**3. Access to maternal and child health care in Ethiopia**

#### **3.1 The legal framework of maternal and child health in Ethiopia**

With a population of above 100 million people, Ethiopia is the second most inhabited country in Africa and is one of the few countries in the globe with a high population of maternal and child deaths [27, 28]. There are legal, policy, and institutional mechanisms that respond to this challenge. The Federal Democratic Republic of Ethiopia (FDRE) Constitution (1995) along with the nine regional states constitutions dedicate a specific provision entirely dealing with the rights of women due to their vulnerability [29]. It states that women have the right "to prevent harm arising

from pregnancy and childbirth and in order to safeguard their health, women have the right of access to family planning education, information and capacity" [29]. Similarly, the constitution guarantees the right to equality of women with men and further provides for the obligations of the state to eliminate the influences of harmful customs, laws, customs, and practices that oppress or cause bodily or mental harm to women [29]. However, none of these provisions adequately mention women's right to access to health care and the underlining determinants of health other than the ones mentioned under Article 35(9) of the FDRE Constitution. This particular sub-article provides for women's right of access to family planning, education, information, and capacity.

With respect to minors, the FDRE Constitution equally incorporates a specific article exclusively governing on children's rights but does not, nevertheless, take an express provision of children's right to health or the underlining determinants of health, such as admission to food, safe drinking water, sanitation, and living accommodations. Although Ethiopia has acceded to international instruments of children's rights the Convention on the Rights of the Child (CRC) in 1991; the International Convention on Economic, Social, and Cultural Rights (ICESCR) in 1993; as well as regional instruments such as the African Charter on the Rights and Welfare of the Child (ACRWC) in 2002, the constitution (article 36) fails to entrench children's right of access to health care and their other socioeconomic rights explicitly [29].

However, children's right to life and the best interests of the child are recognized in the constitution. Besides, women and children have the same rights as all other persons under the constitution, such as the right to life, information, equality, and nondiscrimination. However again, none of these provisions adequately incorporate children's right to access to health care and the underlining determinants of health. The Backman et al. study also indicates the right to health not to have been explicitly recognized in Ethiopia [3]. Overall, this manifests lack of compatibility between the domestic law with the relevant provisions of the ICESCR and ACRWC in the area of health care. As clearly highlighted in the decision of the African Commission in the case of *Purohit and Moore* V *Gambia* (2003), when a state's legislation in the area of health care does not meet human rights treaties that such state has ratified or acceded, then the state is required to repeal its existing laws and replace it with a new legislative regime to ensure compatibility [30]. While the author maintains the importance of explicit legal recognition of the right to health and proposes amendment of Article 35 and 36 of the constitution, in the absence of explicit and women's and children's right to health care and their other socioeconomic rights, the provisions dealing with the right to life and others should be invoked to realize health rights of women and children by way of temporal solution.

#### **3.2 Analyzing the Ethiopian health care plan and health workers**

Ethiopia restructured its health system in 1993, in the same year the national health policy was issued. Under the umbrella of the health policy, the Ethiopian health sector adopts a seemingly innovative and rolling health program, namely, the Ethiopian Health Sector Development Program (HSDP) [31]. The HSDP has been introduced in recognition of the failure of essential health such as in terms of the challenges of reaching health care services and goods to the people at grassroots level, in particular to the underserved rural population. It was projected based on the concept and principles of comprehensive primary health care, which essentially includes maternal and child health [32]. Its target has been the expansion of essential health system inputs towards the achievement of the Millennium Development Goals (MDGs)—an indication that its focus has not complied with the human rights obligations to health [33].

**103**

under five by 62% [36].

country, USAID Administrator Rajiv Shah notes:

*who provide front-line care [38].*

**3.3 The challenges of engaging HEWs**

*A Human Rights-Based Approach to Maternal and Child Health in Ethiopia: Does it Matter…*

will improve women and children's prospects of survival and their well-being? Health extension workers are expected to perform a wide range of functions—from preventive and promotive engagements to case management. HEWs' engagement in these functions has brought about marked achievements. It has improved access to maternal and child health services to the rural poor, and after the introduction of the HEW program, the proportion of households with access to improved sanitation reached 76% in the intervention villages from 39% at baseline [34]. Likewise, child vaccination/immunization results indicate substantial gains. By June 2010, 86% of children had received Penta 3/DPT 3 vaccine, 82% had received measles vaccine, and 62% had been fully immunized—an average annual increase in the number of fully immunized children of 15% since 2006 [34]. In addition, maternal health services coverage has shown progress: 85% of health posts could provide family planning services, 83% could provide antenatal care, 59% could perform clean deliveries, and 47% could provide postnatal care [35]. Awareness of HIV/AIDS has also improved, with the level of knowledge of condoms as a means of preventing HIV increasing by 78% in HEP villages and 46 in control villages. Again, seeking behavior for malaria treatment shows marked progress which results in in-patient malaria cases falling by 73% and deaths in children

