Ethiopia Environmental Health Literature Review

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Department of Community Health, Medical Faculty, Addis Ababa University, Email: aberakumie2@Yahoo.com;
Fax:+251-1-517701; Tel: 157701, Addis Ababa, Ethiopia
Review Article
An overview of environmental health status in Ethiopia with
particular emphasis to its organization, drinking water and
sanitation: A literature survey
Abera Kumie, Ahmed Ali
Abstract
Communicable diseases attributable to poor sanitation, and which principally affect the underprivileged sections of the
population, are still considered as major health problems in Ethiopia. Despite a relatively long history of
environmental health activities in the country, their service provisions in the field are so far not up to expectations. An
extensive literature review was made in this study in order to examine the status of environmental health with
particular emphasis to drinking water and sanitation with respect to its legal, institutional, human resource frameworks
and service outputs. It was found out that environmental health services in Ethiopia have a documented history
spanning five decades. The creation of the Gondar Public Health College in 1954 was the springboard for the
commencement of training and activating sanitation services in the country. Environmental sanitation became a
component of PHC in the 1970-80’s. While the regulatory function in sanitation was developed in the 1950’s, it was
dramatically reoriented in the 1970’s. Sanitation regulations and related activities are now readdressed with the
National Health sector Development programme and Health Extension Packages developed by the MOH. The
progresses made so far in environmental health, however, did not show any significant changes over the last three
decades. Currently, the coverage of safe drinking water and latrines remains very low, at about or less than 30% and
13% for the country, respectively. The per capita drinking water can not satisfy 50% of the minimum requirement.
Access to latrines as well has similar drawbacks. Out come indicators as measured by diarrhoea prevalence still remain
to be significant. KAP towards sanitation is at the low side. The poor achievements in environmental health service
coverages over the past decades are attributed to various socio-economic factors and weak implementation practices
that are detached from policies. Impacting on both the internal and external environment is believed to bring changes
in the current sanitation status. [Ethiop.J.Health Dev. 2005;19(2):89-103]
Introduction
Communicable diseases are considered as major causes
of morbidity and mortality, as well as disability in
Ethiopia (1-4). The high prevalence of communicable
diseases in the country is linked to the poorly developed
socio-economic and environmental factors that have been
inherent for centuries. Seventy five percent up to eighty
percent of the disease burdens in Ethiopia are assumed to
be preventable using measures like improving
environmental health status and nutritional interventions
(1-4). The term sanitation in the narrower and
environmental health in the broader contexts is defined as
the control of all those factors in man’s physical
environment which exercise or may exercise a
detrimental effect on his physical, mental, and social well
being” (5-6). It entertains the satisfaction of basic human
needs with provisions for basic and healthy housing,
drinking water, and waste management in all aspects
including personal hygiene.
Environmental health activities in Ethiopia are
maintained and used as a means to control diseases and
promote health during periods of “Basic Health Service
Provision during 1950-1960’s”, and Primary Health Care
(PHC) during the 1970-90’s, and currently in the Health
Sector Development Programmes (HSDP) (7).
Nevertheless, significant improvement in sanitation
status could not be achieved due to the prevailing and
sustained minimal outcomes given available resources.
The life support environmental components, represented
by air, water, and soil, are the intermediate factors that
are potentially affected by human activities. How best the
benefits from our environment can be maximized with or
no little effect has become a basis for our continued
survival. Ethiopia, with its long history of health services
development, is still waging struggles for the control and
prevention of communicable diseases that are mainly
transmitted because of poor living and environmental.
One can not appreciate the environmental health inputs in
the background of sustained burden of diseases existing
for many decades. The determining factors are believed
to be multiple, but the question of why there could not be
a change in the morbidity situation requires a reviewing
of specific situations at macro and micro levels. The
purpose of this review, therefore, includes an assessment
of organizational, legal, and human resources; at the
national level and their related impacts on morbidity; and
finally to examine of possible factors affecting the
progress of environmental health.
Methods of data review
Review of literature, such as books, journals, online
materials, reports and other relevant documents,
published or unpublished, were used as the main sources
of the inventory.

