concept note for cross-cutting health systems …
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Health System Strengthening Concept Note 15 October 2014│ 1
Investing in Health Systems Strengthening
CONCEPT NOTE
FOR CROSS-CUTTING HEALTH
SYSTEMS STRENGTHENING
IMPORTANT NOTE: Applicants should refer to the Instructions for the Health Systems Strengthening concept note and to the HSS Guidance Note.
The concept note details the applicant’s request for Global Fund support to cross-cutting health systems strengthening (HSS). The concept note should present an ambitious, strategically focused and technically sound investment, informed by the national health strategy and the national disease strategic plans. It should represent a prioritized, full expression of demand for resources, and it should be designed so as to maximize the strategic impact of the investment.
The concept note is divided into the following sections:
Section 1: The description of the national health sector, including health system constraints and the national response.
Section 2: Information on the overall HSS funding landscape, additionality, and financial sustainability.
Section 3: The funding request to the Global Fund, including a programmatic gap analysis, rationale and description of the funding request, and the modular template.
Section 4: Implementation arrangements and risk assessment.
Health System Strengthening Concept Note 15 October 2014│ 2
SUMMARY INFORMATION
Applicant Information
Country Federal Democratic Republic of Ethiopia
Funding Request
Start Date July 1, 2015
Funding Request
End Date
Dec, 2017
Principal
Recipient(s) Federal Ministry of Health
Funding Request Summary Table
Priority HSS Modules Allocation Request Above Allocation Request
Human Resource 12,037,140 10,239,400
Pharmaceutical supply
Chain Management
8,694,319 5,140,411
Health Information System 10,367,826 4,206,200
Service Delivery: Laboratory
System
8,618,145 10,634,045
Financial Management 3,063,590 0
Leadership and Governance 2,913,000 0
Total 45,694,020 30,220,056
A funding request summary table will be automatically generated in the online grant
management platform based on the information presented in the programmatic gap
table and modular templates.
Health System Strengthening Concept Note 15 October 2014│ 3
SECTION 1: COUNTRY CONTEXT
This section requests information on the country’s health system, and the health system
strengthening priorities according to the national health strategy. In addition, information is
required regarding synergies between the health system and community systems, as well
as how human rights and gender are being addressed. This description is critical for
justifying the choice of appropriate interventions.
1.1 National Health Sector
With clear references to the current national health strategy and the relevant national
disease strategic plans (including the names of the documents and specific page
references), and in addition to the portfolio analysis provided by the Global Fund:
a. Provide a concise overview of the national health system in the country, covering
both the public and private sectors at the national, sub-national and community
levels.
b. Describe key problems in the health system at national, sub-national and
community levels that constrain the country from improving health outcomes for at
least two of the three diseases.
c. Highlight the community systems, human rights and gender issues that constrain
health system functioning (as related to two or more of the three diseases), by
leading to poor coverage, access and use of health services.
2-4 PAGES SUGGESTED
a) Overview of the national health system
The Ethiopia’s health policy focuses on democratization and decentralization of the health
care system and assurance of accessibility of health care for all; and encouraging private
and non-governmental organizations (NGOs) participation in the health sector1.
The health sector has a three-tier health care delivery system: level one is a
Woreda/District health system comprised of a primary hospital (cover 60,000-100,000
people), health centers (15,000-25,000 population) and their satellite Health Posts (3,000-
5,000 population) connected to each other by a referral system. The primary hospital,
health centre and health posts form a Primary Health Care Unit (PHCU) mainly in rural
1 Health Policy of the Transition Government of Ethiopia, 1993; page 4
Health System Strengthening Concept Note 15 October 2014│ 4
settings. Level two is a General Hospital covering a population of 1-1.5 million people; and
level three is a specialized Hospital covering a population of 3.5-5 million people (see
figure-1 below). At the various levels, rapid expansion of the private for profit and NGO
sectors is augmenting health service coverage and utilization2.
Figure 1: Ethiopian Health care tier system
There has been massive expansion of health facilities over the last decade. As of June
2014, there are a total of 156 public hospitals (including 26 university and referral
hospitals), 3,335 health centers and 16,251health posts providing health services. A
number of new constructions of health facilities is going on including 123 hospitals, 211
health centers and 203 health posts3. Private health facilities have also significantly been
contributing in increasing access to health services. Furthermore, there are civil society
organizations (CSOs)/faith based organizations (FBOs) backing up the care and support
through community based systems supporting continuity of care. In total, MoH documented
more than 4090 private facilities including 63 private hospitals, 280 higher clinics, 850
medium clinics and 2,899 lower clinics for its consideration of HMIS scale up at private
health institutions4.