Overall, the HEWs program and the intervention in the foregoing show remarkable results. Its impact for reduction of maternal and child fatality rate has been substantial. In this connection the former Ethiopian Minister of Health, Kesetebirhan Admasu, underlines that "the HEWs have led the way to achieve major reductions in child and maternal mortality" [37]. In the same vein, regarding the contribution of HEWs with respect to the reduction of child mortality rates in the

*… Between 2006 and 2010, infant mortality decreased by 23 percent and under-5 mortality by 28 percent. These achievements are largely a result of Ethiopia's investment in a community health system and a cadre of 35,000 health workers* 

Global agencies, such as UNICEF, share the sentiment that the endeavor to deploy health workers to the most remote parts of the country has helped bring about a steep reduction in child mortality [37]. The WHO et al. report in 2014 establishes a significant increase of the maternal mortality rate from 740 in 2005 to 420 in 2013—showing progress towards improving maternal health [39]. Nevertheless, the implementation of the HEWs program has its own challenges.

The task shifting from skilled providers to lower-level HEWs has been a model

of success in Ethiopia for an extensive range of maternal and child services.

After evaluation of the second HSDP in 2002/2003, it was revealed that constraints existed in terms of availability of trained, high-level professionals, and essential services to reach the people at the grassroots level. In response to this challenge, in 2003 the Ethiopian Federal Ministry of Health launched a new health-care plan, the "Accelerated Expansion of Primary Health Coverage," through a comprehensive health extension program (HEP). The HEP is designed to shift health-care resources from predominantly urban to rural areas and rests on the rapid vocational training and deployment of health extension workers (HEWs) starting in 2003. Ethiopia is one country unable to provide a skilled health workforce to the majority of its population, and the question arises: Is there any evidence that the Ethiopian health plan, which incorporates HEWs,

*DOI: http://dx.doi.org/10.5772/intechopen.83513*

#### *A Human Rights-Based Approach to Maternal and Child Health in Ethiopia: Does it Matter… DOI: http://dx.doi.org/10.5772/intechopen.83513*

After evaluation of the second HSDP in 2002/2003, it was revealed that constraints existed in terms of availability of trained, high-level professionals, and essential services to reach the people at the grassroots level. In response to this challenge, in 2003 the Ethiopian Federal Ministry of Health launched a new health-care plan, the "Accelerated Expansion of Primary Health Coverage," through a comprehensive health extension program (HEP). The HEP is designed to shift health-care resources from predominantly urban to rural areas and rests on the rapid vocational training and deployment of health extension workers (HEWs) starting in 2003. Ethiopia is one country unable to provide a skilled health workforce to the majority of its population, and the question arises: Is there any evidence that the Ethiopian health plan, which incorporates HEWs, will improve women and children's prospects of survival and their well-being?

Health extension workers are expected to perform a wide range of functions—from preventive and promotive engagements to case management. HEWs' engagement in these functions has brought about marked achievements. It has improved access to maternal and child health services to the rural poor, and after the introduction of the HEW program, the proportion of households with access to improved sanitation reached 76% in the intervention villages from 39% at baseline [34]. Likewise, child vaccination/immunization results indicate substantial gains. By June 2010, 86% of children had received Penta 3/DPT 3 vaccine, 82% had received measles vaccine, and 62% had been fully immunized—an average annual increase in the number of fully immunized children of 15% since 2006 [34]. In addition, maternal health services coverage has shown progress: 85% of health posts could provide family planning services, 83% could provide antenatal care, 59% could perform clean deliveries, and 47% could provide postnatal care [35].

Awareness of HIV/AIDS has also improved, with the level of knowledge of condoms as a means of preventing HIV increasing by 78% in HEP villages and 46 in control villages. Again, seeking behavior for malaria treatment shows marked progress which results in in-patient malaria cases falling by 73% and deaths in children under five by 62% [36].

