Sometimes restaurants, like the kind seen above on Ras Leoulseged street in Mexico, lock up toilets unless a customer specifically requests to use them.
It was only last week Monday that Yared Alemayehu returned to his job as a cab driver near stadium's taxi terminal after a week and a half of bed rest. He had been sick with typhoid during this time, after having eaten a contaminated beef sandwich at one of the restaurants surrounding the terminal.
Having breakfast outside of his home is not Yared's daily routine. Unlike his friends and colleagues who eat all three of their meals at restaurants, the 29 year old cab driver is selective about where his meals come from.
It is only during lunch time that Yared eats out, usually at the restaurants and café's near stadium area, because he fears he may lose business if he commutes home to Addisu Gebeya, Arada district where he lives with his mother.
Price was the primary concern when eating out for Yared.
"I do not eat at places where food would cost more than 30 Br," he says.
But expenses turned out to be higher than expected when he got sick.
The breakfast that made him sick had cost him 15 Br, but medical expenses were around 500Br.In addition there was a loss of income from the days he spent without working.
In the four years he had worked as a driver, two on a minibus taxi, Yared had noticed many things amiss in terms of sanitation at the restaurants and café's he visits.
"I sometimes find fingernail pieces and hair stuck in my food," he recalled.
Usually when he finds something wrong he changes restaurants. But after his illness he has avoided going to any of them altogether.
"Now I stick to packed foods at supermarkets, or skip lunch all together because I do not want to be sick again," he told Fortune.
In his opinion some of the restaurants in town should be shut down permanently because they are a hazard to health.
"I think supervision is sporadic when it comes to these cafeterias. Sometimes you notice the city government start a campaign to keep them in check and many will be shut down as a result. But these actions are irregular," he tells Fortune. "Customers should be protected by stringent laws that are regularly enforced."
The laws that Yared talks of already exist in several of the city's regulations and a small manual full of codes with detailed sanitary and environmental health requirements for hotels, food and drinks establishments and cottage industries. A clear structure is also set up all the way down to Wereda levels to enforce these rules.
However, the total number of staff deployed to regulate the sector falls far behind the number of eating and drinking establishments popping up almost daily in the sprawling city. There are currently 39,320 food establishments including hotels, restaurants supermarkets, bakeries, oil refineries, millers and many others, in the capital. The bureau, however, offers only 256 environmental health experts to supervise these establishments.
These experts also have the additional job of inspecting the 10,132 health related institutions like gymnasiums, nursing homes, barber shops, malls and different schools, and 5,425 industries, widening the ratio to 298 experts for 54,877 institutions in Addis Abeba.
Not only are these experts tasked with certifying the institutions when the latter renew their business licenses at the start of the year, but they also have to do inspections on all the establishments each quarter of the year. The Bureau has six officials, at the head office, an additional six officials at each district and two experts at each of the 116 weredas available.
At the Wereda level there are 23,932 food establishments, 9000 institutions that give health related services and 3100 cottage industries. This means an environmental health expert at a Wereda would have to cover 155 institutions and supervise them four times a year, on average. For districts an expert would have to cover 274 institutions and at the bureau level 401 institutions.
The deficit in human resources, creates a lag and some institutions go by uninspected, some environmental health officials complain.
At the back of the taxi terminal where Yared works at, there are a number of restaurants most of which serve meat and beer. One of these restaurants, located next to the offices that offer translation services, is known for taking off the toilet door, when customers fill up the restaurants.
Anybody willing to use the toilet is denied privacy and can be spotted by someone who is using the sink to wash their hands.
"We do this because we do not want customers to stay long inside," explains the manager indifferently.
To him this is the appropriate action to take, because they could not manage or control the number of people using the bathrooms or oversee the cleanliness.
But according to the 120 page manual published by the Addis Abeba Health Bureau, this is an infraction and can bring a 100 Br fine and correction.
Not only is an eating establishment with a bar supposed to provide access to toilet facilities it should also provide separate ones for men and women according to the book. However, as inspections come by very sporadically, the restaurant has not so far incurred punishment.
Surprisingly, the current capacity at the health bureau is not something that was set up a long time ago, and failed to be revised as the number of food establishments grew. Instead it is the result of a restructuring that had come out of a business process re-engineering (BPR) in January 2012, aiming at devolving the task down to the Wereda level and scaling up capacity.
The section had been prone to such restructuring even from the beginning. Prior to 2004 the Addis Ababa Health Bureau had two directorates to handle inspections. Licensing and supervision of health institutions and health professionals fell under the Health Services Directorate, whereas the current Environmental Health sub process was under the Hygiene Directorate.
In 2004 the Hygiene Directorate was dissolved and transferred to the Addis Abeba city Code Enforcement Service.
It later came back to the mandate of the city in 2009, and was organized as the Environmental Health sub process under a Health Promotion and Disease Prevention core process. This sub process had six officials at the bureau level, and six officials in each district.
However, these officials worked more on creating awareness about sanitation in relation to disease prevention, and inspection and regulatory services had taken a backseat.
Especially after the Addis Abeba Code Enforcement Service dissolved in 2007/08, there was a gap created, according to Woldesemayat Tesfaselassie, Result Based Monitoring, Evaluation and Award sub process leader at the bureau who is involved in the restructuring process.
At the same time the number of establishments that need such supervision has been increasing at a fast pace. One of the things that contributed to such a high number is service and cottage industry companies organized under the Small and Micro Enterprises (SME), according to Woldesemayat.