The devolution of power to regional governments has resulted in largely shifting the
2 HSDP IV 2010/11-2014/15, Page 4 and 75 3 HSDP IV Annual performance report 2014 4 Special Bulletin 16th Annual Review Meetings 2014, page 71-73
Health System Strengthening Concept Note 15 October 2014│ 5
decision making for public service delivery from the centre to being under the authority of
the regions and down to the district level. Offices at different levels from the Ministry of
Health (MoH) to Regional Health Bureaus (RHBs) and Woreda Health Offices are
mandated to run their own decision making processes, duties and responsibilities. MOH
and the RHBs focus more on policy matters and technical support while Woreda Health
Offices manage and coordinate the implementation of the district health programs under
their jurisdiction.
Ethiopia`s overall strategic development framework, the Growth and Transformation Plan
(GTP 2010/11-2014/15), is geared towards achieving the Millennium Development Goals
(MDGs). The GTP is an important enabling strategic framework for the realization of the
MDG targets. Much broader in scope, the GTP is inclusive of all the MDG relevant sectors
(road, water, education, health, economic sectors) and most of the targets for these sector
programs are in line with MDG targets.
The medium of translating the health component of the GTP is the Health Sector
Development Program (HSDP 2010/11-2014/15), the main program of the health sector
that is being implemented within the framework of the Sector-Wide Approach programs
(SWAP). HSTP is a 20 years program launched in 1997 and includes incremental
investment programs and mid-term plans to reform the health service delivery system. It
serves as guiding framework for detailed planning, implementation, monitoring and
evaluation of intervention in the health sector throughout the country. The primary goal of
this program is to provide comprehensive and integrated essential health service packages
through strengthening the primary health care system. In 2009/2010, MOH developed the
fourth HSDP which was consulted and jointly assessed using the Joint Assessment of
National Health Strategies (JANS) tools. HSDP IV is now in its final year demanding for a
heightened momentum to ensure all health related targets are met. Encouraging results are
achieved so far in all the three health related MDGs, prominently on reducing child mortality
and combating HIV/AIDS, Tuberculosis and malaria (ATM).
Building on lesson learnt in the past and anticipating the potential circumstances in the
future, MoH in consultation with relevant stakeholders has drafted a 20 year envisioning
document and a five year strategic plan named Health Sector Transformation Plan (HSTP)
for the post MDG era.
b) Key problems in the health system
HSDP IV has put clear strategies how to achieve the MDGs in the defined five years before
2015. During the planning of the HSDP IV, there was a big funding gap. However, through
Health System Strengthening Concept Note 15 October 2014│ 6
active resource mobilization activities, considerable amount of the funding gaps were filled
by contribution from the Government of Ethiopia (GoE), bilateral and multilateral
development partners. The GoE has committed itself to cover as much prevailing gaps as
possible so as to reach the MDGs and post-MDG targets, which are being set in the new
Health Sector Transformation Plan (HSTP 2015/16-2019/20). As per the International
Health Partnership (IHP+) compact, development partners have also committed
themselves to provide predictable additional financing and work towards aid effectiveness.
Ethiopia has made a very good progress to achieve many of health related MDGs.
However, sustaining the gains made and continuing further progress is a point of concern
to all stakeholders of the health sector. Financial constraints, gaps in human resource
development, quality of the health information, managing the supply chain and meeting the
ever increasing health needs of the community are among the challenges of the sector.
The need to strengthen the health system has become prominent more than ever to
address the existing and new constraints. It is believed that addressing the prioritized
health system components in this concept note alleviate a considerable size of the health
system constraints:
c) Highlight the community systems, human rights and gender issues that
constrain health system functioning
Community ownership is among the major objectives of the current HSDP and remains so
in the future. Without the community ownership of the health system, sustainable
development in the health and related sectors is unthinkable. Cognizant of this fact, the
government of Ethiopia has put the Health Extension Program (HEP) in place with a key
philosophy of transferring the right knowledge and skill to households can make people
take responsibility for producing and maintaining their own health at household and
community level. The HEP is the flagship health sector program mainly focusing on
community based activities with a strong linkage with the rest of the health system
components.
The PHCU mentioned above make use of HEP as main pillar of the community health
system with the context of PHC approach. This approach insures health is a human right
agenda by making essential health service packages readily available and closer to the
community with minimal barriers to access the services. The 16 health extension services
under maternal and child health (MCH), disease prevention and control (DPC), hygiene
and environmental packages are provided in more than 16,000 kebeles (the lowest
administrative units) for free by deploying more than 38,000 salaried HEWs and millions of
health development army (HDAs) networks. The HEP focuses on women’s and children’s
health carried out by HEWs who are predominantly women that make health
Health System Strengthening Concept Note 15 October 2014│ 7
communication relatively easy to women. The women health development army promotes
women empowerment and improve access to health care by mothers and children in the
spirit of solidarity. With this approach, equity to essential health services is better
addressed including gender disparities.
