The Government of the National Regional State

The Government of the National Regional State of Tigray, Bureau of Health Trends of Key Health Indicator in Tigray (EDHS 2000 to 2016) 29 Nov 2016 Aksum 1

Outline 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Objectives Introduction Maternal Health Child Health Nutrition Hygiene and Sanitation Gender Mortality Figures Way forward Reference 2

1. Objective Ø To review the progress of selective health indicators in the last 20 years (using inter DHS data) Ø Help policy makers, Managers, experts and all stakeholders to make informed decisions for planning and interventions 3

2. Introduction Ø Ethiopia Demographic & Health Survey (EDHS) provides up-to-date estimates of key demographic and health indicators in Ethiopia Ø Commissioned by the FMOH of Ethiopia Ø Implemented by the Central Statistical Agency (CSA) and the DHS Program ICF, Rockville, Maryland, USA Ø Financially supported by the Go. E and different International Agencies through the Mo. FEC Ø Conducted every five years since 2000 (1992 E. C) and captures the situation of about five years preceding the survey time [7 years for MMR] 4

2. Introduction. . . Ø There are only four DHS Reports for Ethiopia, the first was in 2000 (1992 E. C), and the recent was EDHS 2016 Ø DHS Captures different social and health indicators Ø Only few indicators are considered in this presentation 5

3. Maternal Health: Family Planning (FP) 40 Contraceptive Prevalence Rate (CPR) % 27 30 20 9 6 10 14 16 35 35 Ethiopia 21 Tigray 0 EDHS 2005 EDHS 2011 EDHS 2016 CPR (%), EDHS 2016 60 50 50 47 40 40 35 Target: 55% (National STP) National Average: 35% 35 29 30 29 28 20 12 10 1 al i So m fa r A a O ro m iy uz G um D ri H ar e D B/ G am be la y gr a Ti P N SN a ha r m A A A 6

3. Maternal Health: FP. . . • The CPR in Tigray is similar with the national 30 Average (35%) in EDHS 2016 20 • The Unmet need in Tigray is less than the national 10 average (18% Vs 22%) 0 Type of FP Method and Unmet Need, EDHS 2016 22 18 23 19 8 11 2 Injectable Implants 4 Pills Ethiopia 2 1 IUD Unmet Need Tigray 7

3. Maternal Health: TFR • The average number of children a women can have in her reproductive age group • Tigray is relatively lower than the national average (2000, 2005, and 2011, but EDHS 2016 do not show by regions yet) 6 Total Fertlity Rate (TFR) 5. 9 5. 8 5. 4 5 5. 1 4 4. 8 4. 6 Target: 3 (National HSTP 3 2 1 0 EDHS 2005 Ethiopia EDHS 2011 EDHS 2016 Tigray 8

3. Maternal Health: ANC 1+ % of ANC 1+ by Skilled Provider • ANC 1 (at least 100. 0 90. 0 ONE visit) by Skilled Provider 80. 0 in Tigray 40% 62. 4 points showed 60. 0 50. 1 significant improvement in 36. 4 35. 0 33. 9 40. 0 28. 0 the last 5 years 26. 7 (80% change of 20. 0 increase, or 40% absolute 0. 0 points) EDHS 2000 EDHS 2005 EDHS 2011 EDHS 2016 Ethiopia Tigray 9

3. Maternal Health: ANC 1+ . . . % of ANC 1+, EDHS 2016 100 97 Target: 100% 87 76 80 72 69 nal 2% atio e 6 N erag Av 67 60 51 44 40 20 m ro al i O So m iy a r fa A a ha r m A um uz P B/ G N SN la be am G H ar e ri D D ay gr Ti A A - 10

3. Maternal Health: ANC 4+ • ANC 4+ (at least FOUR visits) is a measure of quality of care % of ANC 4+, EDHS 2016 100 Target: 95% (National HSTP 89 80 66 nal 2% atio e 3 N erag Av 57 60 43 42 38 40 35 32 22 20 21 12 al i So m r fa A iy a ro m a O ha r m A H ar er i P N SN uz um be la B/ G G am ay gr Ti D D A A - 11