Overall, the HEWs program and the intervention in the foregoing show remarkable results. Its impact for reduction of maternal and child fatality rate has been substantial. In this connection the former Ethiopian Minister of Health, Kesetebirhan Admasu, underlines that "the HEWs have led the way to achieve major reductions in child and maternal mortality" [37]. In the same vein, regarding the contribution of HEWs with respect to the reduction of child mortality rates in the country, USAID Administrator Rajiv Shah notes:

*… Between 2006 and 2010, infant mortality decreased by 23 percent and under-5 mortality by 28 percent. These achievements are largely a result of Ethiopia's investment in a community health system and a cadre of 35,000 health workers who provide front-line care [38].*

Global agencies, such as UNICEF, share the sentiment that the endeavor to deploy health workers to the most remote parts of the country has helped bring about a steep reduction in child mortality [37]. The WHO et al. report in 2014 establishes a significant increase of the maternal mortality rate from 740 in 2005 to 420 in 2013—showing progress towards improving maternal health [39]. Nevertheless, the implementation of the HEWs program has its own challenges.

#### **3.3 The challenges of engaging HEWs**

The task shifting from skilled providers to lower-level HEWs has been a model of success in Ethiopia for an extensive range of maternal and child services.

*Education, Human Rights and Peace in Sustainable Development*

rights of women and children by way of temporal solution.

**3.2 Analyzing the Ethiopian health care plan and health workers**

Ethiopia restructured its health system in 1993, in the same year the national health policy was issued. Under the umbrella of the health policy, the Ethiopian health sector adopts a seemingly innovative and rolling health program, namely, the Ethiopian Health Sector Development Program (HSDP) [31]. The HSDP has been introduced in recognition of the failure of essential health such as in terms of the challenges of reaching health care services and goods to the people at grassroots level, in particular to the underserved rural population. It was projected based on the concept and principles of comprehensive primary health care, which essentially includes maternal and child health [32]. Its target has been the expansion of essential health system inputs towards the achievement of the Millennium Development Goals (MDGs)—an indication that its focus has not complied with the human rights

education, information, and capacity.

from pregnancy and childbirth and in order to safeguard their health, women have the right of access to family planning education, information and capacity" [29]. Similarly, the constitution guarantees the right to equality of women with men and further provides for the obligations of the state to eliminate the influences of harmful customs, laws, customs, and practices that oppress or cause bodily or mental harm to women [29]. However, none of these provisions adequately mention women's right to access to health care and the underlining determinants of health other than the ones mentioned under Article 35(9) of the FDRE Constitution. This particular sub-article provides for women's right of access to family planning,

With respect to minors, the FDRE Constitution equally incorporates a specific article exclusively governing on children's rights but does not, nevertheless, take an express provision of children's right to health or the underlining determinants of health, such as admission to food, safe drinking water, sanitation, and living accommodations. Although Ethiopia has acceded to international instruments of children's rights the Convention on the Rights of the Child (CRC) in 1991; the International Convention on Economic, Social, and Cultural Rights (ICESCR) in 1993; as well as regional instruments such as the African Charter on the Rights and Welfare of the Child (ACRWC) in 2002, the constitution (article 36) fails to entrench children's right of access to health care and their other socioeconomic rights explicitly [29]. However, children's right to life and the best interests of the child are recognized in the constitution. Besides, women and children have the same rights as all other persons under the constitution, such as the right to life, information, equality, and nondiscrimination. However again, none of these provisions adequately incorporate children's right to access to health care and the underlining determinants of health. The Backman et al. study also indicates the right to health not to have been explicitly recognized in Ethiopia [3]. Overall, this manifests lack of compatibility between the domestic law with the relevant provisions of the ICESCR and ACRWC in the area of health care. As clearly highlighted in the decision of the African Commission in the case of *Purohit and Moore* V *Gambia* (2003), when a state's legislation in the area of health care does not meet human rights treaties that such state has ratified or acceded, then the state is required to repeal its existing laws and replace it with a new legislative regime to ensure compatibility [30]. While the author maintains the importance of explicit legal recognition of the right to health and proposes amendment of Article 35 and 36 of the constitution, in the absence of explicit and women's and children's right to health care and their other socioeconomic rights, the provisions dealing with the right to life and others should be invoked to realize health

**102**

obligations to health [33].

Nevertheless, while the commitment to introducing coherent and effective HEWs programs throughout the country is laudable, there are major obstacles.

First, HEWs lack the necessary knowledge and skills, which restricts the delivery of quality maternal and child health services [40]. A study by A. Medhanyie et al. has found that more than half (54%) of HEWs have poor knowledge about the contents of prenatal care counseling, and the majority (88%) have poor knowledge about danger symptoms, danger signs, and complications in pregnancy [39]. These workers lack the requisite skills to perform clean and safe deliveries. Research shows their basic health knowledge is quite poor regarding the major communicable diseases [40]. In one case, the parents of a 2-year-old child who had developed tonsillitis were taken to the Semera Health Post in Afar [41]. The health worker in charge prescribed amoxicillin pills. However, the next day the child's entire body became swollen, and he had to be taken back to the health post. The health professional in charge on that particular day noticed the complication the child had developed and referred him to a hospital in Dupti, but the child died by the time he reached the hospital. It was noted that the child would not have died had he been immediately referred to the hospital at early stage examination and that the inappropriate drug exacerbated his condition [41]. This clearly raises the need for a proper system to hold HEWs accountable to the community they serve.