Table 1: Packages of the HEP
Hygiene and
Environmental Sanitation
Diseases
Prevention and
Control
Family Health
Services
Health
Education
1. Proper & safe excreta
disposal system
1. Prevention &
control HIV/AIDS
1.Maternal & child
health
1. Health
Education &
communication
2. Proper & safe solid &
liquid waste management
2. Prevention &
control TB
2. Family planning
3. Water supply safety
measures
3. Prevention &
control Malaria
3. Immunization
4. Food hygiene & safety
measures
4. Adolescent
Reproductive
Health
5. Healthy home
environment
5. Nutrition
6. Arthropod & rodents
control
7. Personal hygiene
GoE has a strong focus on gender mainstreaming and human right to be addressed in all
political, economic and societal spheres so that women and men participate and benefit
equally from development. This focus is evident by gender sensitive policies and legal
frameworks such as Developmental Social Welfare Policy, National Reproductive Health
Strategy, Civil Servant Proclamation with Women’s Right to Affirmative Action, Family Law
Addressing Harmful Traditional Practices and the Health Sector Gender mainstreaming
manual to guide equity at all levels of the health sector.
Special attention is given to people of developing regional state to address the existing
Health System Strengthening Concept Note 15 October 2014│ 8
inequalities in accessing health services mainly due to their lifestyle (e.g. pastoralist areas).
Civil society organization particularly the local CSOs are taking part in the health sector
making sure that members of their constituencies are reached with essential health
services. Associations of people affected by diseases are taking part in the health sector
mainly through awareness creation, being voice of the needy and improve access to health
care. Hence, the Ethiopia’s health system is highly considerate of strengthening the
community system to ensure rights of every citizen for health and insure equity to essential
health services.
1.2 National Health Strategy
With clear references to the current national health strategy and the relevant national
disease strategic plans (including the names of the documents and specific page
references), briefly describe:
a. The priority health goals in the national health strategy, as relevant to this specific
request, and how well the disease specific plans are aligned to these goals.
b. The performance of priority health system components, as relevant to this request.
Highlight the strengths, weaknesses and measures needed to strengthen health
system performance in a way that addresses the constraints described in 1.1.
c. The processes for reviewing and revising the national health strategy, including
how the government and partners have addressed or are responding to health
system weaknesses based on lessons learned. If the current strategy has less than
18 months to run, explain the process and timeline for the development of a new
strategy and how key populations will be meaningfully engaged. Also briefly
describe how the health sector review is linked to the disease specific reviews, and
any efforts to align.
4-5PAGES SUGGESTED
a) Priority health goals
The current National Health Strategy, HSDP IV, runs till mid-2015. This strategy was set
based on the countries need and well aligned with the MDGs. Encouraging results have
been witnessed in reducing under-five mortality, improving maternal health and reducing
incidence and death due to HIV/AIDS, tuberculosis and malaria. Even though Ethiopia
registered encouraging results on MDGs, the prevalence and mortality rates of HIV/AIDS,
Health System Strengthening Concept Note 15 October 2014│ 9
Tuberculosis, and Malaria are considerably high, above the global averages. Many children
and mothers are still dying due to avoidable causes. Hence, reducing child mortality,
improving maternal health and combating major communicable diseases remain the priority
goals of the coming strategies with the addition of focus to non-communicable diseases.
The draft HSTP has set the following goals based on projection using OneHealth tool:
Reduce maternal mortality below 200/100,000 live births by 2020
Reduce under-five mortality below 35/1000 live births by 2020
Reduce neonatal mortality below 15/1000 live births by 2020
Reduce malaria cases by 75% by 2020 from 2013 baseline
Reduce TB mortality by 45% by 2020 from 2013 baseline
To prevent at least 70,000 new HIV infections between 2015 - 2020
b) Performance of priority health system components
Ethiopia has achieved MDG 4 three years ahead of schedule by reducing under-five
mortality rate by two-third from the 1990 estimate. Two and half decades ago, 204 children
out of 1000 live births were dying before celebrating their 5th birth day. Through the
concerted effort of the Ethiopian people, the government and our partners, it has been
possible to reduce the under-five mortality rate to 68 per 1000 live births; helping 136 more
children per 1000 live births celebrate their 5th year (WHO’s World Health Statistics report-
2014).
According to the recent UN estimate for the year 2013, Ethiopia has made a considerable
progress in reducing 69% of the maternal mortality from the 1990 estimate (Ref). With the
current rate of reduction, it is possible to exceed the MDG target by the end of 2015. Array
of maternal health programs are in place to improve the maternal health.
Health System Strengthening Concept Note 15 October 2014│ 10
Figure 2: Trend of Under-five Mortality Rate and Maternal Mortality Ratio in Ethiopia5
Mortality and morbidity due to HIV/AIDS, Tuberculosis and malaria (MDG 6) has reduced
markedly. HIV new infection has dropped by 90% and mortality cut by more than 50%
(Ref). Mortality and incidence due to Tuberculosis has declined by more than 63% and
32%, respectively from the 1990 baseline.6 Death due to malaria has declined significantly.
