Forgotten Children: A Plan to Combat the Global Health Disparity of Street Children in Ethiopia

By Shalliah King

Author Note  

Correspondence concerning this article should be addressed to Shalliah King, Buntain
School of Nursing, Northwest University, 5520 108th Ave NE, Kirkland, WA 98033. Email: 
Shalliah.king15@northwestu.edu

Abstract
It is estimated that there are more than 100 million street children globally (Kanth & Harris, 2016). This disparity between children raised in stable homes and those forced to survive in often hostile conditions greatly impacts the health and wellbeing of children from all regions. This paper examines in depth the conditions that street children in Ethiopia must endure. Current efforts to resolve the homeless crisis among Ethiopian children have been met with limited success to date. The traditional, external non-profit organization has not been able to meet the complex needs of these children (van der Wolf, 2013).  Two in-country, indigenous organizations offer revolutionary practices that are proven highly effective in alleviating suffering within this population. Retrak’s focus is on the reintegration of street children with their families and communities, while Sunshine Philanthropy Group assists impoverished students in receiving education and becoming leaders in their communities. I propose that a partnership between these two organizations will create the best outcomes for street children in Ethiopia and should be the foundational premise for assisting street children around the globe.

Problem Statement
Street children are children from the ages of birth-18 years, who work or live on the street.  Street children are divided up into several categories. The first category includes those whose entire livelihood is on the street, both waking and sleeping; they abide and work in menial jobs to eke out a small wage entirely outside. This category is called “children of the street.” These children have no parental or adult supervision and are often left caring for their younger siblings (Appendix A).  Children who work on the street during the day yet have a family to come home to are called “Children part of the street” (Kanth & Harris, 2016). These families live in destitute poverty and often overcrowded conditions.  Children of the street spend the majority of their time outdoors, in many cases to avoid abusive home situations. Children who work on the street, however, do not attend school; instead, they make money to earn their keep at their home.  The types of jobs vary among countries; some “jobs” may include panhandling, selling handmade trinkets or family goods, selling drugs, and resorting to prostitution (Huijsmans, 2014). This makeshift employment is most commonly related to times of conflict in a country, which forces the family to live a nomadic lifestyle. Children support their families by finding daily shelter, gathering food, or working laborious jobs (Kanth & Harris, 2016). 
No matter what category, all street children are exposed to the elements and other harmful agents. This exposure puts them at high risk for developing infections such as Tuberculosis (TB), Human Immunodeficiency Virus (HIV), and other devastating infections (Kanth & Harris, 2016). They live in extreme poverty and are likely to be malnourished. As street children, they are in a vulnerable state, highly susceptible to abuse, both physical and sexual. Street children are known for their use of harmful drugs and involvement in gang and criminal activity (Huijsmans, 2014). Most street children are uneducated. These combined factors can lead to mental and physiological disorders. 
    The magnitude of this health epidemic is extensive. The current estimate of street children worldwide is greater than 100 million and has been on the rise (Kanth & Harris, 2016).  The highest density of street children is in Latin America, with 40 million children currently living or working on the street (Kanth & Harris, 2016). Street execution is the third-leading cause of death of children in Brazil. It is estimated that 14 children are executed daily throughout Brazil and Colombia (YXC Project, 2016).  Because of this high murder rate, street children are not expected to reach their 18th birthday (YXC Project, 2016).  The largest population of street children consists of 10- to 14-year-old boys. Boys are more likely to be sent off on their own, as compared to girls, who are more likely to be sold into sex trafficking or remain at home to help with the housework (Kanth & Harris, 2016). 
    The magnitude of street children stretches far beyond that of Latin America; it has become a global concern. A significant number of street children live on every inhabitable continent, such as Africa with 32 million; Asia-Pacific region with 25 million; Australia with 26,000; Eastern Europe with 166,000; India with 11 million; Latin America with 40 million, and North America with 2.5 million (Kanth & Harris, 2016; YXC Project, 2016; Wikipedia, 2016; Consortium for Street Children, 2016). See Appendix B for more on the global nature of the impact on street children.
    These population numbers can seem overwhelming. Focusing exclusively on the street children in Ethiopia may help to produce a solution to the issue in this country.  Over 150,000 street children live in Ethiopia, with 17,000 living within the capital city of Addis Ababa alone (YXC Project, 2016; van der Wolf, 2013).  According to recent studies, in Ethiopia more than 50 percent of Ethiopian street children lack access to shelter or adequate food (van der Wolf, 2013). Similar to street children around the world, Ethiopian street children are exposed to the elements, making them at high risk for injury and infection. Because of their limited access to food, many street children are malnourished. Children in Ethiopia leave home for the streets for many different reasons. A survey done by Retrak found that 55 percent of the children who left home said that their inability to attend school was their reason for leaving. (Corcoran & Wakia, 2013, p. 20). Of the children surveyed, 33 percent were asked by their parents to go to the capital and work to help pay for school, while 29 percent of children surveyed were being forced to work (Corcoran & Wakia, 2013, p. 20).  Many of the younger street children have been orphaned by parents’ deaths due to HIV/AIDS and, consequentially, are left alone to fend for themselves (Mannert, 2014). Arranged child marriage is a custom in Ethiopia. Because of this widespread cultural practice, many 10- to 14-year-old girls leave home to escape these marriages (Mannert, 2014). Children also leave home because of abuse from family members, both physical and sexual. A population of street children unique to Ethiopia is the children of the Mumbai soldiers. Since the last revolution in the 1900s, people associated with the Mumbai soldiers have been shunned by society. They are denied work or entrance into public places. These children receive some of this same hostility. Along with not having the resources to support their children, many end up on the street. Street children in Ethiopia are exposed to incredible violence, including murder (Mannert, 2014). 

