Federal Democratic Republic of Ethiopia
Environment Protection Authority
Ethiopian Environment Outlook: Health and Environment
Past, Present and Future Perspectives
Prepared by: Fikru Tessema
Position: Author of the Chapter
1.1 Aim of the Report
This report is for a thematic area: Health and Environment as part of Ethiopian Environment Outlook
(EEO) and presents a summary of Health and Environment by describing its sub-thematic areas.
The objective of this report is, therefore, to give sufficient information on Health burden from
environmental factors and contribute to country Environment Outlook Report.
1.2 Layout of the report
This report is divided into five sections dealing with some important sub thematic areas of health and
2 Sub-thematic Areas
The major selected sub-thematic areas that have importance for public health and environment are,
therefore: Water and Sanitation, Physical School Environment, Waste Management, Malaria and
2.1 Water and Sanitation
o Lead indicators
The lead indicators for water and sanitation are the lowest level of water and sanitation coverage of
Ethiopia and that the country is stated as having the lowest coverage in Sub-Saharan Africa
Coverage of potable water supply and improved sanitation services are thought to be generally
proportion of population with access to safe water and basic sanitation and hence meeting
millennium development goals and percentage of existing functioning water supply schemes and
basic sanitation facilities.
Each year in millions of people is in need to tap the earth’s water in Ethiopia and especially rural
population (84%) that also containing the greatest number of poor suffering significantly from lower
water coverage than urban area. 76% of those that do not receive safe and adequate water supply
live in the rural areas and this country’s high rural population makes water supply particularly
challenging and complicated, due to having to supply remote and diverse areas and strong
regional variation in water coverage.
Rural supply is mostly through point sources at present with an urgent need for rehabilitation of
non-functional supply schemes about 30 to 45% of existing schemes. The present key challenges
in Ethiopia are the predominantly rural population and rapid population growth occurring in urban
areas that will have significant impacts on water coverage in years to come. On the other hand the
leaking or oozing effect of most sanitation facilities in urban setting is seen to cause public health
problems and environmental degradation.
The 2015 Millennium Development Goal Target is to halve the proportion of Ethiopians without
access to improved sanitation, i.e., for more than 30.53 million people in 15 years (2.04 million
people/year) should have to have access to improved sanitation facilities. This high number of
people with out improved sanitation facility also makes sanitation MDG of Ethiopia challenging.
o State of water and sanitation in Ethiopia
Safe and adequate water supply and basic sanitation service coverage is extremely low in Ethiopia
– currently, population with access to safe water is about 30% and out of which 72% in urban and
24% in rural and access to excreta disposal 29% in which low number of population (11.5%) with
access to improved sanitation facilities, out of which 50% in urban and 4% in rural. Water service
delivery is particularly poorly managed in rural areas with a lack of community ownership and
investment being flagged as key problems with a vicious circle exists between poor service
delivery, poor maintenance, lack of ownership and lack of investment.
Some regions have abundant, untapped stores of water to support growth well into the future. But
others those far from plentiful are in scare of water, with expensive increases in supplies and
technology options. In urban areas of Ethiopia, water coverage on the whole is much higher
compared with rural areas; however reliability of service is still a problem here. The poor service
delivery in urban areas has resulted in an informal supply network (provided through neighbors and
public taps – this forms 70% of the urban in these areas and an unwillingness to pay amongst
urban stakeholders, who are on the whole more able to pay than their rural counterparts. Tariffs
are set at an unsustainably low level with the use of inappropriate technology (too costly or
sophisticated given existing funding and capacity levels) is a key issue in the water supply sector.
o Impacts from lack of access to safe water and sanitation
The prevailing health burden as a result of low services coverage of basic sanitation is that more
than 250,000 children die every year from sanitation related diseases and about 60% of the
disease burden is related to poor sanitation and hygiene in Ethiopia.