90 Ethiop.J.Health Dev.
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Ethiop.J.Health Dev. 2005;19(2)
Statistical analysis using available data was employed to
predict the trends in drinking water and sanitation
coverage. The regression analysis for a time series trend
is assumed on the conditions that time and coverage
figures are continuous variables for the simplicity of
understanding the situation. Expert judgments as to
whether trends in drinking water coverage sustains the
deficit based on the regression prediction was used to
indicate the prevailing gaps in coverages and benefits.
Data comparison was made using internationally
accepted provisions in drinking water supply, latrine use,
and housing in order to evaluate the present status in
environmental health. The status of environmental health
in the country was evaluated using sanitation indicators
that are relatively reliable because of better data
availability. One criterion is to base the evaluation using
standard output indicators, like drinking water and
sanitation coverages, an approach that deals without
going in detail to the resources and institutional
accountability. An outcome oriented indicator through
the measurement of morbidity, like for example a two-
week prevalence/incidence of childhood diarrhoea, was
also considered. A second approach is using a kind of
framework analysis in which the major inputs are
described and challenged. The former methodological
approach was adopted for this review as it is believed
that evaluating from the national perspective will be
relevant. The following operational definitions were
assumed to evaluate the findings against the
recommended values
Definitions
Drinking water supply accessibility: The geographical
proximity of safe source of drinking water points within
15 minutes walk or a radius of 1 km from users 'homes
(6,8).
Adequateness of water supply: The amount of drinking
water that is available to support an individual’s daily
basic needs required for drinking, culinary, and other
domestic purposes to satisfy his personal hygiene (9,10).
Recommended values are 20 and 50 litres per day per
capita for rural and urban residents, respectively
(6,10,11).
Drinking water coverage: The proportion of populations
or house holds who have access to a safe drinking water
source that ensures and/or limits the absence of
pathogenic micro-organisms (12).
Latrine coverage: The proportion of population or house
holds who have access to some kind of latrine (12).
Findings of the Review
Institutional-Organizational framework
The development of environmental health practices in
Ethiopia has long history dating back to the 1900’s. It is
attached to various time frames during which specific
contributions were made to sanitation. This is reviewed
in order of chronology by main themes of development in
reference to the existing political systems. The Imperial
time had two phases: “traditional efforts” and efforts
associated to the “modernization” of the social services.
The inputs contributed during pro-Marxist period and the
present governments were also highlighted.
Phase 1: Traditional Organization (1900-1946)
The history of environmental health goes back to 1900’s,
a time when the health service was organized under the
Ministry of Interior in 1908. After the Italian Invasion, in
1942, a Directorate of Medicine was established in the
Ministry to undertake medical and public health services.
The issue of sanitation was considered as a domestic
affair during that time. During that time the development
of hospitals and clinics in urban centers to serve the
landlords was a central effort. Activities in environmental
health service rendering, however, were not significant
due to the existing limited manpower and unclear visions
in the field. The Ministry of Interior consolidated its
power to exercise decisions over health matters after the
post Italian invasion period through the proclamation of
1942 P26 and legal notices following its mandate in
sanitation: 2/11 (1943) L25, 2/11 (1943) L26, 7/1(1947)
L104 (13). The limited efforts of the Ministry
concentrated only on big urban centers, leaving the rural
population underserved. Although there were policy
statements were in sanitation for this period, the
institutionalized aspect did not reach the grass root level
to address safe drinking water supply problems, latrine
provision, as well as solid and liquid waste management.
Phase 2: New organization, new task (1947-1974)
During the second phase, the Public Health Proclamation
No 91/1947 (14) has opened the way widely for the
development of environmental health services in
Ethiopia. The proclamation declared the establishment of
a new Ministry of Public Health with defined duties and
responsibilities. Pools of organizational units were
created on the ground to realize the provisions of the
Proclamation. The Municipal Public Health Service in
Urban Centers and the Provincial Public Health Service
for rural areas were the set ups designed to promote
medical and sanitation services. The Provincial Health
Officer and the Municipal Health Officers were focal
authorities for the development of curative and

An overview of environmental health status in Ethiopia 91
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preventive health care services in rural and urban
settings, respectively. The Hygiene and Environmental
Health unit in the Ministry was under the Department for
the Control and Prevention of Communicable Diseases in
most cases and under the Health Services and Training
Departments at times. Its extension to the Provincial
Health Department was represented by a senior sanitarian
to help coordinate and guide sanitation activities. The
organizational aspect for this phase was designed more to
fit with the needs of the 1950’s vertical health
programmes and the end of the 1970’s for Basic Health
Programmes that were distinct in their implementation in
the country. That period was also characterized by the
enacting of various sanitation regulations and the
establishment of a historical Training Center in Gondar
in 1954- the Gondar Public Health College and Training
Center whose graduates served in the training of
sanitarians (1,14). The sanitarians were largely involved
in urban sanitary inspections pursuant to sanitation
regulations and constructions of small scale drinking
water supplies and latrines in rural areas. For example,
they were the key actors in the eradication of small pox
in Ethiopia. Ethiopia also became a member state of the
WHO during the beginning of that period.
Phase 3: Primary Health care emerging: A shift in
health policy (late 1970’s –end of 1980’s)
This was a period when the country was ruled by the
Socialist mode of production. The “Dergue” regime
adopted PHC to suit its Health Policy statements
underlined in its “National Democratic Revolution
Programme” (7). Drinking water and sanitation became
formal components of PHC. Ethiopia, during this time,
had adopted a ten-year perspective plan which PHC
activities were implemented. During the International
Drinking Water Supply and Sanitation Decade
(IDWSSD), covering the period 1984-1994, it was
possible to make interventions some of the basic
sanitation needs. Rural Settlement Programmes were
used as entry points for sanitation efforts. PHC
Committees that were organized at various levels were
used as institutional frameworks in coordination with
“Awraja” Health Departments to run PHC activities. The
previous Ministry of Public Health was renamed as the
Ministry of Health and under it the Department of
Hygiene and Environmental Health was organized since
1983 with four divisions that were responsible for major
sanitation activities: Water and Sanitation, food hygiene,
industrial hygiene, and quarantine hygiene services.
Phase 4: Restructuring of the health policy and shift
in to new strategies (1990 until present)
This phase was the time after the Dergue regime was
over thrown from power by the Ethiopian People’s
Revolutionary Democratic Front (EPRDF). A new
economic and political system was established with
decentralization of powers down to the grass root levels,
the expansion of the private sector democratization of the
social and economic system, and encouraging
investments are the backgrounds under which
environmental health services are managed.
The Department of Hygiene and Environmental Health in
the Federal Ministry of Health has currently maintained
its previous status. Regional States have “Teams” of
environmental health professionals organized under the
Department of Disease Prevention and Control or
Department of Health Programmes. There are efforts to
staff the “Wereda” Administration and “Kebeles” with
environmental Health and Health Extension focal
persons. “Wereda” Administration is an administrative
unit that coordinates and guides socio-economic
developments at the grass root levels. Emerging health
programmes, such as the Health Extension Package
(HEP) was developed and tested as a pilot project in
2002/03, and has been implemented since 2003 with the
training of health extension workers. The package
consists of 16 components, 7 of which are on sanitation
which include housing sanitation, drinking water supply,
food hygiene, personal hygiene, solid and liquid waste
management, latrine provisions, food hygiene and vector
control. HEP is understood as an essential health service
targeting households with strong focus on community-
based approaches and sustained preventive and
promotional health care (15). The goal of HEP is to bring
about positive behavioral changes towards the
maintenance of a healthy environment through the
provision of house to house education to the population.
Health packages are also expected to reach households in
intervention programme areas during the implementation
of the HSDP. This period is characterized by the
introduction of a number of health and environmental
policies and regulations (Table 1) and a restructuring of
environmental health services at the level of a “Team”
under Regional Health Bureaux. The last phase is also
characterized by the emergence of new activities aiming
at bringing about behavioral change at the level of
households. Although priority is give for the provision of
basic sanitation services, the need for closer attention to
emerging environmental issues related to ambient air,

