Health in Ethiopia

Health in Ethiopia has improved markedly in the last decade, with government leadership playing a key role in mobilizing resources and ensuring that they are used effectively. A central feature of the sector is the priority given to the Health Extension Program, which delivers cost-effective basic services that enhance equity and provide care to millions of women, men and children. Ethiopia has demonstrated that low-income countries can achieve improvements in health and access to services if policies, programmes and strategies are underpinned by ingenuity, innovativeness, political will and sustained commitment at all levels. An example is the development and rapid implementation of the Ethiopian Health Extension Programme.

Overview

Ethiopia is the second most populous country in sub-Saharan Africa, with a population of over 94.1 million people. The country introduced a federal government structure in 1994 composed of nine Regional States: Afar, Amhara, Oromia, Somali, Benishangul Gumuz, Southern Nations Nationalities and Peoples Region (SNNPR), Gambela, Tigray and Harrari and two city Administrations (Addis Ababa and Dire Dawa). The Regional States are administratively divided into 78 Zones and 710 Woredas.

Ethiopia experiences a heavy burden of disease mainly attributed to communicable infectious diseases and nutritional deficiencies. Shortage and high turnover of human resource and inadequacy of essential drugs and supplies have also contributed to the burden. However, there has been encouraging improvements in the coverage and utilization of the health service over the periods of implementation of Health Sector Development Plan (HSDP).

HSDP constitutes the health chapter of the national poverty reduction strategy and aims to increase immunization coverage and decrease under-five mortality at large. The health service currently reaches about 72% of the population and The Federal Ministry of Health aims to reach 85% of the population by 2009 through the Health Extension Program (HEP) [1]. The HEP is designed to deliver health promotion, immunization and other disease prevention measures along with a limited number of high-impact curative interventions.

Geography and Climate

Ethiopia is Africa’s oldest independent country. It is the tenth largest country in Africa, covering 1,104,300 square kilometers (with 1 million km² land area and 104,300 km² water) and is the major constituent of the landmass known as the Horn of Africa. It is bordered on the north and northeast by Eritrea, on the east by Djibouti and Somalia, on the south by Kenya, and on the west and southwest by Sudan. Its geographical coordinates are between 8 00 N and 38 00 E. Ethiopia is a country with great geographical diversity and its topography shows a variety of contrasts ranging from high peaks of 4,550m above sea level to a low depression of 110m below sea level. More than half of the country lies above 1,500 meters. The predominant climate type is tropical monsoon, with temperate climate on the plateau and hot in the lowlands. There are topographic-induced climatic variations broadly categorized into three: the “Kolla”, or hot lowlands, below approximately 1,500 meters, the “Wayna Degas” at 1,500-2,400 meters and the “Dega” or cool temperate highlands above 2,400 meters.

Socio-economic Situation

The Government of Ethiopia follows a market–based and agricultural led industrialization economic policy for the development and management of the economy. There have been a number of policy initiatives and measures taken in these directions which included privatization of state enterprises and rationalization of government regulation which the process is still ongoing. Ethiopia's economy depends heavily on the agricultural sector. Agriculture accounts for 83.4% of the labour force, about 43.2% of the Gross Domestic Product (GDP) and 80% of exports . The regular droughts combined with poor cultivation practices, make Ethiopia's economy very vulnerable to climatic changes. Despite these obvious challenges, Ethiopia has shown an impressive economic growth over the last seven years, although the per capita of 235 USD remain below the Sub Saharan average. But, Poverty Head Count Index has declined from the 1996 level of 45.5% to 32.7% in 2007/08. The reduction in poverty has been more pronounced in rural areas than in urban areas. The overall economic dependency ratio for the country is estimated at 93 dependents per 100 persons in the working age group of 15–64 years. During the SDPRP I period (2002/03 - 2004/05), real GDP grew on average by about 5 percent per annum. However, during the first three years of PASDEP period the country registered an average of double digit economic growth of 11.8% per annum with steady and strong positive performance in real GDP . This steady growth marks a significant progress, not only compared to the 7% annual growth target that would be required to meet the MDGs, but also to realize Ethiopia’s objective to become a middle-income country in the next two decades. Another important feature of the economic reform in Ethiopia is equal opportunity for women in the participation of the economic development of the country which is enshrined in the constitution. The Ethiopian Constitution recognizes the principle of equality of access to economic opportunities, employment and property ownership for women. Following this, the government has formulated a national gender policy, which recognizes equality between the sexes and sets up mechanisms for the improvement of women’s conditions, such as the establishment of the Ministry of Women’s Affairs. The main strategies employed to implement the national policy include gender mainstreaming in sector and development programs, advocacy and capacity-building initiatives.

Educational Status

The intimate linkage between health and education has been firmly established in a number of studies which could potentially reinforce each other towards a rapid socio-economic development of a country, especially in developing economies. Education is one of the most critical variables in epidemiological and health service research in Ethiopia and illiteracy is usually associated with high risk and low health seeking behavior. In addition to a wide range of disease and child mortality associated with illiteracy or under education, unfortunately HIV/AIDS infection is disproportionately high in out of school youth. The general level of education in a country becomes a marker significantly influencing the spread of disease, shaping the health seeking behavior of individuals and communities including the utilization of modern health care service. Despite major progresses in Education, the literacy status of the population of Ethiopia is still low. The total adult literacy rate (whose age is above 15 who can read and write) is 36% (62% for male and 39% for female). According to MOE 2010 Progress Report, there has been an increase in the gross enrollment ratio from 2.2% in 2004/05 to 4.2% in 2008/09. The gross enrollment ratio in primary school has risen from 32% in 1990/91 to over 91% in 2006/07, giving a male to female proportion of 55.9% and 44.1%, respectively. This indicates that the gap between school boys and girls has continued to decline although still exist regional disparities in the primary GER. During the period 2004/05 to 2008/09, the overall enrollments as well as the intake capacity of the higher education institutions have significantly increased from 138,199 to 304,371, resulting in a higher education GER increase from 3.6% in 2004/05 to 4.6% in 2008/09. This figure puts Ethiopia achieving close to the African average in GER of 6% in 2007/08.

Health Status

The major health problems of the country remain largely preventable communicable diseases and nutritional disorders. Despite major progresses have been made to improve the health status of the population in the last one and half decades, Ethiopia’s population still face a high rate of morbidity and mortality and the health status remains relatively poor. Figures on vital health indicators from DHS 2005 show a life expectancy of 54 years (53.4 years for male and 55.4 for female), and an IMR of 77/1000. Under-five mortality rate has been reduced to 101/1000 in 2010 and more than 90% of child deaths are due to pneumonia, diarrhea, malaria, neonatal problems, malnutrition and HIV/AIDS, and often a combination of these conditions. These are very high levels, though there has been a gradual decline in these rates during the past 15 years. In terms of women health, MMR has declined to 590/100,000 though it still remains to be among the highest . The major causes of maternal death are obstructed/prolonged labor (13%), ruptured uterus (12%), severe pre-eclampsia/ eclampsia (11%) and malaria (9%) . Moreover, 6% of all maternal deaths were attributable to complications from abortion. Shortage of skilled midwives, weak referral system at health centre levels, lack of inadequate availability of BEmONC and CEmONC equipment, and under financing of the service were identified as major supply side constraints that hindered progress. On the demand side, cultural norms and societal emotional support bestowed to mothers, distance to functioning health centers and financial barrier were found to be the major causes.

Following changes of Government in 1991, the Government produced the health policy which was the first of its kind in the country and was among a number of political and socio-economic transformation measures that were put in place. The translation of the health policy was followed by the formulation of four consecutive phases of comprehensive Health Sector Development Plans (HSDPs), the first phase of which was implemented starting in 1996/97. Both of the policy formulation as well as the development of the first HSDP have been the result of critical reviews and scrutiny of the nature, magnitude and root causes of the prevailing health problems of the country and the broader awareness of the newly emerging health problems in the country.

The core elements of the health policy are democratization and decentralization of the health care system, development of the preventive, promotive and curative components of health care, assurance of accessibility of health care for all segments of the population and the promotion of private sector and NGOs participation in the health sector. Since the development of HSDP I which also paved the way for the subsequent HSDP II and HSDP III, the Federal Ministry of Health has formulated and implemented a number of policies and strategies that afforded an effective framework for improving health in the country including the recent addition of maternal and neonatal health. This include implementations of far reaching and focused strategies such as Making Pregnancy Safer (2000), Reproductive Health Strategy (2006), Adolescent and Youth Reproductive Health Strategy (2006) and the Revised Abortion Law (2005). Others include strategies on free service for key maternal and child health services (Health Care Financing Strategy), the training and deployment of new health workforce called all female HEWs for the institutionalization of the community health care services including clean and safe delivery at HP level, and deployment of HOs with MSc training in skills of Integrated Emergency Obstetric and Surgery (IEOS). In addition, the establishment of the MDG Performance Package Fund and the priority given to maternal health therein is expected to mobilize the much required additional funding opportunities.

