Health infrastructure development and its impact on health security in Ethiopia since the 20^th Century: Focus on Gojjam Province

Abstract

In Ethiopia, the primary source of medical knowledge from antiquity to the turn of the 20th century was local medical expertise. The western contemporary medical healthcare services didn’t begin till the first decades of the 20th century. Health infrastructure has an unambiguous effect on increasing health security. The most overlooked topics in Ethiopian history and historiography are healthcare and medical history because of its fixation on issues of politics. Pertinent to this, no research has been conducted on the historical growth of medical institutions and their supporting infrastructures, the equitable allocation of people and material resources, and the rate at which public health security has increased in order to balance public mortality in Gojjam Province. Thus, the purpose of this research is to investigate health infrastructure development and its impact on health security in Ethiopia since the 20^th century with special focus on Gojjam Province. The qualitative research approach was employed, because it is a representational design that aids in understanding historical processes and human experiences in a specific historical setting. Primary and secondary data sources obtained through interviewing and document analysis were used for this qualitative analysis. The paper discusses the development of healthcare infrastructure, the types of Care Centers, and health security issues in the period under discussion in Gojjam Province. It is hoped that this research will assist experts of the field, the local community, and policymakers better understand how the institutions, infrastructures, and distribution of health services have evolved and impacted health security in Gojjam.

Keywords:

• Infrastructure
• health security
• health history
• health institution

1. Introduction

The quality of care and ease of access to health care delivery within a nation are characterized in both qualitative and quantitative terms as the health infrastructure. It is evaluated based on the level of physical, technological, and human resources that are readily available throughout a period of time. While technology refers to the equipment designed expressly for hospital use, including surgeries, physical structure refers to the buildings and other fixed structures such as pipe-borne water, adequate access roads, electricity, and so on within the healthcare institutions (Erinosho, 2006; Isreal, et’al, 2009). This also includes computer hardware and supplies, whereas human resources are made up of health professionals like doctors, chemists, nurses, midwives, laboratory techs, administrators, accountants, and other varying employees. Any society’s framework for healthcare delivery and the elements that determine its infrastructure are established by the interaction of all of these factors.

One part of the broader idea of a health system is the infrastructure, which also encompasses health policy, financial allocation, implementation, and monitoring (Adebayo & Oladeji, 2006). This is more thorough and durable than a combination of facilities, medical consultation, and compliance in terms of diagnosis, treatment, and compliance. Healthcare consumers and other elements associated with or related to the provision of healthcare are also included.

Additionally, in accordance with these all-encompassing requirements, health infrastructure relates to the people, organisations, and legal frameworks that work together in a structured manner to mobilise and distribute resources expressly for the management, prevention, and treatment of disease, illness, and injuries. On the one hand, good administration, effective finance, and effective communication are all crucial components of a high-quality healthcare delivery system. It is also crucial to have a willing government that actively supports and contributes to the healthcare system for the good of society as a whole (Isreal et al., 2009).

Healthcare access is challenging in low-income countries, especially in rural areas because of weak infrastructure and distribution networks. Despite the lack of and dispersion of government health facilities, private sources frequently focus on more affluent urban areas, leading to unequal service accessibility across a nation. In the absence of a strong healthcare infrastructure, expanding primary care and establishing state-of-the-art community-based health service delivery systems can help to ensure more equitable access to healthcare. In Ethiopia, several activities are now in operation, and the success of those programmes is not reliant on stable infrastructure (CSA, 2011, Nada, 2007; Padmaja & Kumar Behera, 2023).

Ethiopia is a developing nation with subpar healthcare infrastructure and a constrained healthcare system. Similar to most aspects of health, reproductive health frequently falls short, with notable regional differences in treatment accessibility and health outcomes. In the past, communicable diseases and preventable dietary deficiencies, both of which are linked to low socioeconomic development, have been responsible for about 80% of morbidity in Ethiopia. Improving health systems and the underlying physical infrastructure will need a major time and resource commitment to improve health (Ahmed & Abera, 2005; Gidey, 2005; Kebede, 2006; Nada 2007).

In the absence of a well-functioning health care infrastructure, initiatives that provide just traditional health care serve to reach only select population groups, communities, or geographical areas. The researchers emphasise two of these initiatives: the government-led community health service delivery programme and the service delivery programme headed by non-government organisations and locally produced and owned (Ahmed & Abera, 2005; Berhan, 2012; Haddock et al., 2002; Richard, 1990).

On the other side, public health security can be described as the proactive and reactive measures necessary to limit vulnerability to unanticipated public health emergencies that endanger the population’s overall health. This idea is broadened to include serious public health emergencies that endanger the overall welfare of populations residing in different countries and geographical areas. As various scholars have shown, global health security—or its lack—can have an effect on trade, tourism, access to goods and services, economic and political stability, and, if it endures, demographic stability (Aldis, 2008; Behera, 2022; Daniel & Angela, 2006; Guets & Behera, 2022; Mirta Periago, 2012; Stevens, 1996; Turnock, 2001; WHO, 2007).

The wide range of socioeconomic conditions, climates, and topographies across Ethiopia has a substantial impact on health issues, particularly in rural Ethiopia where access to any form of modern health institution is constrained. Travel issues are severe, particularly during the rainy season, and the infrastructure for health care and transportation is inadequate (Nada 2007).

Ethiopia’s main health provider is the government, yet access to and distribution of health facilities within the nation is still uneven. However, it aims to lessen disparities in the provision of healthcare services through its Health Extension Project (HEP). The term “public health” describes coordinated initiatives to enhance the health of communities. The operational elements of this definition are structured for communities rather than for individuals. Instead than being based on a single body of knowledge or expertise, public health practise is based on a blend of scientific and social methods. The concept of public health reflects its main objective, which is to improve health and decrease illness in a community. Initiatives to manage epidemics, ensure the safety of food and water, lessen the spread of diseases that can be prevented by vaccination, and keep track of health issues are just a few examples of population-based approaches to enhancing community health (Tariku et al., 2018; Nada 2007).