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water, and soil pollutions are becoming both global and
national challenges requiring prompt action.
Legal framework
In the field of environmental health, nationwide
legislations were initiated as early as 1943 under the
jurisdiction of the Ministry of the Interior, and then
mushroomed in the 1950’s after the creation of the
Ministry of Public Health. The legislations mainly
concentrated on the maintenance of the natural integrity
of food and beverages, drinking water, and soil by
prohibiting or controlling human activities that can
contaminate or pollute such resources. Regulation on
drinking water, food hygiene, quarantine, disposal of
corpses, and waste management were key areas of the
regulation (13). The enforcement mechanism was in
accordance with Proclamation 91/1947 through the
Provincial and Municipal Public Health Services. The
Provincial and Municipal Health Officers were delegated
to supervise the enforcement of public health legislation,
while the Governor General of the province and the
“Kantiba” (mayor of the urban centers) were responsible
to ensure and enforce the legislations. The enforcement
of the legislation in urban centers that have municipality
status, like licensing and suspension or revocation, of
permits burial of dangerous foods and parts of animals,
were progressively implemented during the 1950-1960’s
by taking into account of the sanitary legal provisions.
There were little inputs for further expansion and
development of regulations during the “Dergue” Regime.
Draft documents on environmental health regulations
existed but never got close attention. The momentum of
environmental health regulations declined, and activities
were mainly related to routine sanitation inspections,
sanitation campaigns and hygiene education which did
not have legal basis as the status of sanitary regulations
were poorly defined or formulated. Extreme measures
taken by sanitarians were re-acted badly by the
authorities. Few sanitarians were fined and imprisoned
in the capital and regional cities (personal
communications). Lack of updated, explicit and
transparent legislation and enforcement mechanisms
deterred the execution of regulatory measures. Moreover,
regional administrators were more of politically oriented
and were not bound to be sensitive to environmental
health issues in practice. Cities with municipal status
heavily closed their doors to Ministry of Health
sanitarians hindering mutual efforts. Unproductive
collective expertise and decision making through
Committees were much preferred for handling efforts
relevant to sanitation.
EPRDF has made opportunities possible for the socio-
economic development of the country based on the
decentralization and democratization of the health
system. Health policies and strategies, perspective health
plans in HSDPs, and health extension packages serve as
backgrounds for the development of environmental
health services.
Each Regional State under the Federal Democratic
Republic of Ethiopia (FDRE) is delegated to formulate
region - specific policies, regulations, and develop its
natural and human resources (16). Accordingly, the
Addis Ababa City Administration, the Regional States of
Amhara, Tigrai, and Oromia have already enacted
hygiene and environmental regulations. These
regulations have brought together the previous
fragmented ones under one core set of sanitary
regulations. New additions like the prevention of noise
and air pollution were also included in the regulations.
They have also explicitly indicated the kind of measures
that would be taken in cases of sanitary violations. Power
delegations to exercise the provisions of the regulations
were also clearly indicated: environmental health
workers (environmental health inspectors) and sanitary
guards for managing technical matters and sanitation
petty offenses, respectively as in the case of Addis Ababa
City regulation (17).
The Federal Ministry of Health has facilitated the Public
Health Proclamation No 200/2000 which concentrated on
the hygienic aspect of water, air, soil, and work places to
structure and harmonize the existing regional specific
sanitary regulations (18). Although guideline
specifications for the enforcement are under way by the
Department of Hygiene and Environmental Health of the
Federal Ministry of Health, its delay will probably nullify
the proclamation before it is enacted on the ground.
Other related legal actions are indicated on Table 1.
Human resource development in environmental
health
The training of environmental health cadres in Ethiopia
goes back to 1946. The UN Relief and Rehabilitation
Administration (UNRRA) took the initiative together
with the Ethiopian Government to organize the training
of sanitary personnel for the duration of six months.
WHO, UNICEF, and USAID were also involved in the
establishment of Gondar Public Health College and
Training Center (GPHC & TC) in 1954. The GPHC &
TC is the pioneer for the mobilization of community
based health cadres that included health officers,
sanitarians, and community nurses. The first batch of

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Table 1: Sanitation regulations: 1990-2004 (Transitional and Federal Government of Ethiopia)
Provisions Implementer Short Descriptions
Constitution: Proclamation No
1/1995
Federal and Regional
Governments; every citizen
Expresses the fundamental laws of the
nation including health and environment:
article 44- All persons have the right to
clean and healthy environment.
Health policy in 1993 Federal and Regional States Expresses that environmental health,
occupational health, and safe guarding of
the environment are priority needs among
others
Public health proclamation
No 200 of 2000
Ministry of Health and its
Branches
Provides the basic descriptions of
hygiene and sanitation needs for
enforcement: water and food sanitation;
waste management; ambient pollution
control are key areas.
Labour Proclamation: No
377/2004
Ministry of Labour and Social
Affairs and its Branches
The enforcement of occupational health
requirements and standards in work
places
Regional regulations: such as
No1 of 1994 for Addis Ababa;
Regulation No16/2000 of
Amhara Region;
Regional Sates Sanitary regulation and guidelines that
are enacted by Regional States pursuant
to their powers and duties.
Proclamation No 295/2002 Environmental Protection
Authority
Establishing the Environmental Protection
Organs
Authority
Need of environmental impact
assessment
Authority and Regional Sates
Environmental Pollution Control: wastes;
hazardous waste, municipal waste; needs
of environmental standards; inspection
provisions
Water and Sanitation Policy Ministry of Water resources Descriptions to the conservation,
exploitation, and use of natural water and
their protection
Proclamation No 7/1992 Federal Government Powers and duties of Central and
Regional Government
sanitarians graduated in 1957. The Gondar Training base
originally had a team training approach which has the
interaction of the team members with the rural Ethiopian
environment was the governing principle (14,19).
Jimma Health Sciences Institute stands second with
respect to producing environmental health personnel,
with advanced diploma, since 1988 and has continued
providing post basic BSc training in the field of
environmental health since 1993. Its training programme
philosophy is similar to that of its precursor GPH (14).
The expansion of human resources development got
serious consideration by the Government of Ethiopia
through the adoption process of the Health Sector
Development Programme (HSDP). The newly organized
training institutions: “Debub” and Alemaya Universities,
Defense University and the "junior" training centers at
Axum (North Ethiopia) are currently involved in the
training of environmental health workers and technicians
side by side with the pioneers- Gondar and Jimma
Universities. Further more, the Addis Ababa, Jimma and
Gondar Universities are involved in the training of
graduates in Community Health while Arbaminch