Second, attrition and retention pose further challenges. In contexts where the health-care system is weak and characterized by a severe shortage of health-care workers, HEWs may be the rural community's only contact with the health-care system, placing a heavy burden on them, possibly resulting in them leaving their jobs. Often one of the HEWs is a member of the community (*Kebele*) and is required to serve in the political administrative cabinet, which adds to the burden [42]. As in some instance, HEWs reside at a distance from their work places; poor transportation and communication which results in job dissatisfaction remains as another challenge [43].

Third, the sustainability of community health projects depends on the availability of on-going funding, a diversity of funding sources and ability to mobilize volunteers or low-paid workers who in the face of their own poverty are willing to care for the needy in their communities. Nearly all the challenges that community health projects faced relate to inadequate and sporadic funding. Funding limitations further affect the availability of health goods and services such as supervisors, medical equipment, supplies of drugs for minimum curative services, furniture, and vehicles [44].

Fourth, administrative functions such as monitoring, supervision, coordination, and management are critical for successful community-based programs. Many HEWs perform their job alone or in small groups in distant sites, which results in a lack of meaningful supervision and reduces HEWs' ability to provide effective focused antenatal care [43].

Fifth, lack of commitment is yet another challenge. Although many HEWs work enthusiastically, there are a few who are not fully dedicated to their everyday activities [43]. This is mainly due to a failure to integrate HEWs as part of the state's responsibility for health-care delivery.

#### **3.4 Implementation challenges in relation to goods and services**

As previously noted, General Comment 14 clarifies the obligation of states to ensure maternal and child-friendly health services, goods, and facilities are available, accessible, acceptable, and of high quality. Although Ethiopia has improved health coverage through deploying HEP, health goods and services are threatened by myriad challenges.

**105**

*A Human Rights-Based Approach to Maternal and Child Health in Ethiopia: Does it Matter…*

With regard to availability, the Committee on Economic, Social and Cultural

*The Committee is concerned that there is no universal health-care coverage. It is also concerned about the low number of qualified health-care professionals per capita in certain regions and critical shortages at health centres, both in medical equipment and staff. The Committee also notes with concern the high rate of maternal and infant mortality, and the low number of births that are assisted by a skilled attendant, especially in rural areas. It is further concerned that access to maternal and infant health care remains poor, in particular in the Somali* 

The United Nations Population Fund (UNPFA) equally observes:

*ment shortages due to budget deficits and poor management [46].*

*Most of the health facilities which are far from Addis Ababa are either not fully staffed with skilled service providers or fully equipped with the necessary supplies and equipment that can provide quality services related to complications during pregnancy and childbirth. Limited human resources, especially midwives, hamper efforts to provide adequate services, especially in rural areas. Gaps in training and remuneration have led to attrition and turnover among public sector health care professionals. Public facilities routinely suffer stockouts and obstetric care equip-*

The range of limitations in terms of availability of health-care facilities, goods, and services restricts the full realization of women's and children's right to health-

With regard to accessibility, a myriad of challenges exist in the country. In one case story in 1980, an Ethiopian woman from the Oromo ethnic group was arrested without a court order. She was pregnant during her arrest and delivered her baby in prison without the help of a doctor. The baby's health was permanently damaged by the lack of timely help in her prison cell. This represents a clear case of limited access to health-care service to women and newborn babies in difficult situations. If there was a regard for human rights laws, the pregnant woman and her newborn baby would have had a health worker or professional who could have helped during childbirth [47]. A further challenge on access is, despite the improvements made in expanding access to health services, the disease burden is still high, and the service utilization rate remains low in the country, partly due to the burden of high out-of-pocket spending that restricts an already poor society from health-care utilization [48]. A recent survey by Berhan and Berhan in 2014 conducted in Ethiopia indicates that inaccessibility of transport, long distances from functioning health-care facilities, and a lack of confidence in the services provided are some of the barriers that impede access to maternal health facilities [49]. Similarly, the 2011 Ethiopian Demographic and Health Survey (EDHS) study shows that the major barriers for pregnant women to access health services are lack of transport to a facility (71%), lack of money (68%), and distance to a health facility (66%) [50]. Moreover, although child malnutrition has declined, many Ethiopian children continue to go hungry. Safe food is considered one of the underlying determinants of the right to health, but the rate of Ethiopia's stunted children (caused by malnutrition) is above the average of other African countries, the average rate for African countries being 38% and that of Ethiopia's is 58% [51]. Besides, although there are marked improvements in the coverage of access to child vaccination, clean water, and improved sanitation, the progress remains slow. This is likely to have a negative impact on the

*DOI: http://dx.doi.org/10.5772/intechopen.83513*

*National Regional State of Ethiopia [45].*

care and the underlying determinants of health.

reduction of under-five mortality rates [52].