Malaria outbreak has not been witnessed for the last 6 years (Malaria NSP).
The roles of the following health system components are immense in achieving the above
mentioned positive trend of health outcomes.
1) Human Resource Development (HRD)
The health workforce is the major component of the health system. Cognizant of this fact,
Ethiopia has given due emphasis for human resource development evidenced by
production of more than 38,000 HEWs, thousands of mid-level health professionals,
medical doctors, midwives, massive expansion of health science colleges in the last
decade.
The ever-growing need of the community in accessing quality health information and
services urges the MOH and RHBs to produce and maintain qualified and committed health
workforce. Production and maintaining of qualified human resource for health in adequate
5 http://www.countdown2015mnch.org/documents/2014Report/Ethiopia_Country_Profile_2014.pdf 6 Global TB report, 2013
Health System Strengthening Concept Note 15 October 2014│ 11
quantity and skill mix remain among key challenges of the health sector (Annex_1). A case
in point in Ethiopian context is HEP. The main focus of HEP was initially on health
promotion and diseases prevention activities of selected priority conditions and diseases
with limited basic curative services. Currently, the community is demanding health
information and services in a much better quality for existing and emerging health
problems. Hence, upgrading HEWs is a pressing need of the sector while keeping on
providing Integrated refresher training (IRT). Similarly, the need to avail Health Information
Technicians (HIT) is increasing as the number of health facilities are increasing as
generating information timely with manual system becomes a daunting task. In order to
transform the current paper based reporting system to electronic based reporting system,
pre-service training of HITs is crucial.
2) Supply Chain Management System
GoE, mainly through Pharmaceutical Fund and Supply Agency (PFSA) and Food, Medicine
and Healthcare Administration and Control Authority (FMHACA) is exerting a tremendous
effort to improve the supply chain of the sector with their role of availing pharmaceuticals
and regulating them respectively. Annual pharmaceutical distribution value has increased
by more than ten-fold in less than a decade. Seventeen modern warehouses are almost
completed raising the national storage capacity to 320,000 metric cub from 30,000 metric
cub and the old chain capacity has grown to 600 metric cub from 50 metric cub five years
ago. However, stock outs of essential supplies are still reported particularly at the lowest
level of the tier system mainly due to inadequate distribution capacity to the lowest service
delivery points. Capacity building efforts are required in forecasting, quantifying, storage
and distribution of medicines, lab reagents, medical equipment and supplies.
Following an extensive Business Process Reengineering work address the challenges,
PFSA has concluded that an efficient and modern pharmaceuticals supplies management
information system is urgently required. This system will enable PFSA manage the
forecasting of pharmaceutical needs, procurement, storage and distribution and support
process. PFSA has identified the need to convert its existing paper-based and semi -
automated system, which has been in use for some years to fully automated electronic
based pharmaceuticals supply information system. This project will serve as a cornerstone
for a modern Integrated Pharmaceuticals Fund and Supply Management Information
System, IPFSMIS. Thus, it shall become a Data Warehouse for the execution of Federal
and Local Government pharmaceutical services. Furthermore, it will process and manage
human resource and the Agency’s property.
While PFSA focuses on procurement, storage and distribution of pharmaceuticals including
Health System Strengthening Concept Note 15 October 2014│ 12
medical equipment, FMHACA plays the regulatory functions to ensure safety of citizens in
receiving health services. Practices, Premises, Professionals and Products (4Ps) of health
services are regulated by the agency and similar arrangements at regional and lower
levels. FMHACA is fully in charge of registration, regulation, inspection, quality control and
supervision, and has authority to take necessary remedial actions regarding
pharmaceutical and health products. FMHACA’s responsibility for quality control includes:
pre-shipment inspection; following process of manufacturing goods; and checking the
quality of pharmaceutical and health products. It also has a mandate for licensing and
registration of drugs and health commodities procured or donated from abroad.
Among the regulatory functions of the agency is pharmacovigilance to ensure quality and
safety of products by closely following up of adverse effects of drugs and post marketing
surveillance of drugs (Annex_2).
3) Health Information System
Quality data is a key factor to generate reliable health information that enables monitoring
of progresses and make decisions for continuous improvement. Ethiopia has undertaken
reform of the health management and information system. Health information technology
initiatives are in place with various level of implementation to improve access and quality of
health services using appropriate technology. The initiative covers a wide range of
applications including telemedicine, tele-education, mobile health, electronic HMIS
(eHMIS), Electronic Medical Records (EMR), Geographic Information System (GIS) and
Human Resource Information system (HRIS). Besides, CHMIS has been designed to make
the information system and decision making effective at the grass root level. Owing to the
family centred provision of health services, a family folder (FF) was put in place to record
health information related to members of the family from birth to death as well as housing
conditions. Though implementation of FF started in 2010/11, its implementation so far
reached coverage of 64.5%.Application of technologies in digitizing FF is expected to
transform the CHIS in particular and the health information system in general7.