In contrast to clinical medicine, public health places a strong emphasis on prevention and customizes therapies to the various social and environmental elements that affect disease. Clinical medicine is focused on treating the individual. However, as individual and community health are parts of a continuum, intervention between public health and medicine is necessary (Callahan & Wassuna, 2006; Haddock et al., 2002; Lloyd et al., 2008 Marilyn, 2010).

In conclusion, contemporary health care system in Ethiopia and Gojjam in particular is still in its infancy. Nevertheless, it has been in a state of perpetual transformation over the past century, helping to further social and political developments. Due to new health reform programmes and policies that were implemented locally in conjunction with global health sector reform initiatives, more progress has been made over the past 20 years. Ethiopia, a developing nation with a low GDP per capita, is making efforts to update its infrastructure for health care services. On the other side, reproductive health is underdeveloped, with notable access gaps between urban and rural areas as well as regional discrepancies. Therefore, the main objective of this study is to make a historical enquiry on the development and equitable distribution of health infrastructure with its impact on the society’s health security in Gojjam region of Ethiopia.

1.1. Historical development and equitable distribution of health institution in Gojjam

In the 1940s, a growing body of historical writing on social welfare and modern state development encouraged historians to write a history of the public health industry. As a result, the history of public health started to be defined beyond the ideas of Sand Rosen and his contemporaries from the 19th century, who focused on the collective act of population health. S. Rosen and D. Porter claim that people’s experiences should be taken into account when formulating bigger concepts, attitudes, and actions about health and illness (Bernard, 2001; Berridge, 1999, 2011; George, 2015; Porter, 1994, 2005).

As recent historical accounts indicate, Menelik II Hospital, which opened its doors in 1906 and has 30 beds, was Ethiopia’s first government-owned modern hospital. In Addis Abeba, a second hospital was also founded in 1922. Building funds for this hospital were contributed by Thomas Lambia of the American Christian Mission Group. Four doctors and five nurses were the only staff members when it was opened. In 1964, it adopted the name Pasteur Laboratory Research Institute. Later, this research organization and the Ethiopian Nutrition Institution were pooled to become the Ethiopian Health and Nutrition Research Institution (ENHRI). More hospitals, health research and training centres sprouted up after the formation of the Ministry of Health in 1948. Some of the major foundations in the history of health service and research institution development include the Gondar Public Health College and Training Centre (1952), the Nursing School of Addis Abeba (1950), the Malaria Eradication Project (1959), the Leprosy Control Project, and the Small Pox Eradication Service. Due to this tendency of development, there were 131 hospitals with 7848 beds, 3231 clinics, and 723 health stations as both government and private establishments across the country as a whole in 2014 (Ayinalem, 2014).

In the several administrative sub-regions of Gojjam province, contemporary health ogranizations may have been founded as early as the imperial period. The province has just two hospitals, seven health institutions, and 29 clinics between the 1940s and 1975. In the ten years after 1967, just two health centers and one hospital were built. The historical data from the Gojjam province health office, as shown in Figure 1, is a reliable confirmation of the validity of offering a suitable concept for the establishment of health institutions from the 1950s of the monarchial period and 14 years of Ethiopia’s military administration. Contrary to clinics, the province’s hospital and health centre development trends during the past 30 years (1958–1988) were sluggish (Gojjam Province Administration, here after GPA), Archive (1987);, East Gojjam Administrative Zone, hear after EGAZ), Archive (1985).,

Figure 1. 30 years health institution development in Gojjam (1958–1988).

Source: Gojjam Province Administration.

Prior to the revolution, Gojjam, like the rest of Ethiopia, had a low level of health-care development. The majority of individuals living in rural areas did not have access to the necessary health care due to the limited quantity and inadequate quality of health facilities; these facilities were mostly located along main thoroughfares and in urban areas. During this time, there were two hospitals, seven health centres, and 31 clinics open. The province had a population of roughly 1,590,400 people during the changeover period from imperial to military rule. Regardless of age or gender 78,875 people, or almost 5% of the province’s total population, were diagnosed in these few hospitals and health centres. In 1974, 31 clinics, health centers, and hospitals diagnosed about 117,855 (7.47%), 65069 (4%), and 13,086 (0.9) of the total population respectively (GPA, 1974).

In the four years leading up to the monarchical government’s overthrow, there was an effort to increase access to health care for the populace. Despite this, the profession still requires crucial studies of policy creation and implementation. Only one physician serviced 80,000 people, and one bed served 3000 patients, out of 1000 infants under one year old, roughly 200 died. Despite the ordinary nature of the number, many people were unable to receive medical treatment. Therefore, the administration highlighted health issues as one of the major difficulties that the revolution would essentially face and it would advance aggressively (GPA, 1979).

During the post-revolutionary era, ministry of health established a plan that improved the nation’s mass society’s access to basic health care. Since the time of the imperial era, organisations for the prevention of leprosy, the elimination of smallpox, and the management of malaria have been established in the country. Even after the revolution, the ministry of health realised how ineffective it was for health organisation to manage and prevent health issues on their own. As a result, it made a brutal effort to fight sickness by organising the activities of numerous health organisations based on common objectives. Thus, 105 leprosy preventive centres with medical professionals were provided within the province’s leprosy treatment service centres. Malaria control center had four sub-centers and it was attempted to unite and work in cooperation with basic health service institutions. The primary goal of the smallpox control centre was to prevent the sickness. It collaborated with organisations providing fundamental health services for effective performance. This programme was established in the Gojjam province in 1970, and the organisation formally declared the disease to have been vanished there. Indicated by aggregated data in Figures 2 and 3, the field of health has evolved since the revolution up until 1979 in terms of institutional development rate, expertise, and technical supports staff (GPA, 1976, 1979)

Figure 2. Health institution development rate in percent (1974–1979).