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University is involved in the training of water and
sanitation engineers at diploma and BSc levels.
Environmental health service and its set up, as measured
by the inputs of environmental health workers, gained
inspiration and strength immediately after the
establishment of the Ministry of Public Health in 1947
and the inauguration of the Gondar Public Health College
& Training Center (personal communications with senior
staffs). It reached momentum during the 1960’s, survived
the 1970-80’s, and is refreshing its strengths currently.
The output of the service is generally seen as a result of
collective efforts made at different times at different
levels of political relations in the country.
Identifying the needs and gaps in human resource
development is a key task for planners and has been
relevant to present it here in order to observe trends in
relation to basic health cadres. In fact, physicians, nurses,
and environmental health workers (sanitarians) are
considered to be key health professionals for the health
sector. Consequently their distribution is directly related
to accessing to some kind of health services. While
nurses and physicians had rapid growth, environmental
health workers exhibited a slow increase in population
ratio over the last two decades since 1984, although there
had been 4 fold growth in absolute numbers due to the
inclusion of certificate courses for environmental health
workers (3-4,20-24) (Table 2). However, the increment
could not guarantee the success of the HSDP and Health
Extension Programmes in environmental health.
Table 2: Trend of Environmental Health workers (sanitarians) distribution compared with other categories, 1984-2003
EC, Ethiopia.
Personnel categories 19841
(20)
1998 2
(21)
1999
(22)
2000
(23)
2001
(24)
2002
(4)
20033
(3)
National population 42.83 mln 59.88 mlln 61.672 mln 63.495 mln 65.344 mln 67.220 mln 69.127 mln
Physicians of all types:
Number
Ratio to population,
per 100 000
444
1.04
1415
2.36
1283
2.08
11263
1.98
1366
2.09
1888
2.81
2032
2.94
Nurses of all types
Number
per 100 000
1604
3.82
4774*
7.97
5498*
8.91
6713
10.57
7723*
11.82
12838
19.1
14160*
20.48
Environmental Health
Workers
Number
per 100 000
257
0.61
661*
1.1
736*
1.19
825
1.29
920*
1.41
971
1.44
1054*
1.52
1A base year for the 10 year health perspective plan (1984-1993) during the Dergue regime;
2 Base year for the HSDP 5 years plan of 1998/99-2002/03; 3 end of HSDP I also about current status;
* Diploma + Certificates.
Inter-sectoral institutionalization of Environmental
Health services
Institutional arrangements have always been dynamic in
Ethiopia. A major overhaul of institutional arrangements
took place in 1993, following the enactment of
Proclamation 41 of 1993 during the present Government.
The Proclamation defined the powers and duties of the
central and regional executive organs of the Government
of Ethiopia (25). There are at least 14 major government
institutions that are participating in the promotion of
environmental health in one or another way (26) (Table
3).
Of all the partners, the environmental protection Agency,
Ministry of Water Resources, Ministry of Labour and
Social Affairs, Ethiopian Quality and Standards
Authority, and Municipalities are the institutions engaged
in the integration of mutual efforts in the protection of
the environment. The other agencies are involved in the
process of implementing environmental and health and
regulatory specifications. However, at times there are
conflicts in their mandates and responsibilities. The
misunderstandings between Ministry of Water Resources
and MOH over policies and standards for drinking water
and sanitation could be cited as examples of such
conflicts. The current understanding is that the Ministry
of Water Resources is responsible for the construction
and control of drinking water sources and maintenance of
their quality using internally adopted drinking water
standards or standards prescribed by the Ministry of

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Health and meant for human consumption (personal
communication with the Ministry of Health). The
Ministry of Health is believed to be responsible for the
quality of water used for public drinking purposes. Such
conflicts of interest are often sources of duplication of
efforts, as well as time consuming and waste of
resources. Instead, the maximization of efforts is meant
for development towards the maintenance of a healthy
environment.
The other major partners in drinking water and sanitation
development are NGOs, and international agencies like
UNICEF and WHO, and bilateral agencies like SIDA,
GTZ, and Save the Children of Norway and Sweden.
Such partners are often involved in either funding or
executing small scale drinking water or sanitation
projects. For example in 1997, 72 (61%) projects on
water and sanitation were managed by NGOs in Addis
Ababa (27). Among these, Integrated Holistic – Urban
Development Project is engaged in the fight against
poverty through the former Wereda 3 and Wereda 23
“Kebeles” through the improvement of housing, drinking
water, and sanitation (28). There are many other NGOs
perating in the rural areas of the country under the
umbrella of the Christian Relief and Development
Agency (CRDA). The importance of working with NGOs
is to maximize their involvement through the creation of
a conducive environment.
Trends of drinking water coverage
The results of coverage by time trends are indicated in
Fig 1 (3-4,12,21-24,29-35). A drinking water coverage
prediction was utilized on the basis of the regression of
time factor to accessing to safe water. The weighted
judgment for the present drinking water coverage based
on the available data indicates less than or equal to 21%,
84%, and 30% for the rural, urban, and country levels,
respectively. However, there was only a marginal
increase per year in the coverage of safe drinking water,
about 0.8% per annum over the last 30 years at national
level since 1970. Outlying data that would indicate extra
efforts in drinking water investments were not observed.
Table 3: Major actors in Environmental health in Ethiopia
Organizations according
Proclamation N0 256/2001
Responsibilities/jurisdictions
Ministry of Trade and Industry Licensing food establishment, hotels, other businesses;
Provision of occupational health to industrial workers
Ministry of Water Resources Formulation of policies in water resources; water production & management; urban
sewerage management; licensing water producers
Municipalities Urban planning; enforcement and provision of sanitary codes, sanitation and water
supply services
Ministry of Labour and Social Affairs Formulation of labour policies, and supervision of Occupational Health in factories
and related work places;
Ministry of Transport and
communication
Formulation of policies and regulation in transport and communication; M & E, and
control of the performance of vehicles
Ministry of Agriculture Registration and the control of pesticides being used
Ministry of Justice Enforcing sanitation regulations
Ministry of Mines and Energy Formulation of policies and strategies for minerals and energy; regulation of mining
activities; Quarry management
Ministry of Federal Affairs Urbanization and housing policies, urban Planning; Standards for housing designs
Environmental Protection Authority Formulation of policies and their supervision in ambient environment
Ethiopian Tourism Commission Tourism development; classification of hotels for tourism use
Ministry of Health Policies and regulations pertaining to drinking water, sanitation, air pollution, waste
management, housing sanitation, noise pollution, food hygiene; Organization of
comprehensive public health services;
Quality and Standard Authority The development of standards in drinking water, food, drinks, buildings, air, and
soil