These initiatives have a huge potential to produce quality data and are means of minimizing
labours burden of manually operated systems. However, much work is needed to build
capacity and scale up of the programs. A Routine Data Quality Assessment (RDQA) was
conducted in 2014 covering 91 districts, 2 health offices and 214 health facilities in all
RHBs and MoH. The following figure is the summary of the finding of the assessment
7 HSDP IV performance report, 2013/14 (page 63, 83, 84)
Health System Strengthening Concept Note 15 October 2014│ 13
indicating the need to improve in all components of HMIS performance.
The figure below (Figure 3) show the summary of system component as an index from 1 –
3 in accordance with WHO standards. The information use component is included as it is
believed to increase demand for quality data. Hence, there is a need to focus more on
resource component (index of 1.28)-inputs/resources include HMIS unit, budget, card
room size, availability of card room worker and runner, standard shelves, computer
and receipt of supervision with feedback, M&E structure & capability (1.632) and
information use (1.63).
Figure 3: Summary of HMIS performance by system components at health facility level8
4) Service Delivery: Laboratory System
Laboratory diagnostics capacity is improving from time to time. However, its contribution in
diagnosing diseases and follow up of patients is affected by suboptimal laboratory capacity
and referral system. Main limitations include infrastructure related challenges that require
renovation, suboptimal networking of laboratories and capacity in maintenance of medical
equipment. Sample transportation for quality assurance and backing up each other in case
of failure to provide service in one facility are sub optimal. There is no well-established
8 Special Bulletin 16th Annual Review Meeting 2014, page 48-55
Health System Strengthening Concept Note 15 October 2014│ 14
laboratory information network that eases exchange of information between referral and
peripheral laboratories (Annex_4).
5) Health Care Financing/Financial Management System
MoH has placed mechanism that can improve mobilization and efficient utilization of
resources including health care financing reform; signing IHP+ compact with development
partners, annual resource mapping exercise under woreda (district) based national
planning as well as strengthening the financial system through placing dedicated grant
management unit, internal audit and implementing Integrated Financial Management
Information System (IFMIS) (Annex_5).
According to the recent National Health Account (NHA V), per capita health expenditure
increased to USD 21 in 2010/11 from USD 16 in 2007/08. This figure is far less than the
WHO’s recommended USD 34, revised to USD 60 by 2015.
Figure 4: Trend in Per capita Health Expenditure in Ethiopia
The health sector is financed by government treasury, households and donors. About 34%
of the source of health expenditure in 2010/11 were households, that are burdened by high
Out-of-pocket costs for health incurred at the time of sickness. Cognizant of this fact,
Health System Strengthening Concept Note 15 October 2014│ 15
introduction of prepayment mechanisms and insurance are being placed to pool risks
between the healthy and the sick as well as the poor and the better-off With this regard, the
country has adopted two financial mechanisms namely community-based health insurance
and social health insurance. The community based health insurance has now been scaled
up to 161 districts from 13 districts in four regions. The social health insurance is organized
for formal sector including pensioners to ensure access to health care services9.
Though good progress has been observed in mobilizing and utilizing more resources for
the health sector from various sources, there is still a need to mobilize more resources to
significantly reduce preventable and avoidable morbidity and death of children, mothers
and productive citizens. Besides, recording and reporting the use of available resources is
critical using reliable mechanisms such as grant management and IFMIS. There is broad
agreement that a fully functioning IFMIS can improve governance by providing real-time
financial information that financial and other managers can use to administer programs
effectively, formulate budgets, and manage resources. Sound IFMIS systems, coupled with
the adoption of centralized treasury operations, can not only help developing country
governments gain effective control over their finances, but also enhance transparency and
accountability, reducing political discretion and acting as a deterrent to corruption and
fraud10.
c) Process of reviewing and revising the national health strategy
The management arrangement of the national strategy is clearly stated in the current
strategic document (HSPD IV). This arrangement is expected to continue in the upcoming
strategic period (HSTP) with some amendments if need be.
Health planning
The Ethiopian health planning is composed of two planning cycles. The first and most
significant reference of planning cycle is the currently five year strategic planning. The next
five year strategic plan, the Health Sector Transformation Program (HSTP 2015/16-
2019/20), is underway. It serves as a guiding blueprint on which all other plans are
developed, e.g., Regional Health Plans, etc. The second is the annual planning cycle that
translates the five year HSDP/HSTP into the annual Plan of Work with details of achievable
targets, strategies and interventions under the different levels of the health care system.