Source. Gojjam Province Administration.

Figure 3. Health personnel per health institution (1978).

Source: Gojjam Province Administration.

In 1978, Gojjam had a population of roughly 2,070,700 and the ratio is computed based on population size, health workers, bed in hospital, and health centre in order to be visible for equal distribution of the health system in the province. In this regard, the ratio can be expressed as follows: 147183 patients were serviced by 1 doctor 207,070 patients by 1 health officer, and 7551 patients by 1 bed, respectively (GPA, 1979).

The government provided a total budget of 2,118,058 birr (1316626 for salaries and 801,432) for the province’s hospitals, clinics, and health centres for the 1978 calendar year. Both domestic and international workers were counted among the health specialists and technicians. Only 5 doctors, 50 nurses, 11 lab technicians, and 2 anesthesiologists were Ethiopians, according to statistics. As a result, in 1978, one doctor provided care for 414,140 people across the province.

In Gojjam, only one hospital was built, most likely in 1941 in Debre Markos, and in 1978 it had 86 beds and saw at least 70 inpatients each day. There were 11 nurses, 30 health assistants and sub-assistants, 1 Ethiopian physician, 1 health officer, 1 sanitarian, 1 ×-ray technician, and 1 pharmacy technician. Despite its modest degree of development, the hospital provided excellent service to the community. Foreign physicians, particularly Cubans, made significant contributions to filling the province’s health institutions’ human resource shortage. It was impossible to run the health system without the use of Cuban health personnel (Ibid).

The internal resources and finances of the hospital were not commensurate with the curative and other medical services it offered. Without being restored, the hospital’s structures were used for many years. The hospital’s site was poorly chosen, which hindered the development of its services and the effectiveness of its execution. The hospital’s buildings were built on two separate compounds 5 kilometres apart. The first compound had a building with 60 beds used for internal disease medication, surgical, child treatment and child delivery service classes, while the second compound had a building with 26 beds used for inpatient and outpatients of communicable diseases like lung cancer and pandemic. This portion of the hospital was built before the hospital began offering services inside the health centre compound. Generally speaking, the hospital’s services were provided with inadequate funding, material and human resources (Ibid).

The location and distribution of governmental health institutions lacked balance because they were all located in provincial, awraja, and district centres. The 1985 provincial health prevention office annual report, as stated in Table 1, is a useful signal to disclose the per kilometre distance of hospitals and health centres from the provincial health care office (Ibid).

Table 1. Distance of health institution from province’s health prevention head office

Hospital/Health Center	Distance from Province’s main health office/km	Remark
Debre Markos Hospital	3	East Gojjam Zone West Gojjam Zone
Finote Selam Hospital Felege Hiywet Hospital	85 265
Debre Markos Health Center Bichena Health Center Motta Health Center	2.5 102 205	East Gojjam Zone
Bure Health Center Metekel Health Center Debre Zeyit Health Center Dangila Health Center Bahir Dar Health Center	110 210 355 185 265	West Gojjam Zone

Source: GPA, Gojjam Province Health Prevention Office 1985 Annual Health Performance Repot.

The overall population of the province in 1988 was 3,530,540. When the service delivery of the institutions is measured against the size of the population, one hospital, health centre, and clinic served about 882,635, 393383, and 24,181 people, respectively. In 1989, 17 new clinics were built in order to better the health of the rural population: three in Debre Markos Awrajja, two in Motta Awrajja, two in Bahir Dar Awrajja, four in Agaw Midir Awrajja, one in Metekel Awrajja, and five in Qolla Dega Damot Awrajja (GPA, 1988).

The Derg government had held the view that, in addition to medical facilities, indigenous knowledge and culture could play a significant role in supplying the people with health care. As a result, the province trained traditional midwives and qebelle health delegates to play their own roles in the area of community primary health care. A nice illustration is the data in Table 2. It displays the training programme and its implementation for traditional midwives and qebelle health delegates in 1988. Attempts were made to hold the training every year for around three months, from February 1 to April 30. The reason for choosing the training months was to avoid conflicts with the threshing and ploughing seasons for peasants. As training institutions, Debre Markos Health Centre, Finote Selam Hospital, and Bahir Dar Health Centre were carefully selected (Ibid). The training plan and performances rate in percentage are organized and well illustrated in Table 2.

Table 2. Customary–midwifes and qebelle health Delegates training Plan and Performance (in 1988)

No	Awrajja	Training Plan		Those who were trained		Training execution Per percentage
		Qebelle Health Delegates	Customary–midwifes	Qebelle Health Delegates	Customary–midwifes	Qebelle Health Delegates	Customary–midwifes
1	Debre Markos	18	18	15	12	83.3%	66.6%
2	Bichena	15	15	6	10	80%	46.6%
3	Motta	15	15	12	7	80%	46.6%
4	Bahir Dar	18	18	17	12	94.4%	66.6%
5	Agaw Midir	15	15	13	0	87%	0%
6	Metekel	17	17	4	4	23.5%	23.5%
7	Qolla Dega Damot	18	18	21	13	116.6%	72%
Total		116	116	88	56	76%	50%

Source: Gojjam Province Health Prevention Office 1988 Annual Report.

The province’s population was less inclined to give birth in a hospital than other parts of the country. As a result, trained traditional midwives assisted expecting mothers during childbirth. Table 3 displays this type of childbirth care offered by traditional midwives in Gojjam in 1988. According to these statistics, Bichena awrajja provided more traditional midwives for childbirth services to the province’s awrajjas. In 1988, 16 deliveries beyond the capabilities of the traditional midwives were reported in Bahir Dar awrajja, with 1438 proper deliveries, 18 incorrect deliveries, and 10 deliveries resulting in fatalities (Ibid).