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Figure 1: Trends of safe drinking water coverage in Ethiopia, 1970-2002
Table 4: Per capita drinking water consumption in Ethiopia, 1980-2003 (3,10,31,34,37-42)
Year Liter per day per capita
consumption
Year Liter per day per capita
consumption
1980 11.5 (rural) 1998 3-5 (rural)
1983 8-9 (rural) 1999 12 (urban)
1988 12.5 (rural town) 2002, 6.68 (rural)
1992 (internet source) 3-4 (rural) 2002 Less than 10
1995 10-20; median 10 (rural) 2003 5.2 (rural)
2004 7 (urban)
This change is understood to be too minimal to give any
worthwhile impact on the prevention of water related
diseases at country level.
Trends in adequateness of drinking water
Drinking water use per capita is also one of the indicators
for the provision of basic sanitation that is mainly used to
make a difference in the maintenance of personal hygiene
and food sanitation. The per capita amount of drinking
water varied from 3 to 20 litres, its average which is not
likely to satisfy 50% of the WHO guide line for the past
and current situations for rural and urban population in
Ethiopia (Table 4) (3,10,31,34,37-42). The figure in most
cases is about or less than 10 liters per capita per day in
rural areas. It appears that there was no significant
improvement in water consumption rates over the last 20
years, the weighted median figure being about 8.5 l/c/d
for the country as a whole. The geographical proximity
of drinking water sources is assumed to be key a factor to
determining the amount of drinking water fetched for a
household. Countrywide data indicate that about 64 % of
the rural population had access within a radius of
1kmfrom water points (36). Accessibility for urban
0
10
20
30
40
50
60
70
80
90
100
1965 1975 1985 1995 2005
Years
Populationaccesstosafe
water,%
Urban
Country
Rural

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centers was found to be less than 200 meters for a rural
town (38).
Trends of latrine coverage
The review time series analysis indicated that the
association between time and latrine coverage was too
weak to detect any meaningful trends. The weakest
association was seen for rural areas. The increase rate in
the proportion of population coverage in latrine use was
less than 0.2% per year over the last 30 years at the
national level since 1970. On expert judgment using the
trend analysis, the current latrine coverage for rural,
urban, and the whole country is less or equal to 7%. 68%
and 15%, respectively Fig 2 (10, 29-38,43).
Figure 2: Trend in urban latrine coverage in Ethiopia, 1980-2002
Morbidity situation in relation to sanitation
Existing data indicated that about 75% of causes of OPD
visits are largely due to the lack basic sanitation
provisions (3,15). Accessibility to safe drinking water,
basic sanitation. Data indicate that the two week
prevalence of diarrhoea did not show marked change
over the last two decades in Ethiopia (1,28,37,43-45)
(Table 5). An episode of diarrhoea on a child below the
age of 5 years was estimated to be 4 to 7 cases per child
per annum (1).
Knowledge, attitudes, and practices (KAP) towards
sanitation
UNICEF in collaboration with the Ministry of Health had
conducted studies in 1997 on knowledge, attitudes, and
practices on water supply, environmental sanitation, and
hygiene education in selected “Woredas” involved under
its Woreda Integrated Basic Services (WIBS) project
since 1990. Findings of the study indicate that the
respondents’ status was very poor regarding KAP. More
specifically, more than 60% of respondents in most of the
rural “Woredas” did not know that diseases could be
transmitted through human excreta; 30-75% of
respondents in different Woredas did not know that
diseases could result from drinking water; and 23 to 87%
of respondents did not know any method of treatment for
drinking water (47). These findings confirm the
prevailing mass ignorance and the absence of any
apparent impact of the health education program in the
country that was active since the establishment of the
first Training Institute in Gondar in 1954. Drinking water
handling practice is another major concern that
0
10
20
30
40
50
60
70
80
1965 1975 1985 1995 2005
Years
Populationaccesstolatrine,%
Urban
Country
Rural