The current HSDP has less than a year to run. The follow up strategic plan, HSTP, is
9 HSDP IV annual Performance report, 2013/14 (page 85-87; 89-90) 10 IFMIS, a practical Guide, 2008; http://pdf.usaid.gov/pdf_docs/PNADK595.pdf
Health System Strengthening Concept Note 15 October 2014│ 16
underway with draft ready for wider consultation in few months and endorsement. High
level discussion has been conducted at the executive committee of MOH and its agencies
as well as Joint steering Meetings (JSC) between MoH and RHBs. The consultation is
going on at different level of the government structures including other sectors. Partners
have been informed of the progress and providing their inputs. A 20 year envisioning
exercise (post MDG framework for the Ethiopia’s health system) is awaiting endorsement
after a wider consultation is done with the participation of civil societies, professional
associations, international and local NGOs, local universities, donors and other relevant
stakeholders. The strategic documents (HSTP and the 20 year strategic framework) are
expected to be endorsed well before the end of the current HSDP (July 7-2015).
Performance Monitoring and Evaluation
The monitoring plan for the health strategy will draw significant lessons from the previous
experiences, which suffered from insufficient and poor quality of information for planning,
monitoring and evaluation purposes. In order to improve M&E, the monitoring and
evaluation system is designed as part of the Policy, Planning and M&E Core Process and
is being implemented at all levels of the health system.
Revision of HMIS is done and being implemented including reporting from the private
health facilities. Community HMIS is being scaled up to make use of information from
community based activities for timely decision making and continuous improvement.
In addition to the JSC meetings with RHB every two months and bi-weekly Executive
Committee Meetings with agencies of MoH, Joint Review Missions are conducted annually
in collaboration with development partners to review performance which usually followed up
by Annual Review Meeting of the sector (ARM).
There is a Joint Consultative Forum (JCF) which serves as a joint forum for dialogue on
sector policy and reform issues between GoE, Development Partners and other
stakeholders. In-addition to these review and dialogue platforms, the Global Fund Country
Coordinating Mechanism (CCM) and the coordination mechanism for the EPI activities
(ICC), will remain as is and strengthened in the future.
Evaluation of midterm reviews of HSDPs has been done by independent reviewers for all
rounds that informed areas of focus and recommendations on remaining periods and
beyond. Program specific reviews and assessments are done periodically including TB,
HIV/AIDS and malaria. Their findings are highly considered in strategic and operational
plans. Four Midterm Reviews (MTR) of the HSDP has been done in the last couple of
decades showing half-way progresses of each strategic period followed by revisions of
Health System Strengthening Concept Note 15 October 2014│ 17
plans and programs accordingly to achieve the targets.
SECTION 2: FUNDING LANDSCAPE, ADDITIONALITY AND SUSTAINABILITY
To achieve lasting impact against the three diseases, financial commitments from
domestic sources must play a key role in the national strategies. Global Fund allocates
resources which are far from sufficient to address the full cost of technically sound health
systems strengthening. It is therefore critical to assess how the funding requested fits
within the overall funding landscape for health system strengthening and how the national
government plans to commit increased resources.
2.1 Overall Funding Landscape for Upcoming Implementation Period
In order to understand the overall funding landscape for health systems strengthening and
how this funding request fits within this, briefly describe, as relevant to this request:
a. The priority health system strengthening areas or initiatives currently receiving
financial support, and main funding sources (government and/or donor). Highlight
any areas that are adequately resourced (and are therefore not included in the
request to the Global Fund).
b. How the proposed Global Fund investment will encourage the commitment of
additional resources to the specific HSS areas being requested.
c. The health system strengthening areas that have significant funding gaps, and the
planned actions to address these gaps.
1-2 Pages
a. The priority health system strengthening areas or initiatives currently
receiving financial support, and main funding sources (government and/or
donor). Highlight any areas that are adequately resourced (and are
therefore not included in the request to the Global Fund).
NB: The funding landscape for this concept note assumed the current trend of
funding landscape will continue for the next three to five years.
The health services in Ethiopia are financed from federal and regional governments, grants
and loans of bilateral and multilateral donors, NGOs and private contribution. MoH conducts
periodic assessments to estimate the flow of health resources through the NHA. Five NHAs
Health System Strengthening Concept Note 15 October 2014│ 18
were conducted since 1995, the recent one was published in 2014 referring to health
expenditures of the 2010/11 fiscal year. The NHA-V showed an incremental trend in health
spending in both nominal and per capita terms. Nominally, the national health expenditure
(NHE) increased from USD 1.2 billion in 2007/08 to over USD 1.6 billion.