Rights (ESCR) notes:

*A Human Rights-Based Approach to Maternal and Child Health in Ethiopia: Does it Matter… DOI: http://dx.doi.org/10.5772/intechopen.83513*

With regard to availability, the Committee on Economic, Social and Cultural Rights (ESCR) notes:

*The Committee is concerned that there is no universal health-care coverage. It is also concerned about the low number of qualified health-care professionals per capita in certain regions and critical shortages at health centres, both in medical equipment and staff. The Committee also notes with concern the high rate of maternal and infant mortality, and the low number of births that are assisted by a skilled attendant, especially in rural areas. It is further concerned that access to maternal and infant health care remains poor, in particular in the Somali National Regional State of Ethiopia [45].*

#### The United Nations Population Fund (UNPFA) equally observes:

*Most of the health facilities which are far from Addis Ababa are either not fully staffed with skilled service providers or fully equipped with the necessary supplies and equipment that can provide quality services related to complications during pregnancy and childbirth. Limited human resources, especially midwives, hamper efforts to provide adequate services, especially in rural areas. Gaps in training and remuneration have led to attrition and turnover among public sector health care professionals. Public facilities routinely suffer stockouts and obstetric care equipment shortages due to budget deficits and poor management [46].*

The range of limitations in terms of availability of health-care facilities, goods, and services restricts the full realization of women's and children's right to healthcare and the underlying determinants of health.

With regard to accessibility, a myriad of challenges exist in the country. In one case story in 1980, an Ethiopian woman from the Oromo ethnic group was arrested without a court order. She was pregnant during her arrest and delivered her baby in prison without the help of a doctor. The baby's health was permanently damaged by the lack of timely help in her prison cell. This represents a clear case of limited access to health-care service to women and newborn babies in difficult situations. If there was a regard for human rights laws, the pregnant woman and her newborn baby would have had a health worker or professional who could have helped during childbirth [47].

A further challenge on access is, despite the improvements made in expanding access to health services, the disease burden is still high, and the service utilization rate remains low in the country, partly due to the burden of high out-of-pocket spending that restricts an already poor society from health-care utilization [48]. A recent survey by Berhan and Berhan in 2014 conducted in Ethiopia indicates that inaccessibility of transport, long distances from functioning health-care facilities, and a lack of confidence in the services provided are some of the barriers that impede access to maternal health facilities [49]. Similarly, the 2011 Ethiopian Demographic and Health Survey (EDHS) study shows that the major barriers for pregnant women to access health services are lack of transport to a facility (71%), lack of money (68%), and distance to a health facility (66%) [50]. Moreover, although child malnutrition has declined, many Ethiopian children continue to go hungry. Safe food is considered one of the underlying determinants of the right to health, but the rate of Ethiopia's stunted children (caused by malnutrition) is above the average of other African countries, the average rate for African countries being 38% and that of Ethiopia's is 58% [51]. Besides, although there are marked improvements in the coverage of access to child vaccination, clean water, and improved sanitation, the progress remains slow. This is likely to have a negative impact on the reduction of under-five mortality rates [52].

*Education, Human Rights and Peace in Sustainable Development*

hold HEWs accountable to the community they serve.

Nevertheless, while the commitment to introducing coherent and effective HEWs

First, HEWs lack the necessary knowledge and skills, which restricts the delivery of quality maternal and child health services [40]. A study by A. Medhanyie et al. has found that more than half (54%) of HEWs have poor knowledge about the contents of prenatal care counseling, and the majority (88%) have poor knowledge about danger symptoms, danger signs, and complications in pregnancy [39]. These workers lack the requisite skills to perform clean and safe deliveries. Research shows their basic health knowledge is quite poor regarding the major communicable diseases [40]. In one case, the parents of a 2-year-old child who had developed tonsillitis were taken to the Semera Health Post in Afar [41]. The health worker in charge prescribed amoxicillin pills. However, the next day the child's entire body became swollen, and he had to be taken back to the health post. The health professional in charge on that particular day noticed the complication the child had developed and referred him to a hospital in Dupti, but the child died by the time he reached the hospital. It was noted that the child would not have died had he been immediately referred to the hospital at early stage examination and that the inappropriate drug exacerbated his condition [41]. This clearly raises the need for a proper system to