Table 3. Child delivery service provided by Customary–midwifes (in 1988)

No	Awrajja	Customary–Midwifes who were found in the Awrajja	Customary–Midwifes who provided service	Type of Child Delivery Service
				Proper delivery	Wrong delivery	Delivery with death	Delivery beyond their capacity
1	DebreMarkos	188	31	665	7	6	2
2	Bichena	175	112	1438	18	10	0
3	Motta	157	30	246	0	0	0
4	Bahir Dar	220	173	299	6	9	16
5	Agaw Midir	191	32	0	0	0	0
6	Metekel	137	63	828	0	1	0
7	Pawi	41	39	0	0	0	0
8	Qolla Dega Damot	182	45	359	2	0	0
Total		1291	525	3835	33	26	18

Source: Gojjam Province Health Preservation Office 1988 Annual Performance Report.

In the period from 12^thJuly 1988, to 11^thJuly 1989, as indicated in Table 4, the Gojjam health institutions employed 146 nurses, 30 doctors, 4 health officers, 12 chemists, 26 health supervisors, 17 laboratory technicians, 8 ×-ray technicians, 8 pharmacy technicians, 449 health assistants, and 60 medium health assistants. Foreigners worked in the province’s health institutions in 1988 alongside Ethiopian professionals who were employed there as part of aid.

Table 4. Distribution of health professionals per health institution (in 1988)

Name of Health Institution	Professionals										Total
	Doctors	Health Officers	Pharmacist	Health Supervisors	Nurse	Technicians			Health Assistant	Medium Health Assistant
						Laboratory	X-ray	Pharmacy
Gojjam Province Health Prevention Office	0	2	2	4	2	0	0	1	1	1	13
Debre Markos Hospital	6	0	2	0	18	3	2	2	13	14	60
Debre Markos Health Center and Clinics	1	0	0	2	10	1	0	0	49	6	69
Felege Hiwot Hospital	8	2	5	1	32	4	3	2	31	15	102
Bahir Dar Health Center and Clinics	2	0	0	4	9	1	0	0	45	5	66
Finote Selam Hospital	5	0	3	1	18	2	1	0	21	7	58
Burie Health Center and Clinics	0	0	0	2	8	0	0	0	54	5	69
Bichena Health Center and Clinics	1	0	0	2	6	1	0	0	38	1	49
Motta Health Centers and Clinics	1	0	0	2	8	0	0	0	37	1	49
Dangela Health Centers and Clinics	1	0	0	2	7	1	0	0	27	2	40
Metekel Health Centers and Clinics	1	0	0	3	6	1	0	0	40	3	54
Wonbera Health Center	0	0	0	0	2	1	0	0	5	0	8
Pawi Hospital and Clinics	4	0	0	2	17	2	2	3	88	0	118
Feres Bet Health Center	0	0	0	1	3	0	0	0	0	0	4
Total	30	4	12	26	146	17	8	8	449	60	760

Source: Gojjam Province Health Preservation Office.

The Derg received medical treatment from Cuba (6 men and 3 women), Italy (7 men and 3 women), Russia (2 men), and socialist nations like Cuba due to its close diplomatic relations. It also received assistance from Russia due to its socialist policies. A programme for in-service training of health professionals was set up to help them develop their abilities and skills (Ibid). The data organized in Table 5 is a virtuous validation for this attempt of the government’s in-service training program.

Table 5. In-service trainees in Gojjam province (in 1988)

No	Areas of Training	Professionals who took the training	Number of Trainees	Duration of Training
1	Anti-six vaccination schedule implementation	Nurse	15	15 days
2	Family planning	Nurse	4	1 month
3	Basic pharmacy program training for trainers	General Doctor	1	15 days
		Pharmacist	1	15 days
4	Awrajja Health Service Management	General Doctor	1	10 weeks
5	Field Food system	Health Assistant	20	3 weeks
6	Diarrhea and vaccination program	Nurse	2	15days

Source: Gojjam Province Health Preservation Office.

The health institutions in the Gojjam province had a total of 470 beds, including 139 beds at the Felege Hiwot Hospital, 105 beds at the Finote Selam Hospital, 66 beds at the Debre Markos Hospital, 3 beds at the Bichena Health Centre, 3 beds at the Motta Health Centre, 8 beds at the Agaw Midir health institutions, and 103 beds at the Pawi vaccination posts.

Several ailments are said to have affected Gojjam residents’ health throughout the first four decades of the 20th century. Smallpox was the most serious illness that the locals of Gojjam had to deal with during the start of the 20^th century, and it still sticks out as a terrible memory. As illustrated in Table 6, devastating effects were also caused by various infectious or endemic illnesses as typhus, typhoid, cholera, measles, tuberculosis, dry cough, gastric, skin disease, goitre, and eye disease. These diseases decimated the population during the months when people were ploughing, sowing, weeding, harvesting, and threshing, significantly reducing output and productivity. Even though there was a lack of information on how many people in the province were impacted, the hospitals, health centres, and clinics in Gojjam were able to identify the top 10 and important illnesses that had the greatest impact on people’s quality of life in 1988. The top three infectious diseases from these were found to be respiratory infection, malaria, and skin infection (Ibid).