3. Maternal Health: Skilled Delivery 80 70 % of Deliveries Attended by Skilled Provider 59 60 50 Increased by 57% points in 5 years (or nearly 6 folds) 40 30 35 28 20 10 69 6 5 6 6 10 12 0 EDHS 2000 Ethiopia EDHS 2005 Tigray EDHS 2011 EDHS 2016 (Since 5 Yrs) EDHS 2016 (Since 2 Yrs) 12

3. Maternal Health: Skilled Delivery. . 100 97 % Skilled Delivery, EDHS 2016, per Region (5 years) Target: 90% (National HSTP) 59 60 57 51 Na Av tio er na ag l e 2 8% 80 47 40 29 28 20 20 16 fa r A i al m iy m ro O So a a ha r A m N P SN uz B/ G um be la am ri G ar e H D D gr ay Ti A A 13

3. Maternal Health: Why Home Delivery? (EDHS 2011) 61. 2 Not necessary Not customary Too far/No transportation Cost too much/No money Husband/Family did not allow 16. 4 29. 5 14. 4 9. 9 2. 2 0. 9 1. 2 Ethiopia 0. 2 77. 0 Tigray Poor quality service 0. 5 1. 1 Facility not open 0. 8 No female provider 0. 3 0. 1 4. 5 Other 2. 9 - 20 40 60 80 % among home delivered mothers 14

3. Maternal Health: PNC, for Mother + Baby 45 32% points 17 3 8 5 Ethiopia 13 EDHS 2000 EDHS 2011 Tigray % PNC, EDHS 2016 per Region Target: 95% (National HSTP) 100 80 55 60 45 40 EDHS 2005 EDHS 2016 l iona Nat 17% rage Ave 37 28 18 17 20 17 15 i al m So iy a m ro SN N P O B/ G um uz ra ha m be la A G am ri ar e H D D ay gr Ti A A 12 9 - fa r 6 7 % of PNC by Skilled Provider A 50 40 30 20 10 0 15

4. Child Health: Vaccination [Penta 1 & 3] 80 73 P 3 DOR: 27% 60 64 58 40 53 44 73 56 60 52 P 3 DOR: 12% P 1 reduced from 94% to 92% 20 6 S 2 01 ED H S 2 01 1 5 S 2 00 ED H S 2 00 6 S 2 01 1 ED H S 2 01 5 ED H S 2 00 0 0 0 ED H 86 85 80 37 21 Penta 3 92 94 81 100 40 32 20 Tigray ED H 100 Penta 1 Penta 3 Ethiopia 16

4. Child Health: Vaccination [Measles & All Antigens] % of Measles Vaccination 100 80 67 84 63 60 Ethiopia % 80 to % 84 m fro 56 tion 54 c edu R 40 Ethiopia 80 67 60 59 44 33 40 35 27 20 80 % All* Antigens 100 20 39 24 20 14 S 2 01 6 1 ED H S 2 01 ED H H S 2 0 0 ED S 2 00 ED H 6 ED H S 2 01 1 S 2 01 5 ED H S 2 00 0 ED H S 2 00 ED H 05 0 0 17

4. Child Health: Vaccination [Measles] 100 % Measles Vaccination, EDHS 2016 93 87 Target: 95% (National HSTP) onal Nati 54% e erag 54 Av 80 80 71 62 58 60 48 43 40 30 20 r fa A a iy O ro m al i So m H ar er i P N SN a ha r A m be la am G B/ G um uz ay gr Ti D D A A - 18

4. Child Health: Vaccination [All Antigens] % All Antigens Vaccination, EDHS 2016 100 Target: 95% (National HSTP) 89 76 80 67 onal Nati 39% e erag Av 57 60 47 46 42 41 40 25 22 15 20 r fa A a iy O ro m al i So m la be am G H ar er i a ha r A m P N SN um uz ay B/ G gr Ti D D A A - 19

5. Nutrition: Under 5 Children, EDHS 2016 Critical Time (6 to 24) 20

5. Nutrition: Stunting, Underweight, Wasting Target: 13% 23 10 (National HSTP) Tigray Target: 4. 9% 4 (National HSTP) Tigray Ethiopia 16 16 S 2 0 11 Ethiopia ED H S 2 0 05 ED H S 2 0 00 0 S 2 0 16 S 2 0 11 ED H S 2 0 05 ED H S 2 0 00 ED H S 2 0 Ethiopia 6 2 0 0 10 S 2 0 10 ED H 24 29 11 20 8 ED H (National HSTP) 20 30 10 S 2 0 Target: 26% 11 10 11 05 30 38 35 38 11 10 ED H 41 47 40 11 12 42 12 S 2 0 44 50 00 40 39 48 ED H 52 14 S 2 0 50 60 51 47 % of Wasting among under 5 ED H 55 % of Under-weight amonng Under 5 ED H 60 % of Stunting, among Under 5 Tigray 21

