| 3. Key
Findings
Lack of a basic information
resource concerning demography, epidemiology and cost of health services was
highlighted as a major problem in the "Health Needs Assessment" study. Without
this information it is difficult to consider these findings as scientific
as is desirable. However, the assessment raises some important issues based
on valid quantitative and qualitative methods. The key findings from the health
needs assessment are given below.
3.1 Cultural diversity
and impact of war and drought in the lifestyle of nomadic pastoralists
Pastoralists make up
12-16% of the total population of and and semi-arid regions of East and West
Africa. The total number is estimated to be around 22 million. The highest
proportion of pastoralists to total population is in Somalia (60%), 14% in
Sudan and 10% in Ethiopia. The exact number or proportion in Eritrea is not
known.
Within this population
there is great ethnic diversity. In Eritrea the main pastoralist ethnic
groups are the Afar, Beja, and Tigre.
The nomadic pastoralists'
hinterland is arid, with scanty, erratic and unpredictable rainfall. This
scarcity, together with uneven pastures can however support livestock, although
on a limited scale. However political instability in the region forced many
pastoralists to flee their homes and settled in neighbouring countries. This
in a way had changed their way of life from a mobile to a temporary sedentary
life. The Eritrean pastoralists lost many of their livestock and, as shown
in the study, had to resort to other means of income generating activities.
- 30% of those interviewed
said they have other sources of income in addition to the main source of
income from livestock. The other source of income include trade (particularly
high among the Tigre and Afar) and settled agriculture (higher among the
Bejas);
- The war had a direct
impact on their lives as well. 23% of the families interviewed had one or
more members of the family who was either killed or wounded in the war. 48%
said they lost property by direct enemy attacks; and
- War and drought over
the last 20 years have restricted their movement and grazing patterns and
at times the internally displaced pastoralists were forced to settle in order
to get rations from relief supplies.
The assessment has also
highlighted the problem of territorial boundaries. The Eritrean nomadic
pastoralists move across the boundaries of three countries at different times
of the year. This
has an effect on the distribution of diseases and the way health services
are being provided.
3.2 Access, awareness
and appropriateness of health services
3.2.1 Access
- The physical accessibility
to health services for the nomadic population has improved a great deal since
the end of war and independence of Eritrea in 1991. There is evidence that
fewer people now travel more than 2 hours to reach to the nearest health
post;
- As to the ability to
pay, most nomads (96%) pay health fees, of which 64% said it was very expensive.
Community leaders also stressed the added travel costs which make the service
almost impossible to access in financial terms; and
- Traditional practitioners
charge higher fees, though only 81 % of patients said they paid fees for
the service;
3.2.2 Awareness of
health & health services
- Boiling milk - Afar
and Beja said they don't boil their milk while 97% of Tigres said they do;
- When asked about malaria
and HIV/AIDS and the modes of transmission: 96% of Tigres, 89% of Bejas and
6% of Afar knew that mosquito is the cause for malaria, while 55% said sexual
contact transmits HIV/AIDS. It is interesting to note the highest awareness
(84%) among Bejas. .
- Most nomadic pastoralists
interviewed (86%) said they were aware about HIV/AIDS and sexually transmitted
diseases. 35% said their source of information is radio, while nearly 50%
get their information by 'word of mouth';
- It was found that there
was a low awareness and up-take of immunisation by women, particularly among
the Beja women. An average of 27% of women respondents said they have attended
ante-natal clinic;
- 85% of women are not
aware of family planning services and they believe that to have or not to
have children and how many children is a matter for God's will; and
- A number of key informers
and focus group participants highlighted that, it would be difficult to raise
the health awareness of the communities, when most if not all, health workers
in the area are men who:
- don't speak the
local languages
- are not interested
in working in the region; and
- not aware or don't
appreciate the culture and lifestyle of nomadic pastoralists.
3.2.3 Appropriateness
of health services
- Language and cultural
barriers are the main barriers to the low up take of services in many of
the health facilities in the area. In Hidareb the key informants and community
leaders stressed the need to train health workers from their own community
or those who speak their language and understand their culture. None of the
current health centre staff speak the local language;
- Shortage or non-existence
of female health workers was one of the main issues raised, indicating the
inappropriateness of the service;
- the type, design and
construction of the health units in the Kerkebet and KemChiewa was completely
inappropriate to the weather conditions in the area. The units are too hot
and have no water;
- In 1994 a highly regarded
programme of community health service run by trained Village Health Workers
& Traditional Birth Attendants from the community was discontinued and
this has resulted in the removal of a well used community health service.
(This concern was strongly expressed by the participants in the Tigre focus
group.); and
- The Tigres in Afabet
had indicated that there is a health station in Felket which is 10 km from
Afabet Hospital. On the other end of migration, in Gadim Halib, which is
well known as a malaria area, the nearest health post is 85 Km away;
3.2.4 Women's health
Nomadic women work much
more harder than non-nomadic women. In addition, they also suffer from culturally
imposed and gruesome harmful traditional practices such as female genital
mutilation. The assessment revealed a number of health problems specific to
women which are intrinsically linked to the low social and economic status
of nomadic women as well as to genital mutilation. These include:
- Low female enrolment
in schools.,
- Low nutritional status;
- Low awareness of health
and health services; and
- Harmful traditional
practices.
3.2.5 Use of health
services
There is a lot of evidence
of the shift of policies in favour of rural and disadvantaged parts of Eritrea
including areas inhabited by the nomadic pastoralists since the independence
of Eritrea in 199 1. Despite the increase in the number of health facilities,
increasing their physical accessibility, there is still evidence of the low
health status of the nomadic population. Maternal and infant mortality
rates are still higher than average with low up take of the services, low
awareness of health needs and health services. The study has identified the
following specific issues among the nomadic pastoralists:
- The current high user
fees which should be reviewed to take into account the average income and
ability to pay;
- Under resource and
ill equipped health units which do not meet the complex specialised needs
of pastoralists;
- The need for well trained
and culturally and linguistically sensitive health workers;
- Lack of health facilities
and personnel to cater for women, dealing with services such as family planning,
maternal and child health care;
- The lack of mobile
and community based health services;
- Lack of well planned
and targeted health education and awareness programmes with appropriate audio
visual facilities and involvement of local people;
- Better designed buildings
to suit the climatic and cultural conditions of the area;
- Shift of some health
facilities to areas more accessible to the nomadic pastoralists; and
- A better system of
management and supervision of health service staff and of resources
in the nomadic areas.
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