Second, attrition and retention pose further challenges. In contexts where the health-care system is weak and characterized by a severe shortage of health-care workers, HEWs may be the rural community's only contact with the health-care system, placing a heavy burden on them, possibly resulting in them leaving their jobs. Often one of the HEWs is a member of the community (*Kebele*) and is required to serve in the political administrative cabinet, which adds to the burden [42]. As in some instance, HEWs reside at a distance from their work places; poor transportation and communication which results in job dissatisfaction remains as another

Third, the sustainability of community health projects depends on the availability of on-going funding, a diversity of funding sources and ability to mobilize volunteers or low-paid workers who in the face of their own poverty are willing to care for the needy in their communities. Nearly all the challenges that community health projects faced relate to inadequate and sporadic funding. Funding limitations further affect the availability of health goods and services such as supervisors, medical equipment, supplies of drugs for minimum curative services, furniture,

Fourth, administrative functions such as monitoring, supervision, coordination,

and management are critical for successful community-based programs. Many HEWs perform their job alone or in small groups in distant sites, which results in a lack of meaningful supervision and reduces HEWs' ability to provide effective

Fifth, lack of commitment is yet another challenge. Although many HEWs work enthusiastically, there are a few who are not fully dedicated to their everyday activities [43]. This is mainly due to a failure to integrate HEWs as part of the state's

As previously noted, General Comment 14 clarifies the obligation of states to ensure maternal and child-friendly health services, goods, and facilities are available, accessible, acceptable, and of high quality. Although Ethiopia has improved health coverage through deploying HEP, health goods and services are threatened

**3.4 Implementation challenges in relation to goods and services**

programs throughout the country is laudable, there are major obstacles.

**104**

challenge [43].

and vehicles [44].

focused antenatal care [43].

by myriad challenges.

responsibility for health-care delivery.

Acceptability of health-care services is another challenge. For instance, the Ethiopian Central Statistical Agency's study conducted in Ethiopia in 2014 shows that close to 90% of births occurred outside a health service facility for different reasons: 45% did not take place in a health facility because the mothers did not think it was necessary, and for 33%, mothers stated it was not customary [53]. In addition, it has been observed that the birthing position used at the health centers made the women feel uneasy and was one of the reasons for Ethiopian women choosing to deliver at home rather [53].

Further, the delay in providing obstetric and newborn care services and treatment is usually the major reason for the poor quality of service [49]. The following are identified as the main causes for delays in treatment: (1) the number of health professionals is insufficient; (2) available health professionals often exhibit poor knowledge and skill; and (3) nonfunctioning health facilities due to a lack of medical equipment essential to manage obstetric problems, such as drugs, supplies, reagents, a blood bank, oxygen, magnesium sulfate, and a broad spectrum of intravenous antibiotics [49]. The lack of these essential medical goods in laboratories, imaging facilities, delivery suites, and operating theaters further lowers the quality of treatment.

#### **3.5 Judicial accountability**

Judicial accountability mechanisms for women's and children's health provide avenues for remedies and redress for women, children, and their caregivers or representatives when their rights to health care are violated. In Ethiopia, the judiciary is vested with the power to consider women and children's rights matters, and the courts are guaranteed, under the FDRE Constitution, to do so free from interference or influence of any governmental body, government official, or any other source [29]. However, interpreting and applying the socioeconomic right to health of women and children in the constitution is arguably the most challenging task facing lawyers and courts in Ethiopia on various grounds.

First, there are problems with the law. The FDRE and the nine regional state constitutions each have a specific provision that deals with the rights of children. Nevertheless, women and children's right to survive, to health, to access to food and safe drinking water, to adequate standard of living, and to other rights relating to the underlining determinants of the right to health have not been explicitly recognized in these constitutions. The absence of explicit recognition might create ambivalence for the judges to enforce these rights when violated. Nor are there special laws that address these rights.

Second, awareness of children's rights is crucial for their overall implementation. However, knowledge about the rights of children has been considered the main challenge [54]. Parents' or guardians' limited knowledge of children's rights and violations of their rights present a challenge to developing proper judicial channels of accountability for children's rights to health or survival.

Third, vulnerable women and children are unlikely to be able to bring claims for violations of their rights on their own behalf. Human rights NGOs could play a major role in representing women and children's rights cases before courts, but the current Ethiopian CSO law limits the possibility of legal representation by civil society for violation of human rights by the state.

Fourth, although the debate over justiciability of socioeconomic rights seems to have been settled in many parts of the world, research shows this is not case within the Ethiopian judiciary and among Ethiopian practitioners [55].

**107**

the country.