The Top Leading Causes of Outpatient (OP) Visits & Admission Deaths
Related to Water and Sanitation, 2000-2004
Helminthes (OP Cases) 6.4 6.7 4.6 2.0
Dysentery (OP Cases) 1.9 3.5 7.5 2.8
Dysentery ( Admission deaths) 2.2 2.6 1.8
Parasitic diseases (OP Cases) 2.2
Skin infections/diseases (OP Cases) 1.7 4.6 3.2
Influenza (OP Cases) 5.8
Relapsing fever (OP Cases) 2.5
Relapsing fever ( Admission deaths) 0.9
2000 2001 2002 2003 2004
Figure-1 shows the top leading causes of outpatient visits and deaths of hospital admissions related to
water and sanitation.
In rural parts of the country, many people have to travel long distance to fetch water for their daily
uses. Especially women and schoolgirls are the one responsible to satisfy the family water need.
This is the case for unproductively of women and absence of girls from school. There is also lack of
plentiful water share among growing cities, the flourishing rural areas, and a thirsty environment.
The inadequacy of water also contributes to burden of water borne diseases from personal hygiene
and sanitation. As a result, greater efficiency is needed in the use of water and fair allocation to
balance the limited supply with rising demand.
The TOP Leading Causes of Epidemics and Deaths from those Epidemics Related to
Water and Sanitation , 2000-2004
Diarrhea (Cases) NA 188
Typhus (Cases)) 758 77 98 226
Typhus (Deaths) 8 NA 4
Relapsing fever (Cases) 1348 444 381 506
Relapsing fever (Deaths) 14 15 6 3
Desentry (Cases) 7662 123 1405 334
Desentry (Deaths) 235 2 46 4
Influenza (Cases) 148 1483
Influenza (Deaths) 2
Food poisoning (Cases) 61
Cholera (Cases) 1146 4670
Cholera (Deaths) 61 35
2000 2001 2002 2003 2004
Figure-2 shows the top leading causes of epidemics and deaths from those epidemics related to water and
o Reponses of the government
Some evidence even suggests that Ethiopia is reversing its progress towards the water and
sanitation. The Government of Ethiopia (GoE) has developed a WSDP (Water Sector Development
Plan), which looks at organizing capacity building at regional and district (woreda) level throughout
Ethiopia. NGOs on the whole tend to fill this funding and capacity gap in the bottom of the rural
supply chain currently. Donors also recommend funds to be dedicated for water, sanitation and
hygiene in WASH programmes.
The Government of Ethiopia (GoE) has dedicated line ministries, the Ministry of Health (MoH) and
Ministry of Water Resources (MoWR) that are responsible for developing and implementing the
national policy, strategy and subsequent government initiatives. The existence of these specific line
ministries gives the issue some prominence in the government.
Ethiopia, as already mentioned, is implementing a generic policy of decentralization, which the
WSDP follows in terms of plans to devolve decision-making powers to regional and woreda
(district) levels. Aadvancing decentralisation is dedicated towards people leading their own
Positive examples abound from the regions offering lessons which can be taken to scale: For
example, Southern Regions have achieved 75% sanitation facilities coverage with its own
resources through political (and budget) commitment, inter-sectoral collaboration, and
accountability and community ownership.
2.2 Physical School Environment
o Lead indicators
The lead indicator for physical school environment is healthy physical school environment that
thought to be generally a contributor to school enrollment rates, especially in girls.
Conducive physical school environment is also thought to be supporting children’s health and
effective learning and hence contribute to have healthy, skilled and productive members of the
Most school environment cannot directly improve children’s health and effective learning and
thereby contribute to the development of healthy adults as skilled and productive members of the
Furthermore, even if schools act as an example for the community, students as members of the
school community did not become aware of environmental risks at school and recognize ways to
make home and community environments safer.
In addition, because of low level of students’ awareness about the link between the environment
and health they would not be able to recognize and reduce health threats in their own homes.
o State of physical school environment
The physical school environment encompasses the school building and all its contents including
physical structures, infrastructure, the site on which a school is located; and the surrounding
environment including the air, water and as well as nearby land uses, roadways and other hazards.
