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Primary Health Care in Ethiopia: From Haue Sellassie to Meles Zenawi Helmut Kloos Department of Epidemiology and Biostatistics, University of California, San Francisco This paper examines developments in primary health care (PHC) in Ethiopia under the authoritarian/feudal regime of emperor Haile Sellassie, the socialist /military rule of Mengistu Haile Mariam and the sprouting democracy and free market economy under Meles Zenawi. The focus is on health policy, progress and problems in implementing programs and on recent decentralization efforts. The primary health services of the Derg have been described1 but continuity and change under these three governments and the relationship with the health services of the rebel forces in Tigray and Eritrea has not been analyzed except for a paper on community participation.2 The grassroots, community based health services of the TPLF and EPLF have been characterized as efficient, equitable and community based, consistent with the PHC approach.3-4 Similar achievements were reported from other liberation movements, including those in Mozambique5 and Vietnam.6 Primary health care essentially is the application of the basic needs approach in the field of health, with a central focus on correcting inequities and improving the health status of the poor and dispossessed. The concept of PHC, developed at the WHO-UNICEF conference in Alma Ata in 1978, has been used during the last two decades in Ethiopia and most other developing countries with variable results. The Alma Ata Declaration of "Health for AU by the Year 2000" implies five PHC principles, namely 1) equitable distribution ofhealth services, 2) community participation in program planning and implementation, 3) emphasis on preventive services, 4) use of appropriate technology, and 5) a multi-sectoral approach recognizing that the requirements for good health cannot be met by the ^Northeast African Studies (ISSN 0740-9133) Vol. 5, No. 1 (New Series) 1998, pp. 83-113 83 84 Helmut Kloos health sector alone but must include improvements in domestic water supply, sanitation, food security and economic status.7 It follows that PHC must go beyond the provision of curative and even preventive medicine, such as health education, immunization and the promotion of environmental sanitation. It also includes the promotion of health as a component of political and socioeconomic development. This implies not only a restructuring of the health system but of most other social institutions as well. While peaceful conditions, the secession of Eritrea and the current decentralization and democratization drives of the Ethiopian administration and the delineation of the country's new regions along ethnic lines are offering new opportunities for health services development they also carry with them inherent dangers of new political crisis and socioeconomic instability.8 This study may thus contribute to the debate whether "top-down" health planning can be transformed to "bottom-up" planning in Africa. Although lack of time will prevent "Health for All by the Year 2000" to be achieved, various country experiences indicate that the prerequisites for any significant progress to be made toward this goal include democratized health planning, decentralization and community participation.9ยท10 Demography and Cultural Aspects Ethiopia's population is the second largest in tropical Africa, after Nigeria. In 1984 the first Ethiopian census reported 42.02 million people rather than the expected 36 million. A second census was carried out on 1 October 1994, but the final results have not yet been made available. Preliminary estimates show that Oromiya is the most populous state (19.9 million people), followed by Amhara regional state 14.4 million), with Tigray having 3.2 million and Addis Ababa 2.3 million persons. The annual growth rate increased from an estimated 1.8 percent in 1950 to 3.1 percent in 1990, the result of slowly increasing fertility and declining mortality.11 The estimated population in 1994 was 54.9 million and in 1998 58.7 million. Only about 2 percent of the population used modern contraceptives during the 1980s and 4 percent in 1993.12>13 Two groups of factors explain much of the low use of modern birth control methods. They are, first, the low social status of Ethiopian women, reflected in property ownership and inheritance, harmful traditional female mutilation practices, Primary Health Care in Ethiopia 85...

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