Table 6. Tope diseases identified in Gojjam province in 1988

Top ten diseases identified at Hospital level			Top ten diseases identified at Health Center level			Top ten diseases identified at clinic level
Type of Disease	Number of Patients	Ranks	Type of Disease	Number of Patients	Ranks	Type of Disease	Number of Patients	Ranks
Other Helminthes	5514	1^st	Other Helminthes	9784	1^st	Malaria	25407	1^st
Infection of skin	4581	2^nd	Infection of skin	9385	2^nd	Infection of skin	19353	2^nd
Trachoma	3383	3^rd	Muscular Reumation	6093	3^rd	Other respiratory infection	16524	3^rd
Gastritis and duodenities	3273	4^th	Ascariasis	5507	4^th	Ascariasis	15334	4^th
All other disease of Genito Urinary system	2939	5^th	Gastritis and duodenities	5423	5^th	Diarrhea	13868	5^th
Muscular Reumation	2807	6^th	Acute upper respiratory infection	4605	6^th	Muscular Reumation	12420	6^th
Muscular Rhoumatism of Rheumatism unspific	2579	7^th	All other disease of Genito Urinary system	3566	7^th	Gonorrhea	8454	7^th
Ascaris	2487	8^th	Gonococa Infection genitc urinary	3384	8^th	Gastritis and duodenities	7076	8^th
Other diseases and condition of the eye	2141	9^th	Amoeblasis	2922	9^th	Other diseases and condition of the eye	5599	9^th
Bron Chial Asthma	1659	10^th	Pneumonia	289	10^th	Catarrh	5121	10^th

Source: Gojjam Province Health Preservation Office.

As one can easily understand from Table 6, there was variation in the level of diseases identified at hospital, health center and clinic level in Gojjam in 1988. As it is indicated in Figure 4 and appendix IV, Skin Infection, Malaria, Respiratory Infection, Ascarisis, Muscular Rheumation, Gonorrhea, Gastritis and Duodenitis, Helminths, Diarrhea and conditions of eye were the top 10 diseases found in the province in 1988. From these, skin infection, malaria and respiratory infection were identified as the first three infectious diseases

Figure 4. Top ten diseases which affected people of Gjjam province in 1998.

Source: Gojjam Province Health Preservation Office.

From the last years of its rule, the communist government of Ethiopia created the policy issues and objectively raised the number of health stations and qebelle health services posts. This demonstrates how the basic healthcare programme for improving basic healthcare in rural Ethiopia is progressing. Through the growth of health stations and qebelle health services posts, the international slogan “Health for all in 2000” and the basic health care programme were realised. Clinics also assisted in the training of qebelle health leaders and traditional midwives in addition to providing health services and health education. Following the training, they kept an eye on the state of the qebelle health services. The rural community’s awareness of health standards and desire to manipulate the services provided by medical institutions served as a barometer for the growth of clinics and qebelle health services. Consequently, expanding the availability of clinics and qebelle health services could promote the growth of the local health system (GPA, 1979).

Throughout the Ethiopian Peoples Revolutionary Democratic Front (EPRDF) period, Ethiopia and the region, Gojjam, as a whole have seen successive shifts in the growth of health institutions and their services. Researchers concentrated on the present-day East Gojjam Administrative Zone (the former Mota, Bichena, and Debre Markos Awrajas) to gain a noticeable grasp of institutional and service expansion for this period of the province. An estimate of the population of this sub-region, which resided in 754 urban and rural qebelle associations at the start of the last decade of the 20th century, was made in a document created in 1990 by the East Gojjam zonal health office. This populace estimate came to be roughly 1,568,750. To support the ratio of actively operating medical centres to those who could access these facilities’ services, researchers calculated and presented the idea in Table 7 (Downie, 2016; GPA, 1990).

Table 7. Institutional service to population ratio/1990

No.	Name of the institution	No. of Institutions	Institution - population ratio
1	Hospital	1	1:1568750
2	Health center	3	1:522916
3	Clinic	48	1:32682
4	Health post	46	1:38262

Source: EGAZ health office/1990.

In the first four years of 1990, the statistical figure of operational hospitals, health centers, clinics, health posts, and leprosy prevention centres in east Gojjam sub-region increased to 1, 3, 49, 36, and 49, respectively. On the basis of this information, Table 9 calculates the ratio of institutions’ service to the overall population size. Contrary to the opening of several clinics in the area, their proportion to the population who sought the service is still below the required level. The hospital was designed to serve the residents of the zone solely, but it actually treated about 1,883,736 residents who live in a 13,936 square kilometre of the region. One health centre in the zone, with a surface area coverage of 4645 sq. km, serviced 627,912 people, while clinics in the zone were as important, treating around 38,444 residents in an area of 284 sq. km. There was an imbalance in the number of healthcare facilities to patients of the area. A National Health Service coverage plan called for one hospital to serve 250,000 people, one health centre to serve 100,000 people, and one clinic to serve 10,000 people. Therefore, it was predicted that an extra 7 hospitals, 16 health centres, and 139 clinics would be built in order to meet this goal of health development. The single hospital in the administrative region of East Gojjam was established in the town of Debre Markos with 68 patient beds and has been operational for many years without further expansion. According to the national health standard, as displayed in Table 8, one bed can accommodate 300 patients. In contrast, one bed was available for 27,702 patients at Debre Markos Hospital (EGAZ, 1994).

Table 8. Institutional service to population ratio/1994

Level	Hospital	Health Center	Clinic	Bed
National	1:250000	1:100000	1:10000	1:300
Regional	1:1442919	1: 360730	1:31300	X
East Gojjam	1:1883736	1:627912	1:38423	1:27702
No. of Institution	1	3	49	-
No. of patient Treated	54159	12374	371778	36019

Source: EGAZ health office/1990.

An archived document from the East Gojjam Plan and Economic Department claims that 15 doctors were engaged to offer care in the zone’s governmental health organisations, with 9 of them being allocated to Debre Markos Hospital and the other 6 to various health centres. Sources claim that of the 61 nurses employed in the zone’s three primary healthcare institutions, 26 were given responsibility for the hospital, 21 for the health centres, and 14 for the clinics. The most crucial employees were the health assistants, who travelled to far locations to provide services to the community. As presented in Table 9, the zone hired 211 health assistants this year, with 144 working in 49 clinics, 44 in health centres, and the remaining 27 in the hospital (Ibid).