Health System Organisation

The recently implemented BPR of the health sector has introduced a three-tier health care delivery system which is characterized by a first level of a Woreda/District health system comprising a primary hospital (with population coverage of 60,000-100,000 people), health centers (1/15,000-25,000 population) and their satellite Health Posts (1/3,000-5,000 population) that are connected to each other by a referral system. A Primary Hospital, Health center and health posts form a Primary health care unit (PHCU) with each health center having five satellite health posts. The second level in the tier is a General Hospital with population coverage of 1-1.5 million people; and the third a Specialized Hospital that covers population of 3.5-5 million. The Ethiopian Health care System is augmented by the rapid expansion of the private for profit and NGOs sector playing significant role in boosting the health service coverage and utilization thus enhancing the public/private/NGOs partnership in the delivery of health care services in the country. Offices at different levels of the health sector from the Federal Ministry of Health to Regional Health Bureaus and Woreda Health Offices share decision making processes, decision powers, duties and responsibilities. The FMOH and the RHBs focus more on policy matters and technical support while Woreda Health Offices have basic roles of managing and coordinating the operation of a district health system under their jurisdiction. Regions and districts have Regional Health Bureaus (RHB) and district health offices, respectively for the management of public health services at their levels. The devolution of power to regional governments has resulted in the shifting of decision making for public service deliveries from the center to largely under the authority of the regions and down to the district level.

Overview of HSDP I, II and III

The three consecutive HSDPs that have been implemented since 1997/98 are reviewed here with respect to achievements, implementation challenges and lesson learned and doable recommendations for further health sector planning. Records from the implementation of HSDP I and II showed encouraging improvements both in the health service coverage as well as in the utilization of services at all levels of the health care system of Ethiopia. In terms of physical health facilities, the improvements have been the construction of additional 3,135 New Health Posts reaching 2899 in 2003/04 . This was from an insubstantial of 76 HPs in 1996/97. The number of Health Centers has also increased from the 1996/07 level of 243 to 519 in 2003/04. Similarly the number of Hospitals has increased from 87 in 1996/97 to 126 in 2003/04. There have been also significant increases in the availability of health workers of all professional categories among which the increase in the number of Nurses and Health officers have been most remarkable. The end phase in the implementation of HSDP II saw the development of new strategic initiative that brought in the inception, successful piloting, and the launching of HEP at the national level with the aim of universal PHC coverage and institutionalization of the community health services at health post level in the midst of villages. The program has required the training and deployment of all female HEWs, and by the conclusion of HSDP II, there have been 2,800 trained and deployed HEWs with 7,138 already enrolled for training in 2004/5 .

In terms of progresses in the implementation of priority health programs including prevention and control of infectious communicable diseases such as HIV/AIDS, Malaria and TB, the recorded achievement showed that there have been notable sign of improvements during these periods, especially family planning services such as contraceptive coverage which has shown a remarkable leap from the 1996/97 level of 4% to 25% in 2004/05 . The following sections provide detailed account of performance of HSDP III in priority programs and health system issues. Health service Delivery and quality of care.

Family Health Service

Maternal Newborn, Child, and Adolescent Health

The major targets for achievement in family health services under HSDP III were: to increase family planning service coverage (CPR) from 25% to 60%, institutional deliveries attended by skilled health workers from 12% to 32%, provision of BEmONC in 100% of HCs, CEmONC in 87% of the hospitals and 20% of the HCs. Other targets were increasing DPT3/Penta3 coverage from 70% to 85%, proportion of fully immunized children from 45% to 80%, expansion of IMNCI implementation from 36% to 90% of Health Facilities, and CIMNCI implementation from 12% to 80% of the districts in the country.

In order to achieve these targets, there have been substantial investments in the procurement of equipment for clean delivery and B/CEmONC services. Accelerated training of health officers has been initiated and around 5,000 were enrolled, of which about 70% were graduated and deployed. Masters level program in Emergency Surgery and Obstetrics for health officers has been introduced and the first batch has already graduated and deployed.. The inadequacy of the pre-service training of HEWs in MCH has been recognized, and a one-month in-service training has been designed and implemented in all regions. Key pilot initiatives such as Making Pregnancy Safer have been evaluated. Subsequently, Antenatal care coverage has reached 68%, Post natal care 34% and family planning acceptors coverage as measured by the contraceptive acceptance rate has reached 56.2% in 2008/09. . Clean and safe delivery by HEW has increased to 10.8%. There has been an increase in the percentage of deliveries assisted by skilled health personnel reaching 18.4% from the baseline of 12% with a wide variation among regions. Regional disaggregation has also shown a performance ranging from as low as 5.6% in Benishangul Gumuz region to 62.5% in Addis Ababa, while five regions (Tigray, SNNPR, Harari, Addis Ababa, and Dire Dawa) performed above the national average .

Fig 2.1, Delivery by Skilled Birth Attendants in regions, 2008/09 Furthermore; Out of the total of 111 hospitals on which EmONC assessment was conducted in 2007, 51% provided comprehensive EmONC, 14% of the hospitals provided basic emergency obstetric services while 34% of the hospitals partially function on EmONC . Similarly, a total of 684 health centers provided obstetric and neonatal services of which only one health center provided comprehensive EmONC, nine Basic and 674 provided partial EmONC services which are far behind the targets set in HSDP III.

Figure 2.2 Trend in Immunization Coverage, EFY 1997-2001 One year before the termination of HSDP III, Pentavalent immunization coverage has reached 82% and measles immunization coverage 76.6%, while the percentage of fully immunized children has reached 65.5% . In this regard, HSDP III target has been already achieved for measles immunization coverage and nearly so for the percentage of fully immunized children. Similarly, five regions (Addis Ababa, Harari, Amhara, Tigray, and SNNP) have persistently showed better achievements than the national average for the last three consecutive years while, Gambella, Afar and Somali regions seem to be far less than the average performing half below the targets.

Fig 2.3, Immunization coverage across regions, 2008/09 The EmONC Assessment Report illustrates that almost half of the facilities did not provide newborn resuscitation and only 80% provided parenteral antibiotics. Lack of equipments such as “Ambu-bags” and masks, and shortage of skilled workers have been identified as the major constraint for such low performance. According to FMOH 2008/09 administrative report, only 930 health centers (68.2) and 81 hospitals (72.9%) were providing IMNCI while 215 Woredas in ten regions provided Community IMNCI interventions, all short of achieving the planned targets.. Further more; encouraging progress was made in terms of developing strategies, guidelines, and standards for Adolescent and youth reproductive health. Minimum service delivery packages for youth friendly reproductive health service was prepared and health care providers were trained on areas of youth friendly services.

Prevention and Control of Diseases

The progress in prevention and control of malaria, HIV/AIDS, Tuberculosis and leprosy, Blindness and Onchocerciasis is described below.

• Malaria and Other Vector borne Diseases Prevention and Control

Malaria prevention and control is the major priority program that has enjoyed over the years utmost government commitment and considerable attention from the health policy makers since the beginning of HSDP I. The overall strategies to substantially reduce the overall burden of morbidity and case fatality rates remained: comprehensive approach to vector control, early diagnosis and prompt treatment and, surveillance, prevention and rapid management of malaria epidemics when and where it occurs. The major targets for HSDP III in malaria prevention and control were: to distribute 20 million ITNs to households in malarious areas, increase the proportion of under 5 children utilizing ITNs from 2% to 63%; and pregnant women utilizing ITNs from 2% to 49%, reduction in the malaria morbidity from 22% to 10% and malaria case fatality rate in age groups of 5 years and above from 4.5% to 2% and in the under 5 children from 5% to 2%.

The achievement so far show that distribution of ITNs has successfully reached around 22.2 million in 2008/09 that makes Ethiopia the third highest bed net coverage achiever in Sub-Saharan Africa after Togo and Sierra Leone. The major proportion of these ITNs are long lasting insecticide treated nets (LLITN) and have been distributed to communities including in hard to reach areas through health facilities, enhanced outreach strategy, and through especial community campaigns. The most effective anti-malarial drug, artemether-lumefantrine, has been introduced nationwide as the first line treatment for Plasmodium falciparum malaria. Access to parasitological diagnosis of malaria has been extended to the peripheral health facilities including HPs through the introduction of rapid diagnostic tests. Indoor residual spraying as vector control measures for the prevention of malaria epidemics has continued to be put into operation. It is important to note that much of the scaling-up in the prevention and control of malaria was mainly community-based, and in particular, basic diagnosis and treatment have been carried out by the HEWs at health post or during house to house visits. A recent malaria assessment in the country has shown that there has been a 54% and 55% reduction in malaria admission and death, respectively as compared to baseline period of 2001-2004. In-patient case fatality rate of malaria in age group >5 years is 3.3%, while the case fatality rate of malaria in age group <5 is 4.5% . Households that own at least one ITN in areas below 2,000m were 65.6% and at least one LLIN were 65.3% .. Nationally, 55.7% of the households own at least one ITN of any kind, 53.8% own at least one ITN and 53.1% own at least one LLIN. Similarly; In malarious areas, ITN use by children under five years and pregnant women has remarkably leapt from 2.8 and 1.6% to 41.2% and 42.5% respectively .

