Ethiopia is often cited by the Global Fund as having done a good job of implementing HIV grants and of strengthening the country’s health systems. When he signed two grant agreements worth $424 million with the Ethiopian government in July 2012, then Global Fund General Manager Gabriel Jaramillo said that the country had made great progress in achieving universal coverage of antiretroviral (ARV) treatment.
“From the day when Ethiopia was the first to set the goal of universal coverage, our partners here have shown tremendous courage and vision. It is phenomenal how much they have achieved, and how much more they are now aiming for,” Mr Jaramillo said.
Simon Bland, then Chair of the Board of the Global Fund, who also attended the grant signing ceremony, said: “We’ve just signed a grant that enables an African country to achieve universal coverage of ARVs. If we had tried that five years ago, we’d have been laughed out of the room. It is astonishing.”
According to a news release from the Global Fund, annual HIV-related deaths dropped from 99,000 in 2005 to 44,000 in 2011. The death rates for children under the age of five fell by half between 2000 and 2011.
There appears to have been three principal reasons for this change: (1) greater availability of ARVs; (2) an improved health system, including at the community level; and (3) strong political commitment.
The Ethiopian government has made the fight against HIV a national priority. HIV is one of the components of the National Plan for Accelerated and Sustained Development to End Poverty. In 2006, Ethiopia signed on to the UN General Assembly’s Political Declaration on HIV/AIDS, which includes a commitment to achieve universal access to HIV prevention, treatment, and care and support services by 2010.
The Global Fund news release quotes Tedros Ghebreyesus, Ethiopia’s Minister of Health and chair of the country coordinating mechanism, as saying that his country’s advances fighting HIV succeeded because outside support was implemented within a broader domestic strategy to improve health care in a sustainable way. That includes the construction of thousands of health centres and the mobilisation of thousands of health workers and volunteers, he said.
“The Ethiopian government has been able to achieve such success in its HIV and malaria programmes largely because of strong leadership and ownership, enhanced community involvement and improved access to services,” Lera Meskele, Deputy Director General of the Federal HIV/AIDS Prevention and Control Office, told GFO.
“Ethiopia has employed three strategies in its fight against HIV/AIDS: strengthening community based health services (such as using a house-to-house service delivery model), expanding service delivery points (using task shifting) and introducing the Millennium AIDS Campaign,” Mr Meskele added.
The Millennium AIDS Campaign was specifically designed to increase HIV testing.
Mr Meskele said that over 38,000 health extension workers have now been deployed to all kebeles (the lowest level administrative units) across Ethiopia. These health workers facilitate community discussions which enable people to discuss and tackle their health challenges.
A key challenge Ethiopia has tried to overcome has been low access to health care services. Thus, as part of health systems strengthening, Mr Meskele explained, primary health care facilities were constructed and equipped with funding from the Global Fund and other sources.
“For every health centre constructed through international support, the local government constructed a matching health centre as an expression of its commitment to achieve universal access,” Mr Meskele said.
(In a recent GFO article, we reported that, historically, access to health services at the district and zonal level in Ethiopia has been a serious problem. In 2005, only 60% of the population lived within 10 kilometres of a clinic or other health service delivery point. However, in recent years, Ethiopia has scaled up health posts, which are staffed by health extension workers, and the larger health centres, such that the ratio of health facilities to population is now 1:5,426, close to the national target of 1:5,000.)
“Through these efforts, the number of sites providing children's home and community treatment services increased from 659 in 2005 to 2,800 in 2011, while the number of ARV sites increased from three in 2005 to 845 in 2011,” Mr Meskele said. “The number of people tested for HIV in a year increased from less than half a million in 2005 to 11.9 million in 2011. The number of people currently receiving ARVs increased from 3,221 in 2005 to 274,000 in 2011.
Another major challenge facing the fight against HIV/AIDS, according to Meskele, is stigma.
“Many communities have adopted bylaws that aimed at reducing stigma and discrimination to people living with HIV and contributed their part to provide care and support to AIDS orphans,” Mr Meskele said.
Mr Meskele said that Ethiopians have also abandoned cultural practices that promote the spread of HIV. Widow inheritance, he said, has been stopped. A new practice of pre-marital HIV testing has become common among young couples. Community opinion leaders such as politicians, administrators, religious leaders, elders, tribal leaders and health extension workers get tested for HIV as an example to others.
Despite its achievements, Ethiopia still faces a number of challenges, according to Ethiopia’s Country Progress Report on HIV/AIDS Response, 2012. Use of prevention of mother-to-child transmission (PMTCT) services is very low; only about 24% of pregnant women are actually tested and a much smaller proportion receive ARVs during labour.
Although some communities are attempting to tackle stigma, the report states that stigma – and even active discrimination – at the senior levels of government and in the health ministry remain prevalent and go unpunished. In addition, the report said, only a small proportion of orphans and vulnerable children are reached with care and support services.
The report also said that only about 20% of the estimated 182,200 HIV-positive children are on ARVs.
In Ethiopia, current interventions are largely focused on to the general population. Some people have called for a more targeted approach in the fight against HIV/AIDS in Ethiopia.
"The government has launched a vigorous campaign to fight HIV, but now it is important to target specific groups among whom the epidemic is raging," Desmond Johns, UNAIDS country director for Ethiopia, said in an article written by IRIN, a UN news service. "High testing numbers mean little unless you are testing people at risk, such as commercial sex workers."
According to the Global Fund website, to date $1.8 billion in grants have been approved for Ethiopia, making it the largest Global Fund recipient.