The physical school environment in Ethiopia is the one that poorly managed especially in rural
settings and even further in primary schools. Currently, it becomes one of the primary determinants
of children’s health. The physical school environment has a strong influence on children’s health for
several reasons: contaminated water supplies can result in diarrheal disease; air pollution can
worsen acute respiratory infectious and trigger asthma attacks; and exposure to heavy metals and
pesticides can cause a variety of health effects and even death.
o Impacts from lack of healthy physical school environment
The higher rate of morbidity in schools is primarily due to the high incidence of acute respiratory
infections, vector borne diseases (malaria), water and food borne diseases (diarrhea, intestinal
parasites) and injuries due to road traffic and poor management of play ground in Ethiopia.
High rate of incidence and prevalence rate of infections and diseases and lack of access to toilet
facilities, especially girls, in school contributed to increased number of absence of children from
In urban settings, children are exposed to outdoor air pollution from poor waste disposal, industry,
traffic exhaust fumes and dusts on their way to school and home, and outdoor air pollutants may
enter into the classroom.
o Reponses of the government
The Government of Ethiopia is promoting school hygiene and sanitation programme in primary
schools in both rural and urban settings by coordinating bilateral and multilateral organizations and
NGOs and strengthening intersectoral collaboration.
The Government of Ethiopia is also standardizing and up-grading school infrastructure and
physical structures so as to make conducive school environment.
The Government of Ethiopia has also developed education policy to enhance access to education
and facilitate private sector involvement.
2.3 Waste Management
o Lead indicators
The lead indicator for waste management is the status of the service coverage, which thought to be
currently in a very weak sate in Ethiopia in terms of infrastructure and capacity.
The indicators for waste management are, therefore, thought to be generally proportion of
population with access to solid waste management services and proportion of environmentally
friendly functioning existing solid waste management and treatment facilities.
Regarding technology in use, most of the urban centers do not have appropriate type solid waste
collection trucks and few municipalities also assigned appropriate type of vehicles to collect waste.
Among those who provide a service with appropriate type of vehicle, the coverage is very low,
usually being limited to street sweeping and municipal waste management.
The majority of the people are suffering from lack of sanitation facilities. Besides, few portion of
wastewater not more than 2% of the total produced is treated by the handling system whereas the
remaining major portion (99%) of domestic wastewater is simply disposed-off in open fields or
simply left in the environment uncollected and/or untreated.
The sewerage system is very limited in its coverage, whereas the majority of the urban population
use on-site sanitation system, still a significant proportion use open fields for disposal of wastes.
The storm water drainage system (both of drain-pipes and open-ditch drains) is mismanaged and
abused for wastewater conveyance.
Health care facilities in Ethiopia are also lacking standard handling and disposal of infectious
wastes. As a result there is high risk of exposure to contamination especially from sharp wastes
and surgical wastes.
Municipal solid waste management (SWM) is also the one that poorly managed in Ethiopia. The
main problems of SWM are due to poor micro routing for collection, lack of standard collection
points, lack of equipment and personnel, lack of budget, and poor disposal facility and operational
o State of waste management in Ethiopia
Municipal SWM service only exists in some urban centers, but in most rural areas there is no SWM
function. There is no overall national strategy for SWM improvements in Ethiopia.
In most rural areas of Ethiopia solid waste management is not carried out in an organized manner.
Many of the people are very poor, and appropriate waste management is not a priority.
SWM investments are minimal and there is no formal structure of charging waste generator
through out the country and therefore recovery no recovering costs. The weak financial and
recovery system are one of the major sources of the poor waste management performances.
At present private sector participation in SWM is also limited mainly to informal pre-collection
companies in some urban centers.
There is a wide variation in performance in relation to waste collection in urban centers of Ethiopia.
In many cities there are not enough skips to cover the population and vehicles are typically poorly
maintained and out of service for long periods of time. The operational performance at the
dumpsite is poor in relation to environmental impacts and health risks in Ethiopia.
Wastewater sources are mainly domestic & industrial. Major domestic wastewater sources are
residences, public toilets, commercial centers (hotels, restaurants, etc.), hospitals & institutions
(GOs, NGOs & private). Industrial wastewater sources are beverage, tanneries (leather & foot
wears), textiles, food, pulp & paper, petrochemicals (dying, plastics & related), soap & detergents,
iron & steel, non-ferrous metals, rubber, tobacco, pharmaceuticals and wood industries.