HIV/AIDS Prevention and Control Program

HIV/AIDS prevention and control was recognized as a top priority health intervention from the start of HSDP I. The national HIV/AIDS policy was issued in 1998, and in subsequent years it was followed by the establishment of a National AIDS Council, National AIDS Secretariat, and other relevant bodies. Notwithstanding, Ethiopia continued facing a mixed HIV/AIDS epidemic amongst the sub-populations and geographic areas.

The estimated HIV prevalence rates for male and female have been 1.8 and 2.8, respectively. Overall, the national point prevalence for 2009 was 2.3 . . During the same year, adult HIV incidence was 0.28 resulting in total AIDS related deaths of 44,751 . Urban HIV prevalence was 7.7% in 2008 with an estimated 62% of total PLHIV in the country residing in urban areas, while rural HIV prevalence was 0.9%, which accounts for 38% of total PLHIV. Among urban settings, the epidemic varies greatly from 2.4% in Somali region to 9.9% in Tigray, 10.7% in Amhara and 10.8% in Afar regions. Rural HIV epidemic also varies significantly among regions with rural HIV prevalence ranging from 0.4% in Somali region to 1.5% in Amhara region . There still exists a challenge of describing the true trend in the incidence and prevalence of HIV due to varying methodologies applied in series of surveys in Ethiopia. In the year 2009, HAPCO, 2007 Single point estimate show that there were around 1,116,216 people living with HIV and of these 336,160 needed ART. There were also a total 855,720 AIDS orphans in the country.

The plan under HSDP III was to achieve provision of VCT/HCT services in 100% hospitals and HCs, PMTCT services in 100% of hospitals and 70% of HCs and increase the number of PLHIV on ART from 13,000 to 263,000. These targets were set to achieve a reduction in the adult incidence of HIV from 0.68% to 0.65% and also maintain the prevalence of HIV at the existing state.

Fig 2.4, Facilities providing HCT/VCT, PMTCT, and ART Services, 2009/10

Recent reports and assessments showed there have been marked increases in the number of health facilities and sites providing HCT, PMTCT, and ART services during the HSDP III period. According to FMoH 2008/09 Administrative report, the increase in health facilities have been from 801 to 1823 for (VCT) HCT, from 93 to 1023 for PMTCT and from 168 to 511 for ART. The number of clients using (VCT) HCT services has gone up to a record of 8,295,483 persons as compared to the 564, 321 in 1998. A total of 6,466 HIV-positive mothers received PMTCT prophylaxis at the end of the fourth year of HSDP III, a performance that only reached 8.2%. The estimate showed that there are 79,184 HIV-positive pregnant mothers and 14,148 HIV-infected births within a year. .

                  Figure 2.5: Trend in the Actual Number of PLHIV Accessed Care, 1998-2002 (FMoH, 2008/09 Administrative Report and HAPCO, 2010 Report)

Recent Service delivery reports from HAPCO (Feb. 2010) indicates that the number of PLHIV ever enrolled in ART program has increased to 443,964, while those ever started on ART increased to 246,347 and the number of PLHIV on ART reached to 179,183 making ART coverage 53% (percentage of PLHIV currently on ART out of the total eligible) that showed significant progress compared to the baseline of 13,000 in 2005/06. Among regions, the highest proportion of PLHIV enrolled in HIV care is seen in Amhara, Oromia and Addis Ababa While, Harari region manages to enroll far more than the target (122%), and Somali region takes in hand only 13% of the eligible target. Similarly, Beneshangul Gumuz, Dire Dawa, Addis Ababa, and Tigray are the regions that performed well enrolling 66%, 66%, 68% and 73% of targeted eligibles respectively.

Fig 2.6, PLHIV Currently on ART across regions, 2009/10

TB and Leprosy Control Program (TLCP)

Tuberculosis has remained one of the major global public health problems. Ethiopia ranks seventh among the world’s 22 high-burden tuberculosis (TB) countries. According to WHO estimates in 2009, incidence ratio of all forms of TB in Ethiopia were 379 per 100,000, while prevalence of TB Infections and mortality rate due to TB in the same year stood at 579/100,000, and 92/100,000, respectively. Prevention and control of TB has created additional challenge and a major strain to health care systems in many of developing countries including Ethiopia due its linkage with HIV/AIDS. WHO recommends a focus on the Three 'I's, isoniazid preventive treatment, intensified case finding for active TB, and TB infection control, to be the key public health strategies to decrease the impact of TB on people living with HIV.

In terms of leprosy control, WHO figures show that the prevalence of leprosy in Ethiopia is estimated at 6 per 100,000 in 2005/2006 with an estimated 4,000-5,000 cases detected every year. Ethiopia runs an integrated TLCP health care intervention since the beginning of HSDP I. The general objective of the TLCP is to reduce the incidence and prevalence of TB and Leprosy as well as the occurrence of disability and psychological suffering related to both diseases; and to reduce mortality resulting from TB to such an extent that both diseases are no longer public health problems. HSDP III mainly focused on enhancing the detection rate and completion of regularly provided treatment as the main strategy for the prevention and control of TB. The target set for the prevention and control of TB have been to achieve 85% treatment success rate and a detection rate of 70% of new sputum +ve TB cases. The national cure and treatment success rates are 67% and 84%, which is on track towards HSDP III target, while the case detection rate remains at 34%, far less than what was planned for HSDP III. Regional disaggregation showed highest Case Detection Rate in urban administrations (Harari 95%, Dire Dawa 81% and Addis Ababa 63%); whereas, Somali, Amhara and Tigray regions performed low at 19%, 23%, and 26% respectively. With reference to Treatment Success Rate, except Tigray (79%), Addis Ababa (72%), and Harari (64%) all regions are above the national average, and highest performances were in Afar (92%) and Gambella (89%). In the year 2009/10, 3,465 (35.4%) health facilities out of the 14,329 health facilities (hospitals, health centers, clinics, nucleus health centers and health posts) were providing TB-DOTs service and 879 (7%) health facilities were implementing TB/HIV collaborative activities

Fig 2.7 TB Case detection, Treatment success and Cure rates, 2008/09 Like Tuberculosis control, leprosy control is based on enhancing the detection rate and completion of regularly provided treatment. There have been improvements in the detection rate and treatment of leprosy although more effort is required to reduce the prevalence of grade 2 disability from 12% to less than 10% as targeted in HSDP III. There were 3,878 new cases detected in 2008/2009. Reports have also shown that there has been a decline in proportion of grade 2 disabilities among new leprosy cases which was 9% in 2007/2008 with a further decline to 7% in 2008/2009. These figures are still far behind the targets of achieving 2% in HSDP III. In addition, treatment completion rate for Leprosy cases has also reached to 89% from baseline of 82% in 2004/05 .

Figure 2.8: Trend in TB Detection, Treatment and Cure Rate, EFY 1997-2001 (FMoH, ARM EFY 2008/09 Report) Blindness Prevention and Control Program Cataract, trachoma, glaucoma and childhood blindness are the major causes of blindness in Ethiopia. The prevalence of blindness in Ethiopia is 1.6%. There are 1.2 million people with blindness of all causes and 2.8 million people with low vision. Cataract and trachoma constitute more than 60% of all blindness . The main strategy in place for trachoma control is “SAFE”, i.e. Surgery, Antibiotics, Facial cleanliness and Environmental Sanitation, including preventive measures.

Major strategic initiatives prior to HSDP III were, launching the Global Initiative on blindness prevention and control,

VISION 2020; establishment of a National Eye Bank and development and Standardization of cataract surgeons' training curriculum. Human resource and service delivery in these areas have improved over the years. For example,

 the number of ophthalmologists increased from 63 to 76 and primary eye care units from 46 to 54;
 the number of cataract surgeries also increased from around 20,000 in 2002 to 25,000 in 2004 and 37,000 in 2008/09.

Under HSDP III, the plan was to reduce active trachoma in the targeted 80 Woredas by 80% and increase the Cataract Surgical Rate (CSR) from 350 to 600 per million populations per year. The HSDP III performance report showed that the number of woredas implementing SAFE Strategy for trachoma has reached 124 and about 37,000 cataract surgeries were performed in 2008/2009 making cataract surgical rate of 460 /million/year with achievement rate of close to 60% of the HSDP III target.