Table 9. Health personnel per institution in East Gojjam administrative zone

No.	Health personnel and Technician	Health Institution			Remark
		Hospital	Health Center	Clinic
1	Physician	9	6	-
2	Health officer	1	-	-
3	Sanitarian	1	4	1
4	Nurse	26	21	14
5	Laboratory technician	2	3	-
6	Pharmacist	2	2	-
7	Pharmacist technician	1	3	-
8	X-Ray Technician	2	-	-
9	Health assistant	27	44	140
10	Vice health assistant	12	3	2
11	Leprosy professional	1	6	7
12	Total	83	92	164

Source: EGAZ Plan and Economic Department.

A nationwide standard for health care coverage, as made known in Table 10, was one doctor for 10,000 patients, one nurse for 5,500 patients, and one health assistant for 1,000 patients. In contrast, the East Gojjam Zone had a ratio of 1 doctor to 125,582 patients, 1 nurse to 30,881 patients, and 1 health assistant to 8928 patients. Therefore, in addition to what was needed, the national standard called for 173 doctors, 281 nurses, and 1673 health assistants (Ibid).

Table 10. National, regional and zonal level health personnel service to people ratio/1990s

Level	Physician	Nurse	Health Assistant
National	1: 10000	1:5500	1:1000
Regional	1:81926	1:25611	1:7009
East Gojjam Zone	1: 125582	1:30881	1:8928

Source: EGAZ Plan and Economic Department.

The provision of healthcare is a fundamental act of human kindness that creates citizens who are mature in both mind and body. Health facilities should have a sufficient number of medical professionals and support staff, as well as medical supplies and medications, in order to provide services. Up to 1999, the East Gojjam Administrative Zone had a small number and range of health establishments. In accordance with the requirements of standards of international health institutions, they were not effectively organised, and the availability of health services was constrained. Similar to this, the zone’s predicted population for 2006 was around 2,514,647 (urban: 240267, rural: 2274380). With this population, 1 doctor provided care for roughly 160,119 people. Statistics created in visual form in Figures 5-8 is an upright account to demonstrate a high professional-to-population ratio and health coverage in five consecutive years are used to support the topic of the study from 1995 to 1999 (EGAZ, 1998a, 1998b).

Figure 5. Health institution development/1995 – 1999/.

Source: EGAZ 2000 Fiscal Year Annual Plane and Performance.

Figure 6. Institutional per population Service/1995–1999/.

Source: EGAZ 2000 Physical Year Annual Plane and Performance.

Figure 7. Health professionals in East Gojjam administrative zone/1995 – 1999.

Source: EGAZ 2000 Physical Year Annual Plane and Performance.

Figure 8. Health professional’s service to population ratio in comparison with the international standard/1995 – 1999/.

Source: EGAZ 2000 Physical Year Annual Plane and Performance.

In this context, the profession must make significant efforts to control the spread of infectious diseases and provide basic healthcare services at the appropriate times and locations (EGA 1998a, 1998b).

1.2. Infrastructural development and its impact on health security

1.2.1. A historical appraisal

Ethiopian governments have implemented programme changes and policy initiatives to raise community health standards. In one instance, the EPRDF government in Ethiopia, which took power in 1991, proclaimed a health policy in 1993 and had a goal for the following two decades that it would focus on the growth of the healthcare industry. Its main components included a system of decentralisation in political and financial matters, the growth of primary healthcare, and encouraging non-governmental actors to actively participate in the provision of healthcare services. To put this strategy into practise, new initiatives like the Health Sector Development Programme (HSDP) and the Health Care and Financing Strategy (HCFS) were created in 1997 and 1998, respectively. In contrast to this, the country’s health system performs poorly, even falling short of sub-Saharan African standards. It is characterised by a lacklustere health infrastructure, minimal financial spending, and decades of inconsistent state health policy (Bhandari & Dutta, 2007; Wamai, 2009).

The nine national regional states of Ethiopia are putting these decentralisation plans into practise. The state’s distribution figures for health facilities for 2006–07 show that, of the institutions constructed up until this year, 143 hospitals, 690 health centres, and 1662 health stations were among them. From these medical establishments and institutions, the government owns 62% of the hospitals, 97% of the health centres, and 77% of the health stations. The type and extent of service offered in each region varied depending on the population size. According to the Ministry of Health, this years’ service ratio is one health centre for every 25,000 people and one health post for every 5000 people (Ibid).

The significance of health infrastructure in the process of building full-fledged and sustained societal health is significant. The medical stuff, physical infrastructure, finance, policy issues, provision of institutions and service delivery activities, particularly in relation to family welfare, maternal health, communicable disease control, diarrhoea control, nutrition, and immunisation, are the important issues discussed in relation to public health infrastructure development and health security assurance. It also covers the provision of comprehensive preventative and curative health care practises for the urban and rural populations of Gojjam. Preventive measures include encouraging better hygiene practices, tetanus vaccination of pregnant women, and others (Laveesh 2007).

The level of socioeconomic development, on the one hand, and the chaos of natural balance, on the other, affects the provision of adequate clean water for a rapidly rising population. As an example, 12 towns in the province’s eastern half region such as Motta, Mertu Lemaryam, Debre Worq, Bichena, Yedwuha, Quy, Dejen, Lumame, Yejjube, Debre Eliyas, Amanuel, and Debre Markos received pure water supplies in 1994. According to the plan and the economic office document, Debre Markos town’s pure water supply reservoir will serve for 100,000 people’s water consumption for 20 years. In contrast, the communities of Bichena and Yejjube’s residents did not have access to sufficient pure water. Yedwuha, in the Shebel Berenta district, had two hand pumps, but they were not equipped to supply the town’s residents with adequate pure water. The zone had just 12.14% clean water coverage in 1996, 12.20% in 1997, and 25.82% in 1998. In conclusion, practically the entire rural and other district town community lacked access to such pure water supply, with the exception of a few of municipalities in the zone. As a result, numerous individuals suffered a water-borne illness (EGAZ, 1994; See Appendix I).