**4. Conclusion**

*A Human Rights-Based Approach to Maternal and Child Health in Ethiopia: Does it Matter…*

according to the procedural law of the country, civil claims may be joined as a single case where they relate to the same transaction or series of transactions, such as in a case where a decision is sought by any group or person who is a member of or

The foregoing renders the health inequality gap deeper and difficult among Ethiopian women and children and society at large. This challenge of inequality is in contradiction to the preamble of the FDRE Constitution, which underlines the need for Ethiopians to live on the basis of equality and without discrimination [29].

Ethiopia has adopted in 2009 the legislation to regulate the activities of CSOs [57] (at the time of writing this Chapter, a proposal was submitted to the Ethiopian parliament to amend this law). Three types of CSOs are classified under this new legislation, "Ethiopian Charities or Societies"; "Ethiopian Residents Charities or Societies"; and "Foreign Charities" [57]. The proclamation defines "Charitable Purpose" to include "the promotion of the rights of the disabled and children's rights" [57]. It indicates that CSOs are also mandated to promote child survival or health rights in Ethiopia, such as through litigation or advocacy or education. Nevertheless, the proclamation prohibits Ethiopian Residents Charities or Societies and Foreign Charities from engaging in issues, including, but not limited to, the advancement of human and democratic rights and promotion of the rights of the disabled and children's rights [57]. This is restrictive as these activities are left to Ethiopian charities or societies alone—which are also required not to generate more

The majority of the Ethiopian population lives below the poverty line, and requiring nationals to raise 90% from domestic sources to form charities not only questions their formation but also their sustenance. The limitation on funding has therefore disabled the work of Ethiopian charities on human rights and democratization issues, which clearly affects advocacy on violations of the rights to health of women and children. Besides, the law has deeply affected the ability of international organizations to work in the field of human rights promotion and advocacy in

Based on the conviction that an equitable health system is a core social institution and its potential for the realization of women's and children's right to health, this chapter argues that the essential HRBA features for ensuring maternal and child health rights in the Ethiopian context include (1) the explicit recognition of the right to health; (2) a national health plan encompassing human resources; (3) achieving health-care services that are available, accessible, acceptable, and of high quality; (4) accountability; and (5) a civil society that draws on the agency of vulnerable groups. Crucially, it examines the manner in which the Ethiopian system reflects such features and identifies the lacunae that exist in the country, including inadequate legislative framework and accountability mechanisms. To address these maladies, this chapter recommends the following: Firstly, the right of access to maternal and child health goods and services and processes to tackle causes of maternal and child mortality be explicitly enshrined in the national legislation. Secondly, the flaws in training, task allocation and supervision of HEWs need to be addressed, and adequate working conditions designed to boost HEWs' morale. Thirdly, programs and strategies must be implemented progressively to ensure that maternal and child

*DOI: http://dx.doi.org/10.5772/intechopen.83513*

**3.6 Non-transformative civil society**

represents a group with similar interest [29, 56].

than 10% of their funding from foreign sources.

Fifth, the requirement of vested interest or locus standi is a further challenge for judicialization of women and children's social right to health. For instance,

*A Human Rights-Based Approach to Maternal and Child Health in Ethiopia: Does it Matter… DOI: http://dx.doi.org/10.5772/intechopen.83513*

according to the procedural law of the country, civil claims may be joined as a single case where they relate to the same transaction or series of transactions, such as in a case where a decision is sought by any group or person who is a member of or represents a group with similar interest [29, 56].

The foregoing renders the health inequality gap deeper and difficult among Ethiopian women and children and society at large. This challenge of inequality is in contradiction to the preamble of the FDRE Constitution, which underlines the need for Ethiopians to live on the basis of equality and without discrimination [29].

#### **3.6 Non-transformative civil society**

*Education, Human Rights and Peace in Sustainable Development*

choosing to deliver at home rather [53].

of treatment.

**3.5 Judicial accountability**

Acceptability of health-care services is another challenge. For instance, the Ethiopian Central Statistical Agency's study conducted in Ethiopia in 2014 shows that close to 90% of births occurred outside a health service facility for different reasons: 45% did not take place in a health facility because the mothers did not think it was necessary, and for 33%, mothers stated it was not customary [53]. In addition, it has been observed that the birthing position used at the health centers made the women feel uneasy and was one of the reasons for Ethiopian women

Further, the delay in providing obstetric and newborn care services and treatment is usually the major reason for the poor quality of service [49]. The following are identified as the main causes for delays in treatment: (1) the number of health professionals is insufficient; (2) available health professionals often exhibit poor knowledge and skill; and (3) nonfunctioning health facilities due to a lack of medical equipment essential to manage obstetric problems, such as drugs, supplies, reagents, a blood bank, oxygen, magnesium sulfate, and a broad spectrum of intravenous antibiotics [49]. The lack of these essential medical goods in laboratories, imaging facilities, delivery suites, and operating theaters further lowers the quality

