I see people become successful and see improvements in life. If you work hard and you have a vision, you can become anyone whom you want to be.

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