______________________________________________________________________________________
determines possible contamination of drinking water. The
overwhelming rural population uses the traditional pot
(“Insra”) for the collection and storage of drinking water.
It holds an average of 15-20 liters of water (9). The
proportion of house holds who put lids/cover for their
stored water was found to be 57%, while those using
pouring water collection method were 88% as seen in a
rural study on determinants of diarrhoea. The same study
indicated that methods of drawing water from house hold
water containers and covering status of water storage
facilities determine the outcome of diarrhea (37).
Table 5: Two weeks prevalence of diarrheal among
under fives in Ethiopia
Year prevalence, %
19884-1986 15.5-26.2, median 17.2%
1984 10.2-18.4%, median 16.5%
1990 11.2, 24% , 9%,
1990 9% (incidence)
1991 14 %
1996 22.7%
1997 36.5% (urban)
2000 15%
2001 15.27% (urban)
2003 24.5% urban; 44% rural; 37.6% overall
2004 9.17% (urban)
source (1,28,37,43-45)
Discussion
The review showed that there were gradual
improvements in the input variables related to the
organizational, legal, and human resources that would
help the improvement of environmental health in the
country. The effort made towards strengthening the
sanitary acts is one major step and serves as a regulating
mechanism for the control and prevention of
environmental pollution. Changes in structure of the
contents of the regulations, delegation of duties and
powers to the concerned authority, and their expression
in terms of enforcing and follow up mechanisms to suit
the prevailing needs are very much appreciated.
Regulatory provisions like any other input variables
should, however, be monitored and evaluated to check if
they have met their own pre-planned purposes. Recent
developments in Addis Ababa indicated that the
regulatory provisions were abused by enforcers (personal
observations and communication with colleagues).
Educating the beneficiaries included in in-service
training of environmental health workers, developing
regulatory monitoring mechanisms are some of the
factors that could sustain the regulatory provisions.
While the institutional aspect which is related to
environmental health is showing changes from time to
time, the capacity that enables the scientific way of
evaluating sanitation indicators is by far changing slowly.
Unreliable data output are result from it. HSDP indicators
require updated and rigorous evaluation in order to check
the timely progression of its components (2).
Major changes in the input variables occurred after the
1990’s in terms of training, policies, and
institutionalization of tasks through a decentralization of
powers to Regional States and Central organs. Efforts
targeting community-based at changing individual health
behavior, although time and resource consuming, should
be highly encouraged and sustained if we have to curb
our health problems. The government’s commitment
towards-enabling the community to access basic health
services, promotion sanitation in specific terms, and
through the health extension packages is believed to
serve as a springboard for the improvement of the health
of population.
The question of how much the key managerial inputs
affect the status of sanitation in Ethiopia, however, could
not be related with the monetary inputs made for drinking
water and latrines as data on these variables were very
limited. The trend of accessing safe drinking water
seems to be in the increasing and predictable for rural
and country wide coverage assessments. However, this
apparent association with time should be observed
carefully so that it does not convey a misleading
message. In fact, it's is misleading if one just look at it in
relation to the low number of the population who have no
access to safe drinking water each year given the
population denominator is not stationary by time. The
reality is that the annual marginal increase rate in potable
water supply could not even compensate the population
growth rate, 9.7% Vs 3%, respectively. The latrine
coverage by time in most cases was found to be
unpredictable unlike water coverages. The reason
probably is linked to uncertainties inherent to the
methods of coverage evaluation made by different data
sources and or very limited surveys on courage. There
was not any meaningful progress in the latrine coverage
for over the last three decades that would make a
difference in health outcomes.
Trend analysis in both outputs of sanitation and water
infrastructure, as well as measurements in the outcome
indicators could not show any significant improvements

______________________________________________________________________________________
over the last 2-3 decades. The WHO data for 2000
indicated that coverage in improved drinking water and
latrine accessability in Ethiopia is one of the lowest in the
world and is even lower than neighboring countries like
Sudan, Kenya, and Uganda, which have 62%, 87%, 79%
latrine coverages, respectively while Ethiopia has only
12% for the same period (12). The per capita drinking
water consumption in a range of 3-20 litres with median
of 8.5 litres is small enough to satisfy that amount, which
is about 15 litres, required even for relief purposes (11).
The data is also consistent with the international practices
in developing countries, where the typical drinking water
per capita consumption from the use of communal water
point which is within 1 km access in rural areas is about
12 litres (48). Geographical proximity is one possible
factor that may affect the overall amount of consumed
daily water. A country wide survey indicated that about
63% of the rural population of Ethiopia have access to
the nearest water source within 1 km of radius (36). In
Butajira, south Ethiopia, villages within 15 minutes walk
to drinking water source was estimated to be for 54%
(37).
A key question in this review was to discuss factors that
could contribute for the success (failure) of
environmental health. These factors are described below
and a conceptual frame work was developed on their
basis.
1) Background factors (Macro-environment)
These factors are closely related to the overall and
individual social, economic, political, and behavioral
factors at the macro-level. While political factors dictate
policy directions in health, the attainment of positive
behavior at the community level plays a significant role
in the control of diseases. Poor countries with positively
established behaviors among their populations can have
equal magnitudes in health achievements compared to
developed nations (49). In a country like Ethiopia, that
has poor social conditions (education, housing,
sanitation, etc) and with more than 50% of its population
illiterate and under the poverty line, the level of
communicable diseases is found to be of the highest
magnitude (22,50). Poverty, unregulated fertility,
ignorance, gender issues, and limited resources in health
programmes are closely related to these factors. Overall
socio-economic improvements are central for the
maintenance of a healthy life. Poverty alleviation
programmes and the expansion of education in Ethiopia
are expected to play key roles in the alleviation of the
burden of malpractices in sanitation.
2) Intermediate factors (underlying institutional
factors)
2.1 Institutional capacity
Organizational readiness to achieve goals, adequate
human resources, skills in environmental health
management, organizational behaviors, accountabilities,
managerial efficiency, good governance, and trans-
parency are some of the issues affecting organizational
capacity. This study attempt to demonstrate this with
personal experiences.
The lack of updated sanitary regulations was identified as
one element contributing to the failure of sanitation in
Addis Ababa in the 1980’s. Hygiene and environmental
regulation was enacted in 1994 by the then Region 14
Administration in response to this concern. This study
organized the necessary procedures and guidelines for the
implementation of the regulations. Training and
awareness creation on various health workers and
partners (Bureau of Justice, Kebele and Wereda
Administrators, sanitary guards, and sanitarians) were
handled seriously. Implementation was smooth and some
improvements were observed during the process.
However, after a few years, mal practices were observed
among the environmental health workers, a concern
which was communicated through the mass media. The
Addis Ababa Administration regretted about the
delegation of its power to environmental health workers.
The lesson is that a lack of systems that could monitor
the activities of the enforcements brought a self defeating
of this effort. Organizational behavior and the lack of
transparency and accountability are key areas for the
failure in implementing the requirements of sanitary
codes.
2.2. Coordination and integration
Maximizing the benefits through coordination of efforts
was identified as one means of achieving Health for All
in PHC. Key national policies in health, water, and
environment are the basis for the diversity of activities
related to various Ministries and Authorities. Despite the
presence of adequate policies and proclamations in the
country, there appear to be occasional clashes between
Ministries over their mandates. This weakens relations
and the attainment of efforts towards common goals in
health. The efficiency of resources could not bring
maximum result under such unfavorable relations. The
uncertainties and imprecise sanitation data could as well
be the outcomes of the less favorable relationship. The