Onchocerciasis Control and Dracunculiasis Eradication

Ethiopia is amongst the 12 dracunculiasis endemic countries and that also agreed to take concerted actions to interrupt local transmission of the disease by 2009. Nonetheless, 23 indigenous cases were reported in 2009 from Gambella Regional state making it difficult to make progress towards a Dracunculiasis free country. Concerning Onchocerciasis control program, the plan was to expand the program to all highly affected districts by 2005 and eliminate the disease by 2020. The evaluation of the past performance indicated that the program has been successfully expanded to all the affected districts during HSDP II period. The target under HSDP III has been to achieve a 65% onchocerciasis control in all CDTI areas and ensure the progress and sustainability of the program. The HSDP III performance reports shows that therapeutic coverage for 2008 and 2009 has reached 75% and 77%, respectively. However, it is very imperative for FMOH, RHBs and development partners to revitalize and strengthen their involvement in the control and prevention of Onchocerciasis and Dracunculosis which are most important but remained amongst the neglected emerging tropical diseases.

Prevention and Control of Non communicable Diseases

The target under HSDP III has been to improve the proportion of people seeking care in case of illness or injury from 41% to 55%. With regard to prevalence of injuries, Injuries from road traffic take the lion share and have become one of the major health burdens in Ethiopia. The health sector recognizes that injuries have multiple causes which, with efforts to strengthening the emergency medical services, necessitate multi-sectoral approach towards effective prevention and rapid responses when it occurs. An assessment report by the FMoH in 2008 has shown that non communicable diseases such as cardiovascular diseases, diabetes mellitus and cancers along with injuries are amongst the major contributors to the high level of mortality and morbidity in Ethiopia. A study finding on the pattern of injuries in Addis Ababa in 2007 has indicated that injuries accounted for 27% of all emergency visits, 5% of all hospitalizations, and 3% of deaths. The findings from a community-based survey in Jimma Zone in 2007 showed that prevalence rate of injury was 8.9% per year and out of the 304 individuals studied, 83.5% had received health care at different levels of health facilities and 5.2% have been admitted for inpatient care.

Integrated Disease Surveillance (IDSR) and Public Health Emergency Management (PHEM)

HSDP-II planned establishing and strengthening integrated disease surveillance in health facilities and at the community level in order to bring significant reduction in incidence of epidemics and outbreaks. A remarkable frequency and geographic coverage of acute watery diarrhea (AWD) has been observed in the last five years. In addition to impact on human health, the outbreaks did also put significant pressure on other programmes by diverting attention and resources.

Consequently, public health emergency management preparedness and response is one of the core processes introduced under the BPR and implementation has been started. In order to establish PHEM teams at FMOH, and RHBs, 13 epidemic intelligence service officers are being trained at master's degree level in Addis Ababa University. Twenty diseases have been selected for surveillance and detection and a new forecasting, early warning, response and record system have been designed.

Hygiene and Environmental Health

The objective of hygiene and environmental Health is to increase the coverage and services to both rural and urban population of the country. HSDP I and II periods saw the development of a National Sanitation Strategy and concerted measures for strengthening the monitoring of water quality by the public sector. During these periods, it also became possible to open two additional International Vaccination Centers at St. Paul and St. Peter TB Specialized Hospitals. There were also some useful achievement records which included access to toilet facilities that was increased from 10% to 29% in 2003/2004. The improvement in the access to sanitation facilities was from 12.5% to 17% in 2002/2003. However, the services for hygiene and environmental health have not sufficiently reached the majority of rural population and have been limited largely to urban areas, particularly in some of the regions of the country. It was during HSDP III that a National Hygiene and Sanitation Strategy and National Protocol for Hygiene have been developed including the commencement in the implementation of Community Led Total Sanitation (CLTS). The HSDP III period also saw the start for a National Millennium Hygiene and Sanitation Movement including the development of mass mobilization and communication strategy. Four regional towns have been selected for the Healthy Cities Program. The work also included the development of Urban Health Service Package with five manuals for the delivery of urban health services.

HSDP III had specific targets for hygiene and environmental health. Some of these are increasing the latrine coverage from 20% to 80% and to reach 100% in the medical and other waste management system in public and private health institutions. Reports so far showed that there has been some significant progresses in latrine coverage which has reached 60%, but fell short of meeting the target . For waste management system it has reached 60%, again very far from the HSDP III target. The other focus for achievement was indicator was reaching 100% in handling and utilization status of existing latrines. The achievement in this regard is not known and is expected to be extracted from the WASH Inventory that was in progress since 2009. Other important activities include the establishment of a committee for infection prevention in public hospitals. The country is also prone to climatic changes resulting in recurrent drought in different parts with potential impact on health of the population and health services infrastructure.

Health Extension Programme (HEP)

The Health Extension program was introduce under HSDP II in 2002/03 with a fundamental philosophy that if the right health knowledge and skill is transferred, households can take responsibility for producing and maintaining their own health. Substantial investments in human resources, health infrastructure, pharmaceutical supplies and operational costs have been made for the successful implementation of the program.

Figure 2.9, Trends in the Training of HEWs, EFY 1997-2002 Under HSDP III it was planned to cover all rural kebeles with the HEP with the aim of achieving universal PHC coverage by 2008 through vigorous and incremental implementation of the programme nationwide. From the very start HEP was supported with the development of 16 different health intervention packages to be delivered by HEWs at community level. These packages along with implementation guidelines were made available to implementers as well as to technical and vocational training institutions. The packages have been subjected to modification commensurate with the life style of the pastoralist population. The training of all female HEWs have been progressing well with encouraging sign and endorsement of community’s acceptance and demand for HEP services.

By the end of HSDP III, a total of 33,819 HEWs were trained and deployed surpassing HSDP III target and reaching 102.4 from the required 33,033 HEWs . Model households who have been trained and graduated have reached a cumulative total of 4,061,532 from an eligible total of 15,850,457 households. This only represented a coverage of 26% leaving a huge gap of more than 11 million households to be trained and graduate thus requiring a progressive and sustained efforts at all regions and levels of the health care system.

Figure 2.10: Trends of Construction of Health Posts, EFY 1997-2002 In terms of the construction of HPs as a home base for the delivery of HEP at community level, the achievement so far has encouragingly indicate there has been tremendous progress. The total number of HPs has increased from the baseline of 6,191 in 2004/05 to 14,416 in 2009/10, more than doubling in a space of only four years. This figure however showed an achievement rate of 89% compared to the planned target of 100% under HSDP III . Equipping Health posts with medical kits remain a major challenge during the implementation years of HSDP III where only 83.1% or 13,510 HPs out the planned target of 16,253 HPs were fully equipped. Other major activities in support of HEP include the establishment of HEP departments at regional levels and respective structures at zonal and woreda levels all aimed at strengthening the management support to HEP. Technical guideline for HEP Supportive supervision technical, reference books for rural HEP and manuals for school health program were prepared and have been adopted in the light of the BPR. Moreover, implementation Manual for Pastoralist and semi-pastoralist areas was finalized and has been distributed to respective regions. As part of the implementation training and deployment were completed for 2,566 HEP supervisors achieving 80.2% coverage against the plan of 3,200.

In order to expand Urban HEP in seven regions of the country, 15 HEP packages along with implementation manual have been developed and distributed for implementation. Training and deployment of Urban HEWs has already in progress in Tigray, Amhara, Oromiya; SNNP, Harari, Dire Dawa; and Addis Ababa. Accordingly, these regions have trained and deployed a total of 2,319 Urban Health Extension workers achieving 42% of the required number.

Medical Services

In addition to the construction and expansion of health facilities, the FMOH focused on strengthening the management capacity of health facilities during HSDP III period to ensure the delivery of effective, efficient and quality medical services. The Ethiopian Hospital Reform Implementation Guidelines that provide guidance for managers to improve hospital management in areas such as nursing care, facilities and equipment management, human resource management, infection prevention and quality management, among others was launched and similar Guidelines are also being developed for Health Centers as well.

An assessment done in 47 selected hospitals on their performance for the year EFY 2001 showed 50.8% bed occupancy rate (BOR), 27.8% patients per bed per year as bed turn-over rate (BTR), and 6.7 days of average length of stay (ALOS). The same revealed that average cost per patient–day equivalent (PDE) of 196 ETB .

With respect to per capita attendance rate, it is difficult to measure progress due to erratic implementation of the new HMIS in regions. Yet an increasing number of indigenous and international NGOs are currently involved in various aspects of service delivery, and there are currently 277 private clinics not for profit and 1,788 private clinics for profit in the country. The total number of hospital beds is 13,922, which mean that there is one bed for a population of about 5,300. This figure is about five times lower than the sub-Saharan African average.