Land routes connected every woreda town in the Gojjam region’s eastern part. The majority of the roads lacked branch networks and did not extend into the hinterlands of the rural community. Due to this, peasant society faced considerable challenges with the transfer of agricultural inputs and outputs. The provision of adequate health care and quick information transmission was further hampered by a lack of road infrastructure (EGAZ, 1999).

In the first decade of 21^st century, the eastern Administrative Zone of Gojjam region had a total length of weather roads roughly 745.82 km. When this anticipated road length is equated into road density of the sub-region, the result is 53 km for every 1000 sq.km of total zone area. These little gravel rural roads connected the rural area’s qebelle to qebelle and woreda to qebelle. From the total road network, about 174.84 (23.44%), 215.97 (28.96%), 89.58 km (12.01%), and 265.43 km (35.59%) were asphalt roads, main gravel roads, rural roads, and minor gravel surface roads, respectively. Only 10.27% of the zone’s total population had access to telephone service, with a total of 246.73 customers. Most people couldn’t access modern communications in remote rural places. In this regard, postal service served as the primary means of communication for people to engage in socioeconomic and political discussions. This postal communication was managed through one branch post office, two main post offices, five regular post offices and ten postal agents with 1160 post boxes (Appendix II and III).

Health services are the outcome of the work done in hospitals, clinics, health centres, pharmacies, and by the people who work in these facilities, including doctors, nurses, sanitarians, nurses’ aides, and pharmacists. The fundamental condition for individual happiness and the growth of the nation as a whole is good health. With the presence of infectious diseases, illnesses from various causes, and parasitic infections, the country cannot move forward in its development. On the other hand, civil society organisations, government and non-government organisations, as well as the community at large, play a significant role in advancing the public’s health and delivering high-quality healthcare services. For instance, funding and improving the transportation system promotes more people to use the health care system (Ayinalem, 2014).

Health security is affected by societal and political developments. Prior to the Ethiopian revolution, the pre-revolutionary semi-feudal and semi-bourgeoisie government’s health service approach was primarily focused on protecting the health of the ruling class. The majority of hospitals, medical facilities, and healthcare professionals, like as doctors and nurses, were concentrated in the major cities of the nation. Agribusiness owners and their agricultural fields were the primary focus of the dissemination of healthcare facilities in rural areas. In post-revolution Ethiopia, changing the socioeconomic and political operations of the previous system was the main goal of the revolution. In order to do this, new revolutionary concepts had to be introduced in place of outmoded regulations and administrative procedures. Based on these principles, the Derg launched national democratic revolutionary programmes in 1984. In Ethiopian socialist history, the health and production campaign programme that was implemented during and after development through cooperation, enlightenment, and working campaign is renowned (GPA, 1999).

The health service strategy and its programmes started to follow better directions towards the beginning of the 1970s. A basic health prevention programme for health security was launched in Ethiopia based on the global campaign “Health for All in 2000.” The health service agenda for basic health treatment and basic health care is carried out in accordance with the socioeconomic and political realities of the country. It is an action blueprint developed by self-assurance that resulted from self-decision. The strategy is implemented when there is a chance for political organisations to be acknowledged and supported in managing and implementing the programme, strengthening community participation, implementing technologies, and engaging developmental organisations by coordinating the health programmes (Ibid).

In Ethiopia, communicable diseases and malnutrition are the main causes of health issues. As a result, the revolutionary government tried to implement a health policy that would emphasise the development of health services and security through disease prevention, illness treatment, and rehabilitation of those who had been affected. The government’s anti-six immunisation programme was another encouraging initiative. It might be seen as the best defence for the nation’s successful implementation of health policy programmes. The community received the vaccination for free, unlike during the imperial era. Thus, up to February 1987, 30% of the population in the province of Gojjam had received the immunisation (Ibid).

Financial issues either billed by the government or generated from the public support is a central element for health security outcomes and sustainable development goals (Mohanty & Behera, 2023; Padmaja & Kumar Behera, 2023). In this esteem the information in Figure 9 makes it possible to compare the financial and human resource advancements in the health sector in the province of Gojjam throughout the course of the last ten years of the monarchical and the first thirteen years of the Derg governments. While hospitals in the province did not expand during the pre-revolutionary ten years (1965–1974), the number of health centres and clinics rose by 3 and 21, respectively. In total, just a 24 percent institutional expansion was projected during these years. From 13 in 1965 to 37 in 1974, it rose. The technical and administrative staff both increased by 163 throughout the course of these ten years (technicians by 103 and administrative by 63). The regular, physical, and health tax budgets allocated and used during the final ten years of the monarchical regime totaled roughly 7,237,646.88 Ethiopian Birr (GPA, 1988).

Figure 9. Budget allocation for health institutions/1965 – 1988.

Source: Gojjam Province Health Prevention Office.

During the 14 years following the revolution (1975–1987), development at the three institutional levels of hospitals, health centres, and clinics increased by 2 (100%), 2 (28.6%), and 70 (250%) correspondingly. In terms of the development of technical and auxiliary human resources, it was justified to expand the number of technicians from 208 in 1975 to 745 in 1987 and the number of administrative personnel from 224 in 1975 to 473 in 1987. Acceptable primary facts in Figure 9 support an increase of 4,148,430.40 Ethiopian Birr in the budget allotted to the health institution of the Gojjam province during these formative years of the military regime. Because of this, it is encouraging to confirm that the Derge has had more institutional and infrastructure development than Ethiopia’s imperial era (Ibid).