5. Nutrition: Stunting, EDSH 2016 50 % of Stunting among Under 5, EDSH 2016 43 al 9% n 41 40 tio ge 3 39 39 Na ra ve 37 A 32 46 40 30 27 20 Target: 26% 24 (National HSTP) 15 10 A A G am be la i al So m er i H ar iy a O ro m P SN N ay gr Ti D D fa r A uz um B/ G A m ha ra 0 22

5. Nutrition: Anaemia (Women and Children) 23

6. Hygiene & Sanitation: Ethiopia 80 Access to HH water Supply & Latrine, National Average 61 60 65 62 54 38 40 20 68 18 18 0 HH Water Supply EDHS 2000 EDHS 2005 HH Laterine (any type) EDHS 2011 EDHS 2016 24

7. Gender: Domestic Violence % Domestic Violence among Women 15 -49 years 40 35 30 25 20 15 10 5 0 35 24 27 25 22 11 Emotional Violence 37 Physical Violence Ethiopia 13 Sexual Violence At least one type (E, P, S) Tigray 25

7. Gender. . . 90 80 70 60 50 40 30 20 10 0 % Women Circumcised 80 74 65 36 EDHS 2000 29 24 EDHS 2005 Ethiopia EDHS 2016 Tigray In ALL Thionic Groups, Age Groups; Across ALL Religious denominations, Educational status, Wealth quantiles and Residence Ethnic group % Age Group Somali 98 15 -19 Afar 98 20 -24 Hadiya 92 25 -29 Welaita 92 30 -39 Sidama 88 40 -49 Guragie 78 Residence Oromo 77 Urban Amhara 60 Rural Tigray 23 Education Other 38 No education Primary Religion % Secondary Orthodox 54 Secondary+ Catholic [58] Wealth Ql Protestant 66 Lowest Muslim 82 Second Traditional [55] Middle Other [10] Fourth Highest % 47 59 68 76 75 % 54 68 % 73 62 50 51 26 % 65 69 69 69 57

7. Gender: Teenage Pregnancy & Motherhood % of Teenage (15 -49) who begun Childbearing, EDHS 2016 25 onal Nati 13% e erag Av 11 8 3 a O ro m iy er i ar H be la am G um uz D B/ G D ay gr Ti P N SN a ha r A m A A 0 r Target: 3% (National HSTP) fa 5 12 A 10 14 13 al i 15 17 17 16 19 So m 20 23 27

7. Gender: Obstetric Fistula % of Women (15 -49) who reported "Ever had an Obstetric Fistula", EDHS 2016 1. 2 1. 1 1. 0 0. 8 0. 7 onal Nati 0. 4% e erag Av 0. 6 0. 4 0. 2 0. 4 0. 3 0. 2 0. 5 0. 4 0. 5 0. 3 ay gr Ti ra ha A m fa r A uz B/ G be am G um la A A i al So m P SN N iy a O ro m D H ar er i 0. 0 D 0. 0 28

8. Mortality: Under 5, Infant, Neonatal Tigray 40 Tigray 29 Ethiopia ED H S 2 01 6 1 S 2 01 H 5 ED H ED ED H S 2 0 00 6 1 S 2 01 H ED S 2 00 Ethiopia 37 Target: 10% (National HSTP) 0 5 0 30 44 39 49 S 2 00 48 59 Target: 20% (National HSTP) H 6 S 2 01 H ED ED H S 2 01 1 5 S 2 00 H ED ED H S 2 00 0 0 30 0 67 60 64 67 ED 85 Target: 30% (National HSTP) Ethiopia 68 77 S 2 00 30 106 NNMR per 1000 Live Births 97 60 H 90 88 104 S 2 01 123 120 60 90 90 H 150 166 120 IMR per 1000 Live Births ED 169 ED 180 U 5 MR per 1000 Live Births Tigray 29