Nutrition

Nutritional disorders are the main causes of morbidity and mortality. The major problems are protein-energy malnutrition and micronutrient deficiencies such as vitamin A, iron, and Iodine. During HSDP I & II, In addition to the efforts by Agricultural and Rural Development Sector which has the role of making adequate nutrition available to the population, the Health Sector initiated enhancing good nutritional practice through health education and treatment of severely malnourished children and prevention of nutritional health problems through provision of micronutrients to the vulnerable group of the population (mothers and children). Nutrition has also been made part of packages of the HEP. One of the achievements of HSDP III is the development and implementation of the National Nutrition Strategy and programme. To achieve HSDP target of creating access for 90% of children 6–59 months for nutritional screening, nutritional screening is underway every three months at HP level with plan to screen more than 95% of the 6–59 months children. With respect to the plan to increase the proportion of infants 0–5 months exclusively breast fed from 38% to 63%, a study done in four regions of (Amhara, Oromiya, SNNP and Tigray) showed that the prevalence of exclusive breast feeding has reached 76% in 2008/09.

The proportion of children aged 6–59 months getting vitamin A prophylaxis through two rounds of Vitamin A supplementation per year reached 95% in 2008/09, far above HSDP III target of increasing from 38% to 54%. Transition of the EOS into the HEP started in 39 districts in conjunction with the CBN roll-out. The core package of CBN interventions was implemented in 849 sub-districts of Amhara, Oromia, SNNP and Tigray Regions (surpassing the target of 60% coverage).

Health Systems

The following sections summarize progress made in the area of health systems in Ethiopia.

Health Sector Reform

Health sector reform in Ethiopia is an undergoing process as a comprehensive endeavor in the socio-economic reform that started with Civil Service Reform covering the entire public sector of the country. As part of this national effort, the reform in the health sector has been intensified through the application of a new concept known as Business Process Reengineering (BPR). BPR has been used as a tool for a comprehensive analysis, redesign and revamping of the health sector in Ethiopia. As a process itself forms a fundamental rethinking and requires a purposeful and radical redesign of health business processes to achieve dramatic improvements in critical, contemporary measures of performance such as cost, quality, service and speed. The BPR is a country led, multisectoral undertaking implemented as a comprehensive approach to the government’s civil service reform. The purpose of the PBR in the context of the health sector was to establish customer focused institutions, rapid scaling up of health services and enhancing the quality of care in order to improve the health status of the Ethiopian people as indicated in the mission of the health sector. Following a deeper and systematic analysis of the “as is” situation at all levels of the health system, including health facilities, the sector has brought in innovative approaches including, benchmarking best practices, redesign new processes, revising organizational structures and a selection of 8 core process and 5 support processes. The new 8 core processes are; Health Care Delivery; Public Health Emergency Management; Research and Technology Transfer; Pharmaceutical Supply; Resource Mobilization and Health Insurance; Health and Health Related Services and Product Regulation; Health Infrastructure, Expansion and Rehabilitation; and Policy, Planning, Monitoring and Evaluation. The 5 support processes designed were: Human Resources Development /Management; Procurement, Finance and General Service; Program-Based Audit; Public Relations and Legal Services.

Subsequent to this, series of training sessions have been given to managers and technicians at all levels, There has been changes in staff deployment and specific job assignments including recruitment of new staff leading to progressive implementations under the close oversight of the top health leadership.

Health Facility Construction and Expansion

Since HSDP I, major activities under the health facility construction, expansion, rehabilitation, furnishing and equipping focused mainly on the PHC facilities: HPs and HCs and to a certain extent hospitals. By the end of HSDP II, the number of public HCs has increased by 70% from 412 in 1996/97 to 519 in 2003/04. For the same periods, the number of HPs increased from 76 in 1996/97 to 2,899. The number of hospitals (both public and private) also increased from 87 in 1996/97 to 126 in 2003/04. There has been also considerable health facility rehabilitation program and furnishing during the HSDP I and HSDP II including improvements in support facilities. As a result, the potential health service coverage increased from 45% in 1996/97 to 64.02% by 2003/04.

The HSDP III plan was to further expand these and other services with the aim of achieving universal health service coverage by the end of 2008 and also improving the delivery of primary health care services to the most neglected rural population. This was an extension of the Accelerated Expansion of Primary Health Service Coverage that has been launched in the midterm of HSDP II. The HSDP III target in this component has been to attain a 100% general potential health service coverage by availing 3200 HCs through construction, equipping and furnishing of 253 new HCs and upgrading 1,457 HSs to HC level and also upgrading of 30% of HC to enable them perform EmONC services

Table 1: Trends of Health Facility Construction

Facility	HSDP I (1996/7)	HSDP II (2003/2004)	HSDP III (2010)
HP	76	2,899	14,416
HC	412	519	2689
Hospitals	87	126	195

Progresses in the Health facility construction, upgrading and equipping under HSDP III were remarkable. Through increasing construction works, the number of HPs has reached 14,416 achieving 88.7% of the target by 2009/10. . Moreover, there are now 2,689 HCs accounting for 84% of the 3,200 HCs target by the end of HSDP-III. Additional 511 HCs are under construction to reach the 100% target. At the beginning of HSDP III, there were 82 all types of Hospitals (37 District, 39 Zonal and 6 Specialized Hospital). The planned target under HSDP III was to increase the number of hospitals to 89 (42 district and41 zonal). However, the 2008/09 report showed that the target has been surpassed with current total of 111 Public Hospitals (nearly 25% increase).

In addition, 12,292 health posts have been equipped which represents 75.6% of the target of equipping 16,253 health posts. Equipment for 2,299 HCs was accomplished and for an additional 390 HCs is underway. The rest 511 new HCs under construction will be equipped following their completion. . Moreover, the construction of 21 blood banks in six regions is on progress with 95% of the construction completed in 2009 and the preparation of a National Laboratory Master Plan has also been already completed.

Human resource development

Human Resource Development (HRD) has been a key component in the successive HSDPs. It has been one of the key components in HSDP III with the main objective of improving the staffing level at various levels as well as to establish implementation of transparent and accountable Human Resource Management (HRM) at all levels. It is envisaged that this will be made possible through increasing the number and capacity of training institutions, use health institutions as a training center as well as through establishing a platform for the effective implementation of CSRP and introducing incentive packages.

With the aims of improving the overall HRH situation in the country the government has initiated BPR process that thoroughly analyzed the HRH situation in the country. Based on this a comprehensive HRH strategic plan that details the HRH planning, management, education, training and skill development, legal frame work as well as financing mechanism have also been developed through involvement of relevant stakeholders, development partners and international consultants. To improve the staffing number and composition at various levels, taking into account the HRH requirement for the universal Primary Health Care (PHC) coverage by the end of HSDP III period, the focus has been on scaling up the training of community and Mid-Level Health Professionals (MLHPs). With regard to community level professionals a total of 31,831 HEWs have been trained and deployed to meet the HRH requirement for HEP. Similarly, Accelerated Health Officer Training Program (AHOTP) was launched in 2005, in five universities and 20 hospitals to address the clinical service and public health sector management need at district level. So far more than 5,000 health officer trainees (generic and upgrade) have been enrolled and 3,573 Health officers were graduated and deployed. In addition; to address the HRH need for Comprehensive Emergency Obstetric Care (CEmONC) and other emergency surgery service need at PHC level, curriculum for masters program on Emergency Surgery has been developed and training has been started in five universities. To address the critical shortage and mal-distribution of doctors, in addition to the existing medical schools a new medical school that uses innovative approach has been opened in St. Paul’s Hospital’s Millennium Medical School. A new integrated curriculum that enhances the clinical skill and social accountability of medical doctors has also been developed.

Overall, the available professionals at the end of HSDP III compared to the HSDP III targets shows that the target has been met for community level and most of MLHP. The number has also significantly increased compared to the levels in the previous HSDP. However, there is still major gap with regard to medical doctors, midwives and anesthesia professionals (See Table below) especially when one takes into account the long lead time and limited involvement of private sector in training of these professionals.