The bureau found it necessary to restart regulation and supervision activities after this. The January 2012 revision was conducted for this purpose. Aside from increasing the environmental health's sub process capacity by 232 more employees, the revision also brought it under the health and health related services and resources supervision core process.
This core process also contains the health facilities and professionals regulatory sub process and the health facilities and professional licensing sub process, and thus brings all the regulatory and supervisory processes under one department.
Since the restructuring only started being implemented in late March 2012, most districts are still in the process of hiring experts at the woreda level and are not yet working at full capacity.
Arada District which boasts the largest number of eating establishments and cottage industries numbering around 1,800, including only those that are inspected at District level, according to district officials, only has two experts at the district level and has only hired a single expert at 10 of its woreda offices.
The two experts only started working in March 2012, and have so far not carried out a single inspection. Instead they have been working on certifying food establishments
The process started on July 8, 2012, and was completed by November 9, 2012. A business will come to the district and pay a 50 Br fee. Abraham Amdeberhan and Yonas Legesse, the two people that are the current environmental experts at the district, usually spend around 30 minutes to license a business.
"If for example we are at a restaurant, we check if all employees have a health checkup, uniforms, and hair net. We also check if the restaurant has a bathroom and a sink, the floors and also the way they store food," Abraham told Fortune.
Although they have the Addis Abeba City Bureau Manual in their office, they say that it is sometimes impractical to demand all the requirements be met immediately as there are some constraints.
The urinal for men found in a restaurant in Arada district is in close proximity to both the ladies room and the kitchen, but fails to use appropriate partitions.
The manager of the restaurant near stadium terminal, also claims the same thing. The toilet at his restaurant is directly at the back of the kitchen. "Because of our limited space, we cannot have the necessary separation between the two," he told Fortune. "We also do not have two bathrooms for men and women for the same reason."
The restaurant has already renewed its license for this year, without a problem.
The expert at their district has overlooked this problem and the restaurant has been able to get licensed again.
The point is to slowly get the people to have a culture of maintaining a hygienic environment, not to shut them down, according to Abraham. Both Yonas and Abraham admit that it had been difficult to conduct their jobs appropriately.
"There is a shortage of experts, lack of equipments, and lack of transportation when canvassing large areas," Yonas told Fortune.
When inspecting and certifying restaurants, it is mostly limited to observation. The only time they do laboratory checks is if they get a tip from customers about contamination, according to Yonas.The bureau takes such samples to the regional laboratory or to the Ethiopian Health and Nutrition Research Institute (EHNRI) also known as Pasteur.
Simple instruments to identify adultration like lactometers for milk have very limited supply and may only be found at the bureau.
Despite these problems, however, Yonas and Abraham are optimistic that things are going to get better. After discovering that the January 2012 BPR has been rendered ineffective because of capacity shortage, the Addis Abeba Health Bureau had launched a study for yet another restructure in June of the same year.
The study proposed removing the Environmental Health sub process along with the Health Facilities and Professionals Regulatory sub process and the Health Facilities and Professional Licensing sub process out of the mandate of the bureau and building a new institution.
The new institution named Addis Abeba Food Medicine and Health Care and Administration and Control Authority, will be under the federal authority of the same name, although formerly it was known as the Drugs Administration and Control Authority (DACA).
The Addis Abeba City council approved the establishment of such an institution soon after. The institution is to have a budget of 12 million Br, according to officials from the health bureau. This is much more than the 1.25 million Br the three sub processes have including the environmental health department were allocated inside the bureau.
There will also be a scale up of manpower, according to Woldesemayat. The institute will have a main office, five branches which will cover two districts each and 29 stations covering four woredas. There will be 16 experts organized into five case teams at the head office, 18 experts at each of the five stations and 12 experts at each of the 29 stations.
The environmental health section by itself will have 454 employees in the environmental health section. "The new restructuring is bound to work as there will be a lot of expertise gathered in one place and we have scaled up our capacity," Woldesemayat told Fortune optimistically.
Even locked up toilets can still have poor sanitary conditions, including a malfunctioning flushing system.
Despite the scale up, however, the ratio between the number of establishments will still be wide, with one expert having to cover 138 of them. But according to Woldesemayet this number is based on research, whereby an expert is expected to work for 1520 hours within the year. With the number of staff available, one establishment is allocated 13 hours, which will be enough for four inspections and a certification throughout the year.
"The institute will have a full staff unlike the previous structuring when the hiring process at the woreda level had not been completed yet." he told Fortune.
But the door is still open to add more staff if the need arises in the future, according to him.
Alemayehu Negash, previous head of the environmental health sub process at the bureau agrees. Previous reshuffles never took off at full capacity, so it should be better to implement the research and see if it goes smoothly, according to him.
He also appreciated the recent restructuring plans since working with limited resources had affected public health during his thirty year service at the bureau.
With the increase of food serving and producing establishments, illness that comes from food contamination and poor hygiene, like dysentery and upper respiratory diseases were becoming a staple on the list of top 10 prevalent diseases in the city, according to Alemayehu, who is now the manager of Tirunesh Beijing general hospital. "The new institution can be a great help in curbing this trend," he told Fortune.
Yared, the cab driver however remains unconvinced. "I have learnt my lesson. I will keep eating at home, as much as I can," he stated.