Industrial wastewater is estimated quantitatively and qualitatively. The average wastewater
production per ton of individual products (by industry type) ranges from 0.09 cubic meters for soap
& detergents to 87.09 cubic meters for pharmaceuticals. Accordingly, quantity of industrial
wastewater produced in Ethiopia between 1990 and 1997 amounts to 35.65 million cubic meters
(on average ~ 4.45 + 0.275 Mm3/yr). Its average growth rate is 2.36%.
Like some other developing countries, the majority of the population of Ethiopia has a very few
toilet facilities and wastewater handling systems.
There is no standard handling and disposal of infectious wastes from health care facilities in
Ethiopia. Special wastes like sharp and surgical wastes are the one that highly contributing to
infections from blood borne pathogens because of lack of segregation at point of their sources.
o Impacts from lack of access to waste management
Since waste management service coverage is low, there are significant environmental and health
impacts from poor waste collection and disposal practices in urban setting and low impacts in rural
areas since waste generation rate is very low. There is a shortfall in collection points in the urban
settings in Ethiopia, and therefore these collection points often overflow with waste.
Due to poor operational performance at the dump site there is negative environmental impacts and
health risks, for example, because of:
lack of covering of waste, which results in odours, wind-blowing of waste, and leachate
leachate management, and lining to the landfill, resulting in potential leaching of heavy
metals and other toxic pollutants into the ground water, as well as surface run-off of these
Unsafe health care waste management highly contributes to risks of exposure to contamination of
the workers and the environment and the community at large. Due to lack of proper design and
routine maintenance, most of the available facilities and equipment do not serve the intended
purpose and are rather acting as sources of health risks.
The unsanitary situation created due to mismanagement and lack of facilities for waste disposal is
seen to cause public health problems and environmental degradation. For example streams &
rivers crossing the city are affected by domestic, industrial and health care wastes and wastewater.
Some 96% of industrial wastewater is disposed-off in the environment without any treatment. This
shows that there is a potential risk to air, water & soil pollution in areas where untreated industrial
wastewater discharges exist.
o Reponses of the government
In some urban settings, they established a responsible body to manage solid waste; decentralized
the management to sub-city level (Kebele) to make them responsible in dealing with their own
waste management problems; conducted public awareness programs on television and radio;
planed improving river banks, streets and greenery of open areas, expansion of composting
activities and pre-collectors and strengthening the capacity of informal recyclers.
The Federal Environment Protection Authority has been developed a national framework for private
sector participation and working on developing national solid waste management strategy.
The Federal Ministry of Health intended to have an efficient, safe and environmentally-friendly
health care waste management that will be the only means of ensuring of contamination from
infectious wastes and disposable syringes and needles are not re-used and does not lead to
accidental needle stick injuries. This important activity included:
o Formulation of a policy stating that disposal is part of the syringe lifecycle and that
healthcare services have a duty to manage sharps waste
o Assessment of the waste management system, including expressed and real needs
o Selection of appropriate waste disposal systems for all levels of healthcare facilities
o Implementation of a regulatory framework (enforcement) and human and financial
resources in place.
o Implementation of a waste management system and supervision and monitoring
mechanism in place.
o Lead indicators
The lead indicators for malaria are its prevalence rate that lead to high morbidity and mortality rate
The indicators for prevalence of malaria are, therefore, thought to be generally outpatient visit,
hospital admission and death rates of malaria.
Malaria accounts for 11 - 15% of the total outpatient morbidity/visits and 18 - 20% of all hospital
admissions in Ethiopia.
Malaria also accounts for 15% of outpatient visits and 21% hospital admissions for female and 11 -
15% of outpatient visits and 18 - 20% hospital admissions for infants. Malaria is also one of the
number one top leading causes of deaths and its case fatality rate in all cases is 27%, in female
27% and in infants 21%.
o State of malaria in Ethiopia
Based on the occurrence of malaria, the country can be divided into malarious and non-malarious
areas. The non-malarious zone with an altitude above 2250m is the area where no indigenous
transmission occurs. This area comprises 15-20% of the total landmass and is inhabited by about
25% of the total population. The malarious zone, which refers to the land below 2200m makes up
80-85% of the total landmass; roughly a minimum of 35-40% of the population live in this region
and are at risk of malaria infection.