Table 2: The total number of available Human Resource for Health during the successive HSDP phases

HR Category	End HSDP I		1994 HSDP II		End 1997 HSDP III
! Total No	Ratio to population	Total No	Ratio to population	Total No	Ratio to Population
All physicians	1,888	1:35,603	1,996	1:35,604	2152	1: 34,986
Specialist	652	1:103,098	775	1:91,698	1151	1:62,783
General practitioners	1,236	1: 54,385	1221	1:58,203	1001	1:76,302
Public health officers	484	1:138,884	683	1:104,050	3,760	1: 20,638
Nurses Bsc, & Diploma (except midwives)	11,976	1:5,613	14,270	1: 4,980	20109	1: 4,895
Midwives (Senior)	862	1:77,981	1,274	1: 55,782	1379	1: 57,354
Pharmacists	118	1:569,661	172	1:413,174	661	1: 117,397
Pharmacy Tech.	793	1: 84,767	1171	1: 60,688	3013	1: 25,755
Environmental HW	971	1: 69,228	1169	1: 60,792	1,819	1: 42,660
Laboratory technicians & technologists	1,695	1:39,657	2,403	1: 29,574	2,989	1: 25,961
Health Extension Workers	-	-	2,737	1: 23,775	31,831	1: 2,437

Table 3: Total number of available Human Resource for Health by region, 2009

Region	Physician (GP & specialist)	Physician : Population Ratio	Health Officer	HO : Population Ratio	All Nurses	Nurse : Population Ratio	Mid-wives	Mid Wife: Population Ratio	HEW*	HEW : Population Ratio
Tigray	101	1:44,880	188	1:24,111	2,332	1:1,944	185	1:24,502	1,433	1:3,163
Afar	15	1:98,258	29	1:50,823	185	1:7,967	−	−	572	1:2,577
Amhara	304	1:58,567	434	1:41,024	3,790	1:4,698	212	1:83,983	7,471	1:2,383
Oromia	378	1:76,075	448	1:64,189	5,040	1:5,706	287	1:100,197	13856	1:2,075
Somali	71	1:65,817	12	1:389,415	314	1:14,882	45	1:103,844	1,427	1:3,275
Ben-Gumuz	12	1:59,309	42	1:16,945	452	1:1,575	37	1:19,235	499	1:1,426
SNNPR	242	1:65,817	220	1:72,398	3,980	1:4,002	316	1:50,404	7,915	1:2,012
Gambella	13	1:25,585	13	1:25,585	91	1:3,655	4	1:83,150	457	1:728
Harari	29	1:6,655	31	1:6,226	276	1:699	29	1:6,655	47	1:4,106
Addis Ababa	934	1:3,056	170	1:16,791	3,377	1:845	244	1:11,699	NA	-
Diredawa	53	1:6,796	19	1:18,957	272	1:1,324	20	1:18,009	142	1:2,537

The above table shows health professional to population ratio in selected key categories of health professionals across regions. Anchored in the recent reports, numbers of health professionals in different parts of the country are lower than what is standard. Especially worsened in agrarian and pastoralist regions. However; the available professionals at the end of HSDP III compared to the HSDP III targets show that the target has been met for community level and most of mid level health professionals. The number has also significantly increased compared to the levels in the pervious HSDPs. However, there is still major gap in highly skilled professionals like Medical doctors, midwives and anesthesia professionals.

Pharmaceutical Services

Since the start of HSDP I, the government was committed to ensuring community’s access to the essential medicines that are safe, effective and of assured quality including rational drug prescription and use. In the ongoing health sector reform, ensuring a regular and adequate supply of pharmaceuticals has been considered as one of the core processes in the BPR and the following have been implemented so far.

In order to introduce efficiency in the supply chain of pharmaceuticals and medical supplies management system, PHARMID has been transformed into Pharmaceutical Fund and Supply Agency (PFSA) with the several measures taken to strengthen the capacity of the new agency. These measures include: • Deployment of more regular staff and mobilization of TAs. • Design of the LMIS • The selection of 18 sites and beginning of the construction of warehouses and hubs. • Overhauling and strengthening the transport capacity of the Agency through the procurement of 92 trucks. • Improvement in the RDF volume by making available additional funding. • Building cold rooms that has increased the national capacity by fivefold.

Furthermore; PFSA has developed a national list for the procurement of Essential Pharmaceuticals. It has been able to develop a pharmaceutical forecasting plan in consultation with health facilities that would be required for need-based procurement. The Agency has also undertaken capacity building activities in the areas of drug supply management and also engaged in the establishment and strengthening of Drug and Therapeutic Committees (DTC) in health facilities in order to improve the supply and rational use of pharmaceuticals. The new Agency has already started handling bulk procurement, storage and distribution of pharmaceuticals.

2.2.5. Health and Health Related Services and Product Regulation A key principle underpinning the design of BPR in the health sector was bringing a significant improvement in the quality of health services through the institutionalization of accountability and transparency. One mechanism of achieving this was to seriously consider the separation of purchaser, provider and regulator in the health system. As part of this important endeavor, the former Drug Administration and Control Agency (DACA) has undergone an institutional transformation into a new Agency called Health and Health related Services and Product Regulatory. The mandate of the new agency is to undertake inspection and quality control of health and health related products; premises, professionals and health delivery processes in an integrated manner. The Agency is strengthened through the construction of new building at federal and branch offices at regional levels that helped the Agency to expand the drug administration and control system throughout the country. The agency has now five branch offices which it provided delegation to RHBs on drug administration and control.. The agency is working closely with RHBs on drug quality and rational use through the process of reviewing drug documents, physical and laboratory quality assurance checks. Prevention and control on the use of narcotic drugs including tobacco are other mandates of the Agency which it works collaboratively with appropriate government offices. The agency has recently procured, installed and commissioned for use modern equipment for the safe disposal of expired drugs.

Harmonization and Alignment

Major objective under harmonization and alignment is putting in place One-Plan, One-Budget and One-Report at all level of the health system. It refers to how the set of actors in the sector should work together with respect to harmonizing and aligning their actions and procedures with the country’s systems. A Code of Conduct instrument between the FMOH and its major Health development Partners was signed in 2005 to guide the conduct of all partners in support of HSDP. Afterwards, an operational manual entitled “HSDP Harmonization Manual” that focuses on ensuring one-plan, one-budget and one-report at all levels of the health system has been developed and endorsed by all stakeholders in 2007. Ethiopia has been one of the signatories of the Global IHP+ Compact and a first country to develop and sign a Country-based IHP+ Compact.

One Plan

The Government has produced and continued the implementation of a comprehensive National socio-economic development plan called “the Plan for Accelerated and Sustained Development to End Poverty-SDPRP”. This is a single national plan which guides all other sectoral plans for the years covering 2005/06-2009/10. HSDP is also a health sector wide strategic plan which is the product of intensive and substantial consultations between the Ministry of Health and the Health Development Partners. In 2005, the Ministry of Health and its partners developed HSDP III as a single program framework, one plan, for coordinating health interventions aligned with SDPRP. The goals, targets and costing of HSDP-III are aligned with health MDGs.

One of the most important refinements in the HSDP III has been the inclusion of “Woreda Based Health Sector Planning” which has brought an additional value and a breakthrough in the health planning system for ensuring vertical and horizontal alignments in the health intervention priorities of the sector. For four consecutive years covering 2006/07, 2007/08, 20008/09 and 2009/10, woreda-based health sector plans have been prepared in line with the principles of “one plan, one budget, and one report” of the HHM based on the agreed priorities and targets. This planning system created a platform for joint planning by all stakeholders at all levels of the health system including health development partners. This exercise has also improved the capacities of Woreda health offices in conducting evidence-based planning that in the course of time have shown remarkable results.

One Budget

The principle of “One budget” in HSDP III and beyond means all available funding for health activities (government and donor sources) are effectively pooled and should flow through government channels. Another important feature of the one budget principle is all of these funds for health activities should be reflected in only one plan and one documented budget, although actual funding disbursement may be effected through separate channels. Subsequent to the signing of the IHP+ Compact, a joint decision between the FMOH and the health development partners has led to undertaking an independent assessment of the health system focusing on financial administration, procurement, equity and social inclusion with an intention of filling the prevailing resource gaps. This assessment has resulted in the establishment of the MDG Performance Fund which was the hallmark towards reaching an agreement for a one-budget framework in the health sector of Ethiopia. The key findings of the assessment were capacity limitations at PPFGD, Finance and Audit section of the FMOH, and PFSA that impeded efforts to enhance performances as per the requirement of the reform design. Another finding was the slow pace in the scaling up of HMIS and M&E. Relevant recommendations have been forwarded for mitigating these challenges and have been documented as part of POA of FMOH. Furthermore, FMOH and Development Partners have developed a Joint Financing Arrangement (JFA) for the establishment of the MDG Performance Fund that has been signed by Seven Development Partners which has led the FMOH accessing and make use of the pooled funds.

In addition, the FMOH in collaboration with development partners have started the formulation of MTEF. The main purpose of the MTEF is to help the health sector at all levels in determining and allocating available domestic and external resources for HSDP IV priorities. It is also seen as a useful instrument for negotiations with the Ministry of Finance and Economic Development (MoFED) as well as a tool for advocacy for the mobilization of increased external resources. A coordinating committee for MTEF has been established and a continuous process of communication and coordination is undergoing across the various institutions at the federal and regional levels including MoFED, and some milestone activities have been completed. Among these activities, resource mapping and gap analysis at federal level has been completed. If not all, many development partners have disclosed their three-year resource commitments to the health sector. Similar activities are on progress at Woreda level where resources from local governments, NGOs and other organizations are expected to be captured in the one plan framework. It is expected that the process will be completed soon and will be available in time as an important input for the development of HSDP IV.