Current Efforts
Several organizations have stepped up to meet the needs of street children in Ethiopia. The largest organization is Save the Children, which is an international organization that advocates for child justice. Save the Children started working with the Ethiopian government in the 1980s. Together they focus on two goals regarding street children. The first goal is changing the public perception of street children from criminals to lost children. Secondly, the group focuses on providing basic needs such as water during a recent drought (van der Wolf, 2013). 
In theory, this organization is highly effective, but according to Azeb Adefrsew, a researcher with Save the Children, 
[t]he limited services provided by local NGOs do not match what the kids see as their greatest needs. The children say that their major problem was shelter.  But the street children organizations were providing mainly food and other items, clothing and so on, Adefrsew explained. But the children were not satisfied with the services they were receiving. (van der Wolf, 2013).
It is hard to gauge their cultural competency when they are failing to meet their main goals. The local NGOs are failing to see what they need to change within their plan of care for a different population (Fountain, 2014). Save the Children is a very large organization; they do not always work with street children nor do they always work in Ethiopia. In this instance, this NGO is stretched too thin. Save the Children has not taken the time to adapt their program to the needs of the children in Ethiopia (Fountain, 2014). One positive point is that this charity works directly with the Ethiopian government. This gives them local support and some insight. 
Private and locally-owned organizations abound as well. Sunshine Philanthropy Foundation is a charity foundation run out of a major construction company that is owned and operated by local business owners Samuel and Fetlework Tafese (Appendix C).  The goals of Sunshine Philanthropy Foundation is to “create life-enhancing opportunity for [a] disadvantaged group of people” (Sunshine Investment Group, 2015). They do this in a number of ways, but their most productive method is their building of four schools for the impoverished children in Ethiopia. These schools are located in rural areas that lack Ethiopia’s national school systems. Schools are at no cost to the children, including books and uniforms. On top of the free education, children are given a monthly allowance of 200 birr, equivalent to 10 U.S. dollars (Sunshine Investment Group, 2015). This allowance helps children have time to come to school by eliminating the need to earn this pittance or to locate food to eat. For children whose families own livestock, it gives them funds to hire someone, so that they can afford to let their child go to school (Sunshine Investment Group, 2015). 
The Sunshine Investment Group program has been effective in gathering and retaining students. They now sponsor over 832 students, almost doubling in size annually (Sunshine Investment Group, 2015). One reason that the program has been so effective, is because it is locally owned and operated. Because of this, Sunshine’s schools are naturally more culturally aware. (Fountain, 2014). For example, Sunshine, knowing that free school is not free until one can pay for the time it takes out of the day, gives a monthly allowance to their students. The school also requires uniforms, which may seem extraneous to Westerners, but this custom is expected in all Ethiopian schools, so the neglible fee required makes sense.
  Being a culturally competent program does not mean that Sunshine schools operate without blind spots. My husband had the opportunity to visit one of the Sunshine Philanthropies schools; what he noted was that many of the children still went back to the street at night (Appendix D). Even with the monthly allowance, the children’s basic needs were not being met. This shortfall is understandable because the allowance is just intended to cover the missed work time during school hours, but not enough to live adequately. Sunshine Philanthropy is meeting its goal of educating children, but it is falling short in supporting their more basic needs. 
The final organization being considered reports that they offer a “beginning to end approach” to helping street children (Retrak, 2016). Retrak is involved within communities in Ethiopia, Uganda, and recently Brazil. They contend that family unity creates the best environment for a child to live in, and that a decent living environment is a right that should be upheld. Because of this conviction, Retrak focuses on reintegration of street children into their homes or their communities over institutionalization (Corcoran & Wakia, 2013). Retrak’s goal is to (whenever possible) reintegrate the children with their families, a foster family within the child’s community, or an independently stable living situation. Retrak’s program equips the children to be economically independent. They consistently achieve this goal through their multi-faceted process.
 The first step is outreach. In this phase, locally-trained volunteers go into the community and build trusting relationships with individual street children. Once trust is established, the children are invited to come to Retrak to socialize or to receive medical services from their free clinic. The medical clinic serves as a way to help recruit street children to the program as well as continued care for those enrolled in the program. Also at this phase when children may remain reticent about accepting outside help, emergency shelters are available for the children to use as well. Once the child decides they want to be a part of the program, the child gets paired individually with a local social worker who spends days with the child. This period provides the child’s baseline assessment to see what action Retrak should take. The children are placed on a scale to rate their level of deprivation in Retrak’s six categories of wellness, which are health, safety, emotional wellness, economic independence, education, and training. The categories of wellness are used as a way to assess a child’s needs and document their progress throughout their journey (Appendix E). 
Counseling is deeply integrated within Retrak’s program. Counseling is always available and is used to help the children learn to regain the ability to attach themselves to a caregiver and work through traumatic events, or to assist the family throughout the reintegration process. Formal education and job training are done on the Retrak campus, as a way to get children into a learning environment again. It is necessary to help the children regain basic skills and return them to a learning level that will be sufficient for the public school system. Once a child’s level of wellness has advanced to a stable, healthy state according to their scores, the reintegration process can begin. Reintegration to the child’s own family is always investigated before attempted. This is determined by the family’s ability to meet all the areas of wellness for the child. Ample amounts of counseling and social work are used to assist the family in this process. If it is unsafe for a child to return home, foster parents within the child’s community are found. Lastly, it is a goal that the eldest children become economically independent. The reintegration process involves the community and utilizes many forms of resources and support, including checkups from Retrak. This organization is also involved in legal child protection, by working within communities, with law enforcement, and alongside the country’s legal system—all bringing attention back to the protection of the individual child’s rights. Most importantly, Retrak works to prevent children from returning to the streets. This prevention is accomplished through giving counseling services to at-risk families and fostering a relationship with the children. 
The Retrak program has been wildly successful. The issue of street children is complex, yet Retrak has been able to successfully reintegrate 1,200 children with a 70 percent retention rate after six months. This program’s achievements have now been endorsed by UNICEF as the research behind the new Standard Operating Procedure (Corcoran & Wakia, 2013, p. 7). In all six fields of wellness, the children showed improvements in their deprived areas compared to when they first entered the program (Appendix F). In Retrak’s yearly outcome review for Ethiopia, their biggest struggle was keeping the children in school after they became reintegrated with their families. 
Compared to other aid organizations that are helping street children in Ethiopia, Retrak has the most conclusive, holistic, and culturally competent care. Their effectiveness is seen from the very beginning in how they form trusting relationships. To an Ethiopian, to be asked a question is to be cared for (Chiatti, 2016). Ethiopians want to know that they have been heard, requiring that others listen for longer periods of time than what Western society would usually dictate. Retrak intuits this need and puts it into practice with the use of the one-on-one social workers talking with the street child over the course of four full days (Corcoran & Wakia, 2013). Retrak strongly believes in the power of the family unit and deinstitutionalization of children—affirming the belief that children need to grow up in their own communities.