Anticipated increase in temperature and change in rainfall would have direct and indirect impact on
the health sector. It will in particular influence weather and climate sensitive diseases by increasing
population of vectors such as misquotes, by increasing heat stress, etc. Climatic, altitudinal and
topographic diversities in Ethiopia create micro and macroclimatic conditions that result in a
discontinuous and widespread malaria distribution.
Malaria in Ethiopia is a major public health problem. It occurs in most parts of the country and is
unstable in its nature mainly due to topographical and climatological conditions. The transmission
of malaria is dependent on temperature, rainfall and humidity. Since 1958, major epidemics of
malaria occurred at intervals of approximately 5-8 years, but recently there is a trend of more
frequent small or large scale epidemics occurring in the same or different parts of the country.
Currently, there are number of epidemics precipitating factors in addition to natural environmental
or climatological factors including drug resistance of malaria, high-scale population movement (due
to resettlement and labor forces in agro-industrial development areas) and expansion of
development activities such ad irrigation schemes.
o Impacts from malaria
The environmental and temperature changes in the country led to the spread of malaria, which
could also, led the morbidity and mortality rates reaching epidemic proportion in the past. People
living in the malarious area were suffering from the disease and brought an economic burden
because of the decrease of the population in the productive age. These communities are especially
vulnerable to climate change as most of the mitigation measures are beyond their resources.
Figure-3 shows malaria epidemics and deaths from those epidemics.
The emergence/occurrence of malaria in new areas; for example, in 1998, large-scale and severe
malaria epidemics occurred in most highland areas in the country. The outpatient visits, hospital
19 110 3 474822
2000 2001 2002 2003 2004
Y e a r
Malaria Epidemics and Deaths from those Epidemics, 2000-2004
admissions and deaths rates are increasing from time to time in the country and hence put socio-
economic burden from the treatment of malaria on the health services.
o Reponses of the government
The Federal Ministry of Health has formulated different intervention mechanisms for the prevention
and control of malaria:
- Establish surveillance system and integrated vector control approach;
- Conduct awareness raising programme on malaria prophylaxes, environmental control, and
- Encourage the use of malaria bed net and developed guideline on environmental health
management for settlements and during disasters, which includes the control of malaria.
o Lead indicators
The lead indicators for HIV/AIDS are morbidity and mortality rates from its high prevalence rate and
impacts on Ethiopia’s society and economy.
The indicators for prevalence of the HIV/AIDS are, therefore, thought to be generally sero-positive
cases, hospital admission and death rates of HIV/AIDS.
The cumulative numbers of population lived with HIV/AIDS and orphaned children needing care
and support will be taxing, to say the least. So will the demand on the limited social services,
particularly the health care delivery system.
The other socio-economic impacts are also expected to be daunting and require special attention if
we were to continue and succeed on the present mode of economic development and poverty
alleviation efforts. On the other hand, given the magnitude of the impact, the disturbing picture of
the after effects and the poverty level of the country, the positive trends are not satisfactory enough
to give respite.
o State of HIV/AIDS in Ethiopia
HIV was first detected in Ethiopia in 1984 in stored sera. The first two AIDS cases were reported
to the Federal Ministry of Health (MOH) in 1986. HIV/AIDS surveillance activities began in 1989
and since then the HIV epidemic appears to have steadily increased in Ethiopia. There are many
cultural factors that promote the spread of the disease. Known risk factors include the presence of
sexually transmitted infections (STIs), multiple sexual partners, and harmful traditional practices
such as female genital mutilation, uvulectomy, blood letting, skin cutting, and piercing practices.
The estimated national adult HIV prevalence in 2003 is 4.4%, of which 12.6% are urban and 2.6%
rural. Trend analysis of prevalence from 1982-2003 showed an urban epidemic that rose sharply
to a peak, and that has plateaued over the last 7 years; a steady rise of rural prevalence with
consistent decrease inn the rate of progression; and a continuing gradual rise in national
prevalence but with beginning signs of levelling at relatively low level.