______________________________________________________________________________________
low achievement in Drinking water Supply and
Sanitation Decade is a good example (7).
3) Proxy factors
3.1 Behavioral factors These factors are related to
community and individual behavior. Behavior is a social
phenomenon associated with human knowledge, attitudes
and practices under specific environmental contexts.
Educational status and IEC are some of the interventions
that believed to bring about changes towards positive
behavior if the desired actions are continuously
monitored and evaluated. However, such changes require
sustained and committed action against diseases.
Willingness and readiness of the community to cooperate
in the joint effort to fight diseases is also one factor.
Ethiopia has highly appreciable social and cultural
values, but its population still suffers with high morbidity
and mortality due to risky behavior that are observed at
the community and individual level. The need for simple,
but basic personal hygiene measures like washing
hands with detergents before eating is one good example
among others that is lacking or mal practiced. This is
worse in the rural population, who are believed to have
lesser knowledge and awareness about the modes
of transmission of diseases. Behavioral factors are
assumed to be strong predictors in sanitation (9).
3.2 Environmental factors
Access to safe drinking water, latrines, and the provision
of personal hygiene in Ethiopia is very low and thus
inadequate to satisfy the hygienic needs of an average
person. The amount of water daily used even in urban
centers does not attain the minimum recommendations
set by WHO. Again such shortcomings could be related
to the socio-economic background of each individual and
partly also to behavioral and personal factors.
3.3 Personal factors
These factors are low status of education and income,
occupation, and place of residence that determine the
individual’s behavior. These factors are determinants for
the provision of basic sanitation and the occurrence of
diarrheal diseases (37,47). Personal factors are predictors
next to behavioral ones (9).
The above factors can be evaluated and criticized by the
framework indicated in Fig 3.
Figure 1: A framework of the determinants of sanitation in Ethiopia
Background factors:
Social
Economical
Cultural
Physical
Institutional:
Responsibilities
Coordination
Integration
Policies, regulations
Organizational behavior
Environmental:
Latrine, hygiene
Water
Housing
Personal:
Education,
Occupation
Residence
Behavioral:
Community
Individual
Communicable diseases:
Diarrhoea. etc

______________________________________________________________________________________
Conclusion and Recommendations
Available data in the areas of environmental health
indicated the existence of limited success stories that
were sustained over decades with out significant
improvement that could impact on health status in the
country. The overall socio-economic, behavioral,
environmental and personal factors of the people are
assumed to be potential contributing factors for the
failure to register achievements in sanitation services in
Ethiopia. The availability of sanitation regulations and
other institutional factors alone can not solve the
problem. Although major short comings exist in the
improvement of basic sanitation in our country there are
at the same time opportunities that could bring about
tangible achievements. Such hopes are tied to HSDP
programmes, health extension programmes integrated
with rural development, and poverty alleviation efforts
being implemented at the national level. The enforcement
of Constitutional rights and policies should be maximized
to assist the way forward for better success in the
maintenance of environmental health. The following are
specifically suggested in reference to the above remarks:
There is a need to explicitly review overlapping areas
among institutions/ministries to develop a framework for
the delineation of authorized jobs.
1. Scientific research for the evaluation of drinking
water and sanitation coverages and descriptions of
determinants for the success and failures need to be
encouraged.
2. The improvement of organizational behavior of
institutions involved in the enforcement of
environmental health regulations should be
strengthened.
3. There, is a need to popularize, reinforce and sustain
a modest approach to encourage demand driven,
community involvement and hygiene education in
order to bring rapid improvement in water and
sanitation services.
Acknowledgement
The authors wish to thank the Ministry of Health for
making available the data and reports used in this review.
References
1. Helmut K, Zein AZ (editors). The ecology of health
and diseases in Ethiopia. Westview Press, Boulder,
USA, 1993; 29-33, 203-204.
2. Ministry of Health. Programme Plan of Action for
the Health Sector Development Programme, April
1998, Addis Ababa, Ethiopia.
3. Ministry of Health, Planning and Programming
Department. Health and health related indicators,
2002/03 (1995 EC)
4. Ministry of Health. Planning and Programming
2001/02 (994 EC).
5. Victor ME, Ernest WS. Municipal and rural
sanitation. Sixth edition, McGrow-Hill Book
Company, New York, 1965.
6. Gabre-Emanuel T. Water Supply-Ethiopia: An
introduction to environmental health practice. Addis
Ababa University press, Addis Ababa, Ethiopia,
reprinted 1982
7. Chanyalew K. Health before and beyond year 2000
in Ethiopia. Proceedings of the Xth Annual
Conference of the Ethiopian Public Health
Association, 1999; 9-22.
8. WHO. The international drinking water supply and
sanitation decade, minimum evaluation procedure
for water supply and sanitation projects. ETS/83.1,
CDD/OPR/83.1, February 1983
9. Mengistu A, Gebre-Emanuel T. Water handling
programmes and their association with childhood
diarrhea. Ethiop.Med.J 1992; 6(2): 9-16.
10. Gabre-Emanuel T. Environmental health: Water
handling programmes and their association with
childhood diarrhoea. Ethiop Med J 1992;6(2):9-16.
11. Diminishing standards: How much water do people
need?
http://www.icrc.org/web/Eg/siteeng0.nsf/htmlall/57j
PL6?OpenDocument&view-defualtboo.
12. WHO Afro Regional Office. Water supply and
sanitation sector assessment 2000, African Region
Part 1. WHO, 2000.
13. Faculty of Law. Addis Ababa University.
Consolidated laws of Ethiopia. Artistic Printers Ltd,
Addis Ababa, Ethiopia, 1972.
14. Gondar College of Medical Science. Focus GCMS,
Chronicle Vol3, No1 March 2003; 102-105).
15. Ministry of Health. Health Sector Development
Programme Phase II: 2202/03-2004/05, June 2002.
16. The Transitional Government of Ethiopia.
Proclamation N0 7/1992. A proclamation to provide
for the establishment of National/Regional
Autonomous Governments, Addis Ababa, Ethiopia,
14th
June 1992, 51st
year No.2.
17. Region 14 Administration. Hygiene and
environmental health regulation No.1/1994, Addis
Negari Gazeta, Addis Ababa, Ethiopia, April 15th
1994.