Recommendation
Upon review, there is great work already taking place in Ethiopia by Retrak and Sunshine Philanthropy Group. Retrak is successful at getting children off the streets and back into a steady environment in their community, while Sunshine is concerned with educating children. Together, Retrak and Sunshine, have created sustainable, effective, and culturally competent systems for addressing the needs of street children. Because of these two significant organizations, no need to create a new entity is warranted. (Fountain, 2014).  Partnering together can improve upon the weak points of the individual organizations through the strength of the other.   
According to Retrak’s latest outcome review, the largest deficiency of children, is their remaining in school after reintegration into their communities (Corcoran & Wakia, 2013). What is the root of this problem? Children report from both Retrak and Sunshine Philanthropy Group that they are excited to learn and understand that education is the key to their future (Retrak, 2016; Sunshine Investment Group, 2015). Education is highly valued by Ethiopians, to the point that society considers the uneducated person worthless (Chiatti, 2016). The desire to be educated is not the problem. 
The basic problem contributing to the street children epidemic stems from inability to pay for school. Research shows that the number one reason a child turns to the streets is that they can no longer afford school (Corcoran & Wakia, 2013). The second-leading cause is that the child’s parents encouraged them to leave home and go to Addis Ababa, to find work in order to pay for school. Many of the children who leave the city end up on the street and never return home. There is a definite increase in the incidence of recent street children ages 14 and above.  This is related to the Ethiopian school system. Secondary school starts when a child becomes 14 years old, equivalent to starting high school in the United States. Secondary school is not paid for by the Ethiopian government like primary school is. This creates a dilemma for poor families and their eldest children. In many cases, children are forced to work to pay for their tuition. 
 On the other hand, Sunshine Philanthropy Group uses a proven model to get street children into secondary school. Sunshine Philanthropy can reach out to the children who are graduates of Retrak. In this partnership, Retrak would alert Sunshine Philanthropy Group of a new child placement. If the child’s home was near one of the four existing schools, then the child would be guaranteed a place in the school program. If the child stays more than a 20-minute walk away from one these schools, the student will need to attend school in their own community. Studies show that if students have to walk more than 20 minutes, they will not attend school (Corcoran & Wakia, 2013).  Sunshine Philanthropy Group would pay for the child’s tuition and supplies along with the 200 birr monthly allowance at their community’s school, just as if the child was attending Sunshine’s institution. This proven method of getting street children into school, will increase Retrak’s school retention rate and provide the students with skills for the future. 
 In return, Retrak will reach out to Sunshine Philanthropy Group’s school populations who are living on the streets. By doing this, Sunshine Philanthropy Group’s students will have the opportunity to reintegrate with their families, giving them a stable living environment where they can thrive. This partnership uses two organizations that are already established and effective. These organizations are operated by locals and meet the needs of the children in their own communities. Through Retrak’s and Sunshine’s working together, they are removing their weaknesses by combining their strengths.  
Evaluation will be integrated into the programs’ existing procedures. Retrak will continue to monitor school attendance during their check-in visits, at the three- month-, six-month-, and one-year checkpoints. At the same time, Sunshine Philanthropy Group teachers will document school attendance, and will alert Retrak if a child misses more than one week of school. Teachers will also inform Retrak of children who are currently living on the streets, so that Retrak can intervene. This data will be compiled to evaluate the effectiveness of the particular interventions intended to meet the following goals. First, school attendance of Retrak graduates will increase by 70 percent at their six-month checkup. Second, Retrak will successfully reintegrate 70 percent of the street children attending school at Sunshine Philosophy Group in one year’s time. These percentages are consistent with Retrak’s data on retention rates that form the current standard for UNICEF.