One Report/One M & E

Establishing HMIS at all levels of health service delivery system and setting up HMIS units at all levels for ensuring information use for evidence-based health planning and decision-making were the major targets that were set during HSDP-II. Subsequently, HMIS national advisory committee (NAC) was established with representation from different stakeholders and had been instrumental in facilitating the design and pilot testing of the new HMIS during HSDP III. HMIS has been redesigned and was pilot tested. Scaling up the new HMIS to all regions has started after the development of detailed implementation plans by RHBs. FMOH printed and distributed HMIS tools to regions after a thorough assessment in the readiness for implementation. HMIS Resident Mentors have been deployed to implementing regions. Electronic Medical record (EMR) has been pilot tested in a hospital setting and is now ready for scaling up at the national level.

As part of the BPR, integrated supportive supervision, operational research, performance review and quality assurance and inspection have been added to complete M&E in the strategic planning of the health sector. Implementation manuals, tools and system requirements for implementation has been finalized. Joint Performance reviews such as ARM and JRM were also undertaken according to the plan and Annual Review Meeting (ARM) has been conducted every year and the level of Completeness in the annual HSDP report has shown significant improvements over the HSDP III periods.

Governance of HSDP

FMOH-RHBs joint Steering Committee, FMOH-HPN Joint Consultative Forum and the Joint Core Coordinating Committee have been functioning very well. The FMOH-RHBs Joint Steering Committee that is chaired by the Minister meets regularly (every two months) to promote and monitor the implementation of HSDP Harmonization Manual and Civil Service Reform agendas (BPR) amongst other strategic objectives of the HSDP III.

The CJSC, which is the top policy decision-making and governance body of the sector meets far less often while the FMOH-Donor Joint Consultative Forum and JCCC meetings on the other hand have been regularly functional with the JCCC focusing on technical and operational issues.

Health Care Financing

As it has been clearly indicated in the 4th National health Accounts (2010), health service in Ethiopia is primarily financed from 4 sources: the federal and regional governments; grants and loans from bilateral and multilateral donors; non-governmental organizations and private contributions. Although it has significantly improved over the years, health care financing remain a major challenge for the health care system of Ethiopia. Since HSDP III, a health care financing strategy was adopted by FMoH, mainly focusing on improving the efficiency of allocation and utilization of public health resources, mobilization of additional resources from international donors and health development partners, retention and utilization of user fee revenues at health facility level, introducing private wings in the public hospitals and, more importantly, an initiation in the development of risk sharing mechanisms in the form of public and community-based health insurances.

The objective of health care financing component of HSDPs center on the mobilization of increased resources to the health sector, promoting efficient allocation, effective expenditure for allocative equity and utilization of the available health resources, aimed at achieving a sustainable health care financing system. Since HSDP I, there have been a number of background studies on health care financing issues that have contributed to the introduction of reforms and strategies that were closely monitored and evaluated. Since the first HSDP, four National Health Accounts (NHA) have been conducted. A Proclamation on Health Service Delivery, Administration and Management including five regulations on all the components of the reform were drafted and endorsed. RHBs of Tigray, Amhara, Oromiya, Benishangul-Gumuz, SNNPR, and Addis Ababa translated most of the reforms into action. The reform components include: retention and utilization of revenue, administration of the fee waiver system and establishment of functioning facility governance bodies. Outsourcing of non-clinical services, establishment of private wing in health facilities and exemption of certain services have also been a part of the reform and on process of implementation at the national level.

Retention and Utilization of Revenue

Ratification of the Health Care Financing Reform proclamation and regulation by the regional governments and City Councils are the initial steps for the commencement of user fee revenue retention and utilization at health facility level. To assist the implementation, a number of generic operational manuals have been designed to be used, if needed with modifications, for the implementation of the reform as seen fitting to the local conditions. The manuals describe in details the process of user fee revenue collection, financial administration, accounting, auditing and procurement of goods and services. Moreover, establishing a functional health facility governance board with key representatives from health, finance, community and other relevant sectors is a fundamental requirement of the reform. The board meets on regular basis and decides on the use of the retained revenue for the eligible expenditure areas as broadly described in the operational manual.

The performance report for the health care financing report showed that up to the end of 2008 (EFY 2001) 73 hospitals and 823 health centers have started retaining revenue and 95% of them utilized the user fee revenue they have collected. This shows that the utilization rate of the revenue from user fees by these facilities is encouragingly high. In terms of achieving the target of retention and utilization of 100% of revenue generated at hospitals and HCs, the report showed that out of 172 potential hospitals, 73 (42.4%) and out of 2,193 health centers 823 (37.5%) have been able to collect user fee revenue in 2008/09. Of these, 66 (38.4%) and 782 (35.6%) utilized their collected revenue, respectively.

Health Insurance

To build a national health insurance system, universal healthcare systems in other parts of the world were studied. A study conducted in 2009/10 based on 2007/08 data found that out-of-pocket payments constitute 37% of the total health expenditure.

Ethiopia is currently striving to achieve universal health coverage through two types of health insurance; social health insurance and community-based health insurance. The social health insurance system will cover employees in the formal sector which is mainly payroll-based, while community-based health insurance will cover the rural population and the informal sector in urban areas.

Participation in the social health insurance system will be compulsory for employees of a public office or enterprise, or any establishment that employs at least 10 people (with the exception of the military), and will be financed by contributions taken out of the salaries of employees, with the amount based on their income, and by employers, who will a contributions for every employee identical to the employee's contribution. A federal health insurance agency with regional offices around the country will be established to run the program.

Under the community-based health insurance system, each district of Ethiopia, or woreda, will have a collective health fund to which participants will contribute to. Enrollment is done at a household rather than individual basis. The poor are eligible for membership in community health funds that is subsidized by the woredas and regions. The federal government also provides a 25% subsidy to the health funds. The health funds cover treatment at local health centers or at hospitals that local health centers refer them to. Introduced in April 2012, it was piloted in 13 woredas, and has so far been successful.

Trend of Expenditure in the Health Sector

The finding from Ethiopia’s fourth National Health Accounts (NHA, 2010) showed that national health expenditure has grown significantly from the 2004/05 level of 4.5 Billion Birr (USD522 million) to Birr 11.1 billion (USD 1.2 billion) in 2007/08.

In terms of per capita health expenditure, the increase has been from the 2004/05 level of USD7.14 to USD16.09 in 2007/08. The report also provided the proportion of health expenditure by each source of financing in the order of 40% by the rest of the world followed by 37% by household out-of-pocket expenditure, the Government (both central and regional) 21% and the remaining being covered by a combination of employer-based insurance schemes and other private sources. Official government reports monitoring health expenditure showed that over the years the share of government health budget allocation as a total government budget during the PASDEP period has shown some sign of improvement. For example, health budget allocation as a proportion of received regional public block grant from federal government accounted for 10.1% in 2008/09. However, health care funding still remain a continued challenge for the health care system of Ethiopia prompting to an inward and outward looking for the mobilization of additional health resources such as community and social insurance schemes, enhancing in the user fees revenues and increased mobilization of funding from external sources-global and health development partners.

Figure 2.11: Trends of Health Expenditure in USD/Capita Pastoralist Health Service Pastoralist population in Ethiopia constitutes about 10% of the total population of the country. Yet, there is Lack of appropriate health service delivery package to address the health care needs of the communities in the Pastoralist regions. This has prompted to establish two core objectives under HSDP-II regarding the Pastoralist health services and systems. These were to establish an appropriate health service delivery for the pastoralist population and to increase coverage and utilization of health services in pastoralist population. In this regard, a concept paper, "Health Service Delivery to Pastoralists", was developed by FMOH and the 16 HEP packages were tailored to pastoralists needs and have been translated into local languages. In addition, as part of government’s effort to give technical assistance to the emerging regions, a board composed of members form six ministries was established under the Ministry of Federal Affairs including a technical committee for the integration of support to the Newly Emerging Regions.

Following the redesign and implementation of CSRP and the BPR, one of the major organizational transformations in the FMoH was the establishment of Pastoralist Health Promotion and Disease Prevention Directorate to focus and draw attention to this pastoralist population. 2.2.8. Operational Research Operational research in health is very crucial to identify priority health and operational problems by producing evidences for planning and decision making for improving health services. Although it is a critical part of M&E, operational research has not been conducted in a coordinated manner during the HSDP I and II periods. Research and Technology Transfer is one of the core processes redesigned as part of the BPR. There have been a surge in the number of operational researches during HSDP III covering wide areas such as on the causes of maternal mortality (Maternal death audit), prevalence of cervical cancer, coverage of child and TT immunization, coverage and impact of the expanded program of immunization, EPI coverage survey, effect of Misoprostol, choice of family planning, nutritional surveillance, traditional medicine, HIV/AIDS, TB, and malaria, surveillance of major public health problems and health commodity tracking. Operational researches were also conducted on the EOS coverage validation survey, national nutrition baseline survey, effectiveness of Coartem, effectiveness of residual DDT spray, and cost of health services.