The rate of new infections (incidence), which is usually the most reliable in indicating the
progression of an epidemic, showed an urban incidence that rose sharply until 1990/91, declined
over the following 7 years and plateaued there after albeit at a high level; rural incidence rose
slowly until 2000 and levelled off at a much lower rate than the urban; and although national
incidence parallels both the urban and rural trends, it is closer to the rural incidence.
The cumulative number of people living with HIV/AIDS is about 1.5 million (3.8% male and 5%
female; 12.6% urban & 2.6% rural) out of which about 96,000 are children under 15 years. The
estimated number of new AIDS cases in the adult population in 2003 was 98,000 (46% male &
54% female) while that in children was 25,000. Some 245,000 people living with HIV/AIDS were in
need of antiretroviral treatment (ART) in 2003 and some 90,000 adults and 25,000 children had
died of AIDS also in 2003.
Although the behavioural surveys to date indicate some encouraging signs, the limited impact
surveys and socio-economic impact analysis on blood sample results such as life expectancy,
orphaned children, trained workforce and the social services, indicate a grave situation requiring an
immediate scaled up and focused intervention.
The national HIV incidence rate in Ethiopia is levelling off and the rate at which it is progressing is
declining over the last few years and the epidemic appears to be stabilizing, particularly in urban
areas, indicating some behavioural change in the population. This is also supported by the level of
awareness about the disease, the tremendous increase in condom distribution and the increasing
utilization of voluntary counselling and testing services by different social groups. We need to
capitalize on these achievements and do more.
15-24 25-34 35-49 Total
HIV Prevalence by Age Group and Site Setting, 2003
Figur-4 shows HIV prevalence (%) by age group and site setting.
o Impacts from HIV/AIDS
Possible impact analysis on different variables shows that HIV/AIDS has a variable effect and
detrimental impact on Ethiopia’s society and economy.
Therefore the impact of HIV:
1. On annual TB cases accounted for an estimated 38% or 54,000 of all TB case in incidence in
2. On total population size is that the population lost to AIDS was about 900,000 by 2003 and is
projected to reach 1.8 million by 2008 if present trends continue.
3. On young adult deaths account for about a third of all young adult deaths in the country.
4. On life expectancy (LE) on average is expected to reduce LE in Ethiopia by 4.6 years in
5. On number of orphans is causing an increase of the number of AIDS orphans in the past.
There were an estimated 539,000 AIDS orphans in 2003 and would also lead to 332,000
fewer AIDS orphans by 2008 with anti-retroviral treatment (ART).
Estimated and Projected Adult HIV Prevalence (%) by Sex and Setting
Selected Years, 1982 - 2008.
1982 1985 1990 1995 2000 2001 2002 2003 2008
Figur-5 shows estimated and projected adult HIV prevalence (%) by sex and setting selected years,
1982 - 2008.
The National HIV/AIDS taskforce was established in 1985 as a national response to the epidemic.
The National AIDS Control Program (NACP) was later established at a Department level at the
Ministry of Health in 1987. Two medium-term prevention & control plans were designed and
implemented in 1989 and 1996 respectively. Currently, a team under the Disease Prevention and
Control Department functions as the focal point of the health sector's response to HIV/AIDS and
has representation from the federal to the district levels of health care management.
The HIV/AIDS Policy was formulated by MOH and adopted by the Council of Ministers in 1998.
This created an enabling environment for HIV/AIDS prevention and control. The policy
supplemented several policies such as the Health Policy, Women's Policy, and the Education and
Training Policy calling for a multisectoral response; guaranteeing rights for PLWHA; and facilitation
the development of policies on the supply and use of antiretroviral (ARV) drugs, amongst other
The HIV/AIDS Prevention & Control Office (HAPCO) was established in 2002, under the Prime
Minister's Office. It is responsible for resource mobilization, advocacy, and for the coordination of
the sectoral responses. HAPCO developed the National Strategic Framework as a national
response to HIV/AIDS.
The priority interventions implemented in the country include: information education and
communication/ behaviour change communication (IEC/BCC); condom promotion & distribution;
voluntary counselling and testing (VCT); management of sexually transmitted infection (STI); blood
safety; universal precaution; prevention of mother-to-child transmission (PMTCT) of HIV; care and
support to the infected and affected; legislation and human rights; surveillance; and research.
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