Percentage Share of the Public Health Budget Allocation from the Total Budget
In 2013/14 (EFY 2006), the percentage of total budget allocated in the health sector at
regional level was 10.30%, which was higher than in 2012/13 (9.75%) (Figure below). The
regional block grant budget allocated to the health sector ranged from 5.6% in Harari to
15.6% in Gambella in 2013/14. Figure 6: Percentage of public health budget by region in
2010/11
Figure 5: Public health budget allocation by regions, 2012/1311
Contribution of Development Partners (DP)
The contribution of DPs is one of the major sources of funding for the Ethiopian health
sector. In 2013/14, a total of USD 558 million was committed and a little more than 100 %
disbursed. The share of the DPs disbursement is seen in figure below. Global Fund
accounted 50.4% of the total, followed by DFID (23.4%), GAVI (6.2%), World Bank (5.8%),
UNICEF (5.3%), WHO (3.6%) and others (5.5%). Considerable amount of resource
provided by US government partners through channel 3 modality are not captured in MOH’s
11 HSDP IV annual Performance report, 2013/14; page 92
Health System Strengthening Concept Note 15 October 2014│ 19
financial monitoring system.
Figure 6: Percentage distribution of disbursement by development partners/2010-11
In the framework of the Ethiopia IHP+ Compact, the MDG Performance Fund (MDG PF) is
in place according to the GoE’s preferred funding modality for scaling up development
partners assistance in supporting the HSDP.
Figure 8: MDG PF Disbursement 2007/8 – 2013/4
Health System Strengthening Concept Note 15 October 2014│ 20
Majority of the health service delivery, community health systems, leadership &
governance, vaccines and essential supplies, expansion and rehabilitation of health
facilities, PHCU strengthening efforts are relatively easier to be financed by GoE,
community contribution and development partners. Hence, much of the subcomponents of
the health system building blocks are not requested in this funding request as the above
mentioned trend of funding landscape is expected to continue covering a sizable cost of the
health sector. Hence, some activities of the following health system modules are requested
in this concept note.
1. STRENGTHEN HUMAN RESOURCE DEVELOPMENT FOR HEALTH
The FMOH recognizes that the successful implementations of the various health reforms
are dependent on the availability of adequate number and skill mix of clinical, public health
and administrative personnel. Hence, strengthening the human resource for health is
identified as one of the major means for achieving the priorities and targets set under HSDP
IV and beyond. Evidences have demonstrated that the performance and level of human
resource strengthening initiatives has the potential to determine and impede the progress
toward health-related MDGs and targets set beyond MDGs. The recruitment, training,
deployment, and retention of qualified human resource are among the main functions of
HRD.
Health System Strengthening Concept Note 15 October 2014│ 21
HRD has been a key component in the successive Ethiopia HSPDs. In HSDP III, the main
HRD objective was improving the staffing level at various levels as well as establishing
implementation of transparent and accountable Human Resource Management (HRM) at all
levels. HSDP IV has focused on ensuring demand driven production of human resources
and maximizing use of available resources in producing key categories of health workers for
which there is scarce supply.
The 2012/13 Annual health sector review report has indicated the need to strengthen the
human resource to ensure the challenges faced in the implementation of the targets. This
review has indicated the need for recruitment, enrollment, deployment and retention of
additional HEWs and HITs.
2. STRENGTHEN PHARMACEUTICALS SUPPLY CHAIN MANAGEMENT
SYSTEM
A well-functioning medicines supply management system is the backbone for effective
implementation of all health programs by assuring un-interrupted supply of essential
medicines that are efficacious and of good quality, physically accessible and used
rationally. Having understood this important fact the Government of Ethiopia has taken a
very important step by establishing federal organ called the Pharmaceuticals Fund and
Supply Agency (PFSA) in accordance with the Drug Fund and Pharmaceuticals Supply
Agency Establishment Proclamation No. 553/2007. The establishment of the agency marks
the Government’s ambition to supply quality assured essential pharmaceuticals in a
sustainable manner to the public.
The supply management of pharmaceuticals in Public sector of Ethiopia is currently guided
by the Integrated Pharmaceuticals Logistics System (IPLS). IPLS is a system designed to
integrate the management of commodities of the various programs; including ARVs and
pharmaceuticals for TB, Leprosy and Malaria programs and essential drugs managed
through Revolving Drug Fund. For proper implementation of IPLS and to operate an
effective logistics system key logistics area need to be strengthened. These include
construction of distribution outlets accessible to all public health facilities, efficient fleet
management and a robust Logistics information management system. Towards this end, in
the past three years modern warehouses are being built and the old ones were being
renovated to increase their storage capacity, vehicles of different size were procured to
strengthen the distribution capacity of the agency. When the constructions of all new
warehouses are completed the number of PFSA’s distribution Hubs will reach seventeen.
(IPLS SOP, March, 2014 & PFSA annual report, June 2014).
Health System Strengthening Concept Note 15 October 2014│ 22
In the face of the above efforts there is still a need to construct and equip additional hubs in
some corridors to attain the objective of having distribution hubs accessible to health
facilities within 160- 180 Km radius and additional vehicles to enhance the distribution
capacity of all hubs as per the design envisaged in the logistics master plan. Further
Furthermore, a robust Integrated Pharmaceuticals Fund and Supply Management
Information System (IPFSMIS) that furnish improved National forecasting on re-supply
requirement planning, Procurement, storage and distribution, Fund management, cost
recovery works of all pharmaceuticals. Besides, it will process and manage Human
resource and the Agency’s property in harmonized way. IPFSMIS is expected to replace
the existing paper-based and semi -automated system.