• Cross cutting issues
  • Gender

Gender is among the cross cutting issues and has remained a crucial concern that has prompted the setting of clear objective for gender mainstreaming at all levels of the health system. In this regard, the government has completed the preparation of a training manual on physical violence and analytic framework on gender and health, compilation and analysis of data on female workers to be used for advocacy purposes. The final version of this document will be published and distributed to stakeholders. There has been also a rapid assessment aimed at prevention of physical abuse on women and on the provision of adequate health services for the victims of abuse. Based on the results of the assessment and the identified gaps, a draft training manual has been developed for use by health workers. This training manual has been further refined through a consultative workshop attended by all concerned stakeholders

Indicators

Indicator description	Value
Hospitals	149
Health centers	732
Health posts	11,446
Health stations +NHC	1,517
Private clinics for profit	1,788
Private clinics not for profit	271
Pharmacies	320
Drug shops	577
Rural drug vendors	2,121

Throughout the 1990s, the government, as part of its reconstruction program, devoted ever-increasing amounts of funding to the social and health sectors, which brought corresponding improvements in school enrollments, adult literacy, and infant mortality rates. These expenditures stagnated or declined during the 1998–2000 war with Eritrea, but in the years since, outlays for health have grown steadily. In 2000–2001, the budget allocation for the health sector was approximately US$144 million; health expenditures per capita were estimated at US$4.50, compared with US$10 on average in sub-Saharan Africa. In 2000 the country counted one hospital bed per 4,900 population and more than 27,000 people per primary health care facility. The physician to population ratio was 1:48,000, the nurse to population ratio, 1:12,000. Overall, there were 20 trained health providers per 100,000 inhabitants. These ratios have since shown some improvement. Health care is disproportionately available in urban centers; in rural areas where the vast majority of the population resides, access to health care varies from limited to nonexistent. As of the end of 2003, the United Nations (UN) reported that 4.4 percent of adults were infected with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS); other estimates of the rate of infection ranged from a low of 7 percent to a high of 18 percent. Whatever the actual rate, the prevalence of HIV/AIDS has contributed to falling life expectancy since the early 1990s. According to the Ministry of Health, one-third of current young adult deaths are AIDS-related. Malnutrition is widespread, especially among children, as is food insecurity. Because of growing population pressure on agricultural and pastoral land, soil degradation, and severe droughts that have occurred each decade since the 1970s, per capita food production is declining. According to the UN and the World Bank, Ethiopia at present suffers from a structural food deficit such that even in the most productive years, at least 5 million Ethiopians require food relief.

In 2002 the government embarked on a poverty reduction program that called for outlays in education, health, sanitation, and water. A polio vaccination campaign for 14 million children has been carried out, and a program to resettle some 2 million subsistence farmers is underway. In 2003, the government launched the Health Extension Program which will provide universal primary health care coverage by 2009. This includes placing two government-salaried female Health Extension Workers (HEW) in every kebele, with the aim of shifting the emphasis of health care to prevention. About 2,700 HEWs completed their training by the end of 2004 at 11 technical and vocational education centers, while 7,000 HEWs were still in training in 2005, and over 30,000 HEWs were expected to complete their training by 2009. However, these trainees encountered a lack adequate facilities, which included classrooms, libraries, water, and latrines. The selection of trainees was flawed, with most being urban inhabitants and not from the rural villages they would be working in. Reimbursement was haphazard as trainees in some regions did not receive stipends while those in other regions did. In January 2005, the government began distributing antiretroviral drugs, hoping to reach up to 30,000 HIV-infected adults.

According to the head of the World Bank's Global HIV/AIDS Program, Ethiopia has only 1 medical doctor per 100,000 people. However, the World Health Organization in its 2006 World Health Report gives a figure of 1936 physicians (for 2003), which comes to about 2.6 per 100,000. There are 119 hospitals (12 in Addis Ababa alone) and 412 health centers in Ethiopia. Globalization is said to affect the country, with many educated professionals leaving Ethiopia for a better economic opportunity in better-developed countries.

Ethiopia's main health problems are said to be communicable diseases caused by poor sanitation and malnutrition. These problems are exacerbated by the shortage of trained manpower and health facilities. Ethiopia has a relatively low average life expectancy of 62/65 years. Only 20 percent of children nationwide have been immunized against all six vaccine-preventable diseases: tuberculosis, diphtheria, whooping cough, tetanus, polio, and measles. Rates of immunization are less than 3 percent of children in Afar and Somali Regions and less than 20 percent in Amhara, Benishangul-Gumuz, and Gambela. In contrast, almost 70 percent of children have received all vaccinations in Addis Ababa and 43 percent in Dire Dawa; children in urban areas are three times as likely to be fully immunized as children living in rural areas.

Maternal and child health care

In June 2011, the United Nations Population Fund released a report on The State of the World's Midwifery. It contained new data on the midwifery workforce and policies relating to newborn and maternal mortality for 58 countries. The 2010 maternal mortality rate per 100,000 births for Ethiopia is 470. This is compared with 589.7 in 2008 and 967.7 in 1990. The under 5 mortality rate, per 1,000 births is 109 and the neonatal mortality as a percentage of under 5's mortality is 34. The aim of this report is to highlight ways in which the Millennium Development Goals can be achieved, particularly Goal 4 – Reduce child mortality and Goal 5 – improve maternal death. In Ethiopia the number of midwives per 1,000 live births is 0.4 and the lifetime risk of death for pregnant women 1 in 40.

Traditional medicine

The low availability of health care professionals with modern medical training, together with lack of funds for medical services, leads to the preponderancy of less reliable traditional healers that use home-based therapies to heal common ailments. High rates of unemployment leave many Ethiopian citizens unable to support their families. In Ethiopia an increasing number of "false healers" using home-based medicines have grown with the rising population. The differences between real and false healers are almost impossible to distinguish. However, only about ten percent of practicing healers are true Ethiopian healers. Much of the false practice can be attributed to commercialization of medicine and the high demand for healing. Both men and women are known to practice medicine from their homes. It is most commonly the men that dispense herbal medicine similar to an out of home pharmacy.

Ethiopian healers are more commonly known as traditional medical practitioners. Before the onset of Christian missionaries and Medical Revolution sciences, traditional medicine was the only form of treatment available. Traditional healers extract healing ingredients from wild plants, animals and rare minerals. AIDS, malaria, tuberculosis and dysentery are the leading causes of disease-related death. Largely because of the costs, traditional medicine continues to be the most common form of medicine practiced. Many Ethiopians are unemployed which makes it difficult to pay for most medicinal treatments. Ethiopian medicine is heavily reliant on magical and supernatural beliefs that have little or no relation to the actual disease itself. Many physical ailments are believed to be caused by the spiritual realm which is the reason healers are most likely to integrate spiritual and magical healing techniques. Traditional medicinal practice is strongly related to the rich cultural beliefs of Ethiopia, which explains the emphasis of its use.

In Ethiopian culture there are two main theories of the cause of disease. The first is attributed to God or other supernatural forces, while the other is attributed to external factors such as unclean drinking water and unsanitary food. Most genetic diseases or deaths are viewed as the will of God. Miscarriages are thought to be the result of demonic spirits.

One medical practice that is commonly practiced irrespective of religion or economic status is female genital mutilation. Nearly four out of five Ethiopian women are circumcised. There are three levels of circumcision that involve different degrees of cutting the clitoris and vaginal area. Many of these practices are done with an unsanitary blade with little or no anesthetics. It can result in heavy bleeding, high pain, and sometimes death.

It was not until Christian missionaries traveled to Ethiopia bringing new religious beliefs and education that modern medicine was infused into Ethiopian medicine. Today there are three medical schools in Ethiopia that began training students in 1965 two of which are linked to Addis Ababa University. There is only one psychiatric treatment facility in the whole country because Ethiopian culture is resistant to psychiatric treatment. Although there have been huge leaps and bounds in medical technology there is still a large problem in the distribution of medicine and doctors in Ethiopia.

See also

• List of hospitals in Ethiopia
• HIV/AIDS in Ethiopia
• Water supply and sanitation in Ethiopia
• Famines in Ethiopia

Further reading

• Richard Pankhurst, An Introduction to the Medical History of Ethiopia. Trenton: Red Sea Press, 1990. ISBN 0-932415-45-8

External links

• The State of the World's Midwifery - Ethiopia Country Profile