______________________________________________________________________________________
18. The Federal Democratic Republic of Ethiopia.
Public Health Proclamation No.200/2001; 6th
year,
N0 28, Addis Ababa, Ethiopia.
19. Ministry of Health. Revised draft curriculum for the
advanced diploma in environmental health.
20. Ministry of Health. PHC review, February 1985.
1999.
1998/99 (1991 EC)
1999/00 (1992EC)
2000/01 (1993EC)
25. The Transitional Government of Ethiopia,
Proclamation N0 41/1993. A proclamation to Define
Powers and Duties of the Central and Regional
Executive Organs of the Transitional Government of
Ethiopia. Negarit Gazeta, Addis Ababa, Ethiopia,
20th
January 1993.
Reorganization of the Executive Organs of the
Federal Democratic Republic of Ethiopia
Proclamation No 256/2001, 8th
year No2, Addis
Ababa, Ethiopia.
27. UNDP/World Bank Regional water and sanitation
group. Ethiopia urban sanitation status. Final
Report, 1st
draft, December 1997.
28. Integrated Holistic Approach Urban Development
Project. Pre-phase out evaluation in former Wereda
23, Keble 08, Addis Ababa: Health component, May
2004.
29. UNDP. World Development Report 1994,
Infrastructure for Development, World Development
Indicators.
30. Central Statistical Authority. The Provisional
Military Administrative council/government of
Socialist Ethiopia, Office of National Committee for
the Central Planning. Report on the Rural Health
Survey, 1982/83. Volume 2, Statistical Bulletin No
52. CSA, Addis Ababa September 1986.
31. Central Statistical Authority. The 1984 Population
and Housing Census of Ethiopia.
32. UNICEF Plan of Operation in Cooperation with the
Ethiopian Government 1994-1999: www.africa-
upenn.edu.eue-web/health.htm
33. Central Statistical Authority. The 1994 Population
and Housing Census of Ethiopia: Results at Country
Level. II. Analytical Report. Addis Ababa, Ethiopia,
1999.
Health Sector Investment Programme for Ethiopia.
Prepared for the Consultative Group Meeting of
December 10-12, 1996, Addis Ababa, Ethiopia,
November 1996.
35. Ministry of Water resources, Federal Democratic
Republic of Ethiopia. Environmental Support
Project, Component 3, National Water Supply and
Sanitation Master Plan. Volume II, physical
Resources Base, Addis Ababa, Ethiopia, July 2001.
36. Centeral Statistical Office, Ethiopia. Welfare and
Monitoring Survey, Analytical Report. CSA, Addis
Ababa, 1998.
37. Teklu M. Socio-economic, environmental, and
behavioral factors associated with the occurrence of
diarrhoeal diseases among under-five children,
Meskanena Mareko Woreda, Southern Ethiopia. A
Thesis Submitted to the School of Graduate Studies
of Addis Ababa University, 2003, Addis Ababa;33-
35.
38. Gebre-Emanuel T, Amare M, Wondwessen A,
Gezahign W, Kibru B, Nesuru N , Yilma D.
Assessment of accessibility, acceptability, and usage
pattern of the water supply system in an Ethiopian
rural town. Ethiop J Hlth Dev, 1989;3(2):91-104.
39. Mengesah A, Mamo Wt, Tesfaye T. Sanitary survey
in Gondar town. Ethiop J Hlth Dev, 2003;17(3);215-
219.
40. Mengesha A, Abera K, Misganaw F. Factors related
to sustainability of water and sanitation projects in
the rural setting of North Gondar, Ethiop J Hlth Dev,
2003;17(3);221-229.
41. Yayehyirad K. Water supply in a small village in
Western Ethiopia. Ethiop Med J. 1980;18(165)165-
169.
42. Department of Community Health, Medical Faculty,
Addis Ababa University. Rural Community Health
Attachment Reports.
43. Ministry of Water Resources. National Water Supply
and Sanitation Master Plan. Status Report, Vol II,
Physical Resources Base, July 2001.
44. Getaneh T. Diarrhoea morbidity in an urban area in
southwest Ethiopia. East Afr Med J. 1997;74(8);
491-494.
45. Teklemariam S, Getaneh T, Bekele F.
Environmental determinants of diarrhoea morbidity
in under five children, Keffa-Sheka Zone, SW
Ethiopia. Ethiop Med J 2000; 38(1); 27-34.

______________________________________________________________________________________
46. Ministry of Water Resources, Ethiopia. Sanitation
and hygiene, issues paper, Vol 1 Main Report (final).
Addis Ababa, June 2003.
47. Environmental Health Department, Ministry of
Health. KAP study on water, environmental
sanitation, and hygienic practices. Ministry of
Health, Addis Ababa, Ethiopia, 1995.
48. International Research Center. Small scale water
supply system in developing countries. Technical
paper series 18, 1983.
49. World Health Organization. Our Planet, Our Health:
A Report of the WHO Commission on Health and
the Environment. World Health Organization,
Geneva, 1992; xi-xxxi.
50. Abebe Asmelash. Addressing the problem of
poverty in Ethiopia and policy issues. . UN
Economic Commission for Africa. Web site:
http://eea.ethiopiaonline.net/Econ-foc/ef2-5/abeshim
.htm

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