8. Mortality: Under 5, Infant, Neonatal • Under five year Morality Rate (U 5 MR); Infant (Under one year) Morality Rate (IMR); and Neonatal (Under one month) Morality Rate (NNMR) has reduced significantly over that last 20 years, • However, the pace of reduction is very slow among NNMR: According to EDHS 2016, out of every 1000 live births, 29 Neonates are dying within 28 days of Birth, other 19 Infants are dying within one months to one year (in 9 months), and the rest 19 children are dying during the rest 4 years time (1 to 5 year). 29 Within the 1 st ONE Month 19 Within 9 months 19 (Within 48 months) Out of the U 5 MR: 67/1000 LB in the EDHS 2016 30

8. Mortality: Mothers • Maternal Mortality Ratio (MMR): the number of registered deaths among women, from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy, childbirth or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, for every 100, 000 live births in a given year or period of time • One of the most sensitive indicators of socioeconomic development of a nation! 31

8. Mortality Figures: MMR. . 1, 000 800 1, 039 871 600 400 810 673 676 548 703 799 541 551 412 273 200 350 266 198 199: Target (HSTP) Maternal deaths per 100, 000 live births 1, 200 Seven years "Tigray preceding the Survey" 2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHS (Godefay, etal, (1993 -2000) (1998 -2005) (2004 -2011) (2009 -2016) 2015) 32

9. Summary • Some Health indicators in Tigray has showed significant improvement [EDHS 2011 Vs EDHS 2016] Ø ANC 1: nearly doubled in 5 yrs (50% to 90%), but there is also missed opportunity for ANC 4+ (57%) Ø Skilled delivery: increased by more than 5 folds, 12% to 69% Ø PNC: increased by more than 3 folds, 13% to 45%, but at lower rate than for skilled delivery (missed opportunity) • Some figures were high and kept to be high like Penta and Measles vaccines, >80% with marginal increment or even few reduction in EDHS 2016 (Penta 1 and Measles) • Some figures like Newborn morality, under 5 malnutrition (Stunting) and Gender Based Violence have showed marginal decrease, still prevalent 33

9. Way forward. . . Hit while the Iron is hot: Act on the 4 Transformation agenda and the effective use of the HDA concept in PRACTICE! Pillar 1: Community • Empowered households/Mothers • Women Development Groups (WDGs) • Religious Leaders, Associations, and School community, etc. Pillar 3: Political Leadership Pillar 2: Government System • At Network level (Health Care Structure) HDA • Kebele Steering • HEW/HP as a PHCU Committee (SC) and CP • Hospitals • Zonal and Regional • Private Sector Command Post (CP) • Sector bureaus, Agencies, • Development Partners • Etc. 34

9. Way forward. . . Consolidate and Sustain the gains to date Immunization Maternal, Newborn and PMTCT Build systems/platforms Strengthen institutional capacity Mobilize domestic investment Quality, Equity, Gender Civil and Vital Registration System Nutrition and Early Childhood Development

9. Way forward. . . Resource Management!!!!! Partnership!!! Resource Mobilization!!! 36

11. References 1. 2. 3. 4. 5. 6. Central Statistical Agency [Ethiopia] and ORC Macro. 2001. Ethiopia Demographic and Health Survey 2000. Addis Ababa, Ethiopia, and Calverton, Maryland, USA: Central Statistical Agency and ORC Macro. Central Statistical Agency (CSA) [Ethiopia] and ORC Macro. 2006. Ethiopia Demographic and Health Survey 2005. Addis Ababa, Ethiopia, and Calverton, Maryland, USA: Central Statistical Agency and ORC Macro. Central Statistical Agency (CSA) [Ethiopia] and ICF Macro. 2012. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia, and Calverton, Maryland, USA: Central Statistical Agency and ICF Macro. Central Statistical Agency (CSA) [Ethiopia] and ICF. 2016. Ethiopia Demographic and Health Survey 2016: Key Indicators Report. Addis Ababa, Ethiopia, and Rockville, Maryland, USA. CSA and ICF. Godefay H, Abrha A, Kinsman J, et al. Undertaking cause-specific mortality measurement in unregistered population: an example from Tigray Region, Ethiopia. Glob Health Action. 2014; 7. TRHB. The Government of Tigray National Regional State Bureau of Health ten Years Health Bulletin (EFY 1998 -2007). Mekelle, Ethiopia. : 2016. 37

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