Appendix A
A young street child taking care of his younger sibling in India (Holley, 2012). 

Appendix B

A figure of current data about street children around the world (Consortium for Street Children, 2016). 

Appendix C

Children from one of Sunshine Philanthropy Group’s schools with its founders, Mr. Samuel Tafese and his wife, Mrs. Fetlework Elala (Sunshine Investment Group, 2015).

Appendix D

This is a picture taken of my husband Kevin in 2009 in Ethiopia. Panagiotis Hatziandreas, was an Ethiopian faculty member of Kevin’s, at Cascadia Community College. Hatziandreas had a heart for learning and wanted to bring that opportunity to his home country. Kevin was the student body president at the time. He took Hatziandres’s passion and implemented it. Kevin started a textbook drive and generated over 2,000 lbs. of textbooks for the children in just two months. Kevin was sent to Ethiopia to deliver the books. He took the books to a school funded by a local business owner allied with the Sunshine Philanthropy Group that provides free education and a monthly allowance for the extremely impoverished. 

Appendix E

Table 1b: Child Status Index Domain Goals and Sources (Corcoran & Wakia, 2013, p. 13).
This is an example of how a child’s deficiencies are rated in each domain. This chart shows the criteria for the physiological, psychological, and educational domains (Corcoran & Wakia, 2013). This scoring system is used to help assess the child’s wellbeing throughout the program, in order to best assist and document their personal situation.  

Appendix F
Figure 3: Spider plots showing the changes in wellbeing (Corcoran & Wakia, 2013, p. 20)
This graph represents children’s wellbeing in each of the six states of wellness and their related subsections (Corcoran & Wakia, 2013). Clearly, as a whole, the group moved from a place of great deprivation to a state of wellbeing. 

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