Judicial accountability mechanisms for women's and children's health provide avenues for remedies and redress for women, children, and their caregivers or representatives when their rights to health care are violated. In Ethiopia, the judiciary is vested with the power to consider women and children's rights matters, and the courts are guaranteed, under the FDRE Constitution, to do so free from interference or influence of any governmental body, government official, or any other source [29]. However, interpreting and applying the socioeconomic right to health of women and children in the constitution is arguably the most challenging task

First, there are problems with the law. The FDRE and the nine regional state constitutions each have a specific provision that deals with the rights of children. Nevertheless, women and children's right to survive, to health, to access to food and safe drinking water, to adequate standard of living, and to other rights relating to the underlining determinants of the right to health have not been explicitly recognized in these constitutions. The absence of explicit recognition might create ambivalence for the judges to enforce these rights when violated. Nor are there

Second, awareness of children's rights is crucial for their overall implementation.

However, knowledge about the rights of children has been considered the main challenge [54]. Parents' or guardians' limited knowledge of children's rights and violations of their rights present a challenge to developing proper judicial channels

Third, vulnerable women and children are unlikely to be able to bring claims for violations of their rights on their own behalf. Human rights NGOs could play a major role in representing women and children's rights cases before courts, but the current Ethiopian CSO law limits the possibility of legal representation by civil

Fourth, although the debate over justiciability of socioeconomic rights seems to have been settled in many parts of the world, research shows this is not case within

Fifth, the requirement of vested interest or locus standi is a further challenge for judicialization of women and children's social right to health. For instance,

facing lawyers and courts in Ethiopia on various grounds.

of accountability for children's rights to health or survival.

the Ethiopian judiciary and among Ethiopian practitioners [55].

society for violation of human rights by the state.

special laws that address these rights.

**106**

Ethiopia has adopted in 2009 the legislation to regulate the activities of CSOs [57] (at the time of writing this Chapter, a proposal was submitted to the Ethiopian parliament to amend this law). Three types of CSOs are classified under this new legislation, "Ethiopian Charities or Societies"; "Ethiopian Residents Charities or Societies"; and "Foreign Charities" [57]. The proclamation defines "Charitable Purpose" to include "the promotion of the rights of the disabled and children's rights" [57]. It indicates that CSOs are also mandated to promote child survival or health rights in Ethiopia, such as through litigation or advocacy or education. Nevertheless, the proclamation prohibits Ethiopian Residents Charities or Societies and Foreign Charities from engaging in issues, including, but not limited to, the advancement of human and democratic rights and promotion of the rights of the disabled and children's rights [57]. This is restrictive as these activities are left to Ethiopian charities or societies alone—which are also required not to generate more than 10% of their funding from foreign sources.

The majority of the Ethiopian population lives below the poverty line, and requiring nationals to raise 90% from domestic sources to form charities not only questions their formation but also their sustenance. The limitation on funding has therefore disabled the work of Ethiopian charities on human rights and democratization issues, which clearly affects advocacy on violations of the rights to health of women and children. Besides, the law has deeply affected the ability of international organizations to work in the field of human rights promotion and advocacy in the country.

### **4. Conclusion**

Based on the conviction that an equitable health system is a core social institution and its potential for the realization of women's and children's right to health, this chapter argues that the essential HRBA features for ensuring maternal and child health rights in the Ethiopian context include (1) the explicit recognition of the right to health; (2) a national health plan encompassing human resources; (3) achieving health-care services that are available, accessible, acceptable, and of high quality; (4) accountability; and (5) a civil society that draws on the agency of vulnerable groups. Crucially, it examines the manner in which the Ethiopian system reflects such features and identifies the lacunae that exist in the country, including inadequate legislative framework and accountability mechanisms. To address these maladies, this chapter recommends the following: Firstly, the right of access to maternal and child health goods and services and processes to tackle causes of maternal and child mortality be explicitly enshrined in the national legislation. Secondly, the flaws in training, task allocation and supervision of HEWs need to be addressed, and adequate working conditions designed to boost HEWs' morale. Thirdly, programs and strategies must be implemented progressively to ensure that maternal and child

health is accessible, available, acceptable, and of quality. Fourthly, accountability must be strengthened to monitor the implementation of the rights and the effectiveness of national programs tackling the issue of maternal and child survival. To enhance accountability, the legislature should amend legal provisions to allow CSOs to engage in human rights advocacy and litigation and promulgate legislation that creates a supportive and enabling environment for public interest litigation.