According to the World Health Organisation (2006), the number of health care providers should be greater than the number of health management and support workers (administration personnel). In contrast, the historical development trends displayed in Table 11 substantiate that during the imperial government in 1965 and the Derg regime in 1976, the number of administrative staffs was bigger than the number of health specialists. This was one of the failings of both regimes in the health sector because, throughout the period under examination, the health security of the Gojjam people necessitated more health experts than administrative staffs (GPA, 1988; WHO, 2006).

Table 11. Budget allocation development trend for health institutions

Years	Total Budget Amount
1965	206679
1976	2222959.67
1988	7155027.74
Development Trends of Budget for Health Institutions’ in Gojjam from 1965 to 1988 or 23 years (+ or -)	+6948348.74

Source: Compiled from Gojjam Province Pre and Post Revolution 24 Years Health Performance Report.

Theodore Vestal claims that the Derg used more than half of the nation’s annual budget to pay the war and maintain military forces to put down the rebels (Theodore, 1985). Though this was the case, Tables 11 and 12 plainly illustrate that throughout the Derg administration in Gojjam, both the number of health professionals and the budget for medical institutions had increased.

Table 12. Health professional and administrative stuff development trend/1965 – 1988

Years	Health Institutions’ Personnel in Gojjam
	Health Professionals	Administrative staff
1965	108	150
1976	218	240
1988	760	504
Trends of Health Institutions’ Personnel in Gojjam from 1965 to 1988 or 23 years (+ or -)	+652	+354

Source: Compiled from Gojjam Province Pre and Post Revolution 24 Years Health Performance Report.

The primary goal of the zonal health offices was to reduce the number of health issues that prevail at the zonal level by strengthening health care procedures for communicable disease prevention. To give an example, the number of hospitals, health centres, health posts, and government and non-government pharmacies in the east Gojjam zone in 2006/07 was 2, 14, 131, and 58, respectively. The total number of professional and administrative staff members at the health institutions in the zone increased to 834. When this number of employees is broken down by field of expertise, there were 15 doctors, 11 health officers, 154 nurses, 61 laboratory technicians, 129 health sanitarians, and 441 administrative staffs. This results in a ratio of service of 1 doctor to 160,119 people, 1 health official to 218,344 people, 1 nurse to 15,596 people, and 1 laboratory technician to 39,373 people (EGAZ, 1999).

International communities have backed a number of Ethiopian health strategies that were created in conformity with the UN Sustainable Development Goals. A few of the health programmes that the government is achieving promising results in include universal health coverage, the elimination of preventable diseases in mothers and children, the reduction of the emergence of chronic diseases, and other community health disasters. Another impressive feat by the Ministry of Health is allocating significant funds to improve the coordination of healthcare systems. It takes a lot of effort to improve the infrastructure, manage the health system, and develop human resources—all of which have a big impact on the availability and standard of health security. Ethiopia is a top-ranking African nation when it comes to reducing maternal mortality, at least in recent memory. Primary healthcare is available to 99% of the population in 2014, and the under-five mortality rate has decreased from 123 per 1000 live births in 2005 to 59 per 1000 live births (Admasu, 2016).

The total area of the old awrajjas of Gojjam, Motta, Bichena, and Debre Markos was 13,917.61 square kilometres (8.5% of the Amhara regional state). It had 1,926,021 people living there in total, which was 13.7% of the region’s population, and density of 138.8 people per square kilometre, according to the 1999 demographic figure. The sub-region is made up of hot, temperate, cold, and frost zones make up of 27%, 53.7%, 17.5%, and 1.8% respectively. Commonly, the type of weather and geographical characteristics of an area are directly correlated with the prevalence, distribution, and rate of transmission of communicable diseases. The prevalence of malaria is seen to be highest in hot, temperate regions, while pandemic and girsha (recrudescence plague) are more prevalent in cold regions. According to the sub-region’s 1999 health indicators, 142 out of 1000 children in the province’s eastern administrative sub-region passed away before their first birthday. This data reveals a low level of health condition and services when compared to other regions in Amhara National Regional State. The area’s life expectancy was roughly 43.3%, which is lower than the Amhara region’s reported 50.8%. This further illustrates the existence of significant obstacles in the zone’s and the region’s health sectors. This year, there were 56 clinics, 18 health posts, 2 health centres, 1 hospital, 374 technical staff, and 412 support staff operating in the zone. The zone’s professional-population ratio fell below the global health standard. According to world health protection standard indicator, One doctor should care for 10,000 people, one nurse should care for 5,055 people, one health assistant should care for 1,000 people, and one bed should accommodate 2,000 patients. However, in the East Gojjam zone, 1 doctor, 1 nurse, 1 health assistant, and 1 bed were available to service 125,581, 2216, 10293, and 14,704 patients respectively. The zone’s health coverage was roughly 34.5% in 1999, and efforts were made to increase it to 37.63% the next year (in 2000). It makes sense that the area needs more health posts to achieve this goal (EGAZ, 1999).

2. Conclusion

Ethiopia has implemented necessary changes to its health policies and programmes in an effort to improve the population’s health standards. Expanding healthcare services and addressing the fundamental requirements of society’s health have both been attempted. Efforts have been made to guarantee that all social groups have equitable access to infrastructure and healthcare services. However, the sector’s success in Gojjam, like other regions of the nation, is hampered by a lacklustre infrastructure and an uneven distribution of medical facilities. Across the province, there was limited electric power infrastructure, lack of pure water and underdeveloped road networks. Health care and infrastructure developments differ significantly across urban and rural areas. Furthermore, the governments’ biggest weaknesses are their low health investment and the absence of a cohesive health policy for many years. This poor quality of health service at the regional, zonal, and local levels needs ongoing attention to be addressed in a comprehensive manner. One of the key elements that makes performance goals unreasonably difficult to achieve is financial instability. The magnificent duties in the health system are created with a small domestic budget but with benefactor support of kind donors.

Disclosure statement

No potential conflict of interest was reported by the author(s).