Current major challenges in pharmaceutical supply chain management include the need to
have robust Logistics management information system. The Agency identified lack of
harmonized comprehensive system that integrate efficient management of pharmaceuticals
including forecasting, procurement follow-up, inventory management, warehousing, finance,
Human resource and fleet management. Accessibility of PFSA distribution hubs within a
defined distance to all public health facilities in the country is also an area that calls
attention. Furthermore, Lack of handing and warehouse security equipment (CCTV camera,
Bar-coding), poor inventory management, limited number of vehicles for distribution of
pharmaceuticals from Hubs to all health facilities including the last miles (heath post) are
also among the bottlenecks that needs immediate intervention.
With relation to pharmacovigilance, more emphasis will be given on awareness creation of
Adverse Effects of Drugs including drugs of HIV/AIDS, malaria and TB as well as
strengthening the laboratory of FMHACA in its effort of ensuring quality of imported
medicines and post market surveillance.
3. IMPROVE HEALTH INFORMATION SYSTEM
Routine health service statistics is the main source of data to analyze health service
coverage and to take appropriate decision for program improvements. Because of its
importance, Ethiopia has invested a lot to improve Health management information system
and routine health service data quality.
Shift from paper-based HMIS to electronic HMIS and Medical Record System (e-HMIS and
EMR) has been initiated and there is a need for rapid scale up of e-HMIS and digitalizing
family folder of the community health information system (CHIS) in the country. Besides
this, FMOH has completed the revision of the HMIS indicators, recording and reporting
formats.
Health System Strengthening Concept Note 15 October 2014│ 23
4. STRENGTHEN SERVICE DELIVERY THROUGH ENHANCING LABORATORY
CAPACITY AT ALL LEVELS
The 4th Health Sector Development Program (HSDP IV) envisioned the attainment of the
health related millennium development goals (MDGs) by 2015. The review of performance
of HSDP III has identified challenges & gaps of HSDP III & linkages to HSDPIV. This
process has showed that weak laboratory diagnostic services is one of the challenges and
gaps in the implementation of targets set for major communicable disease prevention and
control initiatives including Malaria, Tuberculosis and HIV/AIDS. For this effect the 4th
Health Sector Development Program has prioritized to enhance laboratory capacity at all
levels through upgrading laboratory networks, establish & strengthen laboratory equipment
maintenance workshops and strengthening laboratory information system.
The recent evaluation of the health sector has revealed the need to strengthen quality and
accessibility of laboratory services at all levels. The 2005 EFY health sector review report
identified and prioritized; strengthen sample transportation to effectively utilize available
high-tech diagnostic facilities; production and use laboratory service information for local
decision making and decreasing the laboratory instrument down time to be acted in the
coming consecutive years.
5. IMPROVE FINANCIAL AND GRANT MANAGEMENT CAPACITY
The fourth Health sector development program and subsequent disease specific strategic
documents have envisioned the attainment of ambitious and resource intensive targets
through increasing harmonization and efficiency in resource allocation and utilization.
Strengthening health system and providing quality and equitable health care to all of its
citizens remains a priority for the government of Ethiopia and all stakeholders in the health
sector. Due to the success of preventive focused government health policy, financial
resources committed both from government and donors’ side has increased in the past
decade. Presently the health sector receives significant financial resources from multiple
sources through different channels.
However, the financial management capacity of the health sector needs to be enhanced
with the increasing financial resources and the entailed sustainable financing strategy.
HSDP IV has set a target of 90% utilization of financial resources through implementation of
innovative initiatives. Hence, it becomes more important for FMOH to design and
implement different grant and financial management reforms/initiatives that are able to
catalyze timely grant fund utilization and reporting capacity at different levels. To this effect,
Health System Strengthening Concept Note 15 October 2014│ 24
improving the coordination of grant implementation and scaling up of automated financial
reporting (IFMIS) is prioritized in the HSDP IV targets to improve resource utilization and
included as part of this Health System Strengthening support. IFMIS is expected to be the
single source for national consolidated financial information, with all stakeholders accessing
government financial information from a unified source. The project is expected to adopt
global best practices and ensure that data are entered only once, avoiding data entry
repetition during consolidation, therefore ensuring harmonization and integration between
different departments. In this perspective, GoE has purchased an internationally recognized
enterprise resource planning software (Oracle). The health sector represent by FMoH has
been participating in the national project since 2011/12. However, the pace of enrollment at
regional level and below is slow. Hence, the MoH is highly interested to cease this funding
opportunity and speed up the scaling up of IFMIS in collaboration with Ministry of Finance
and Economic Development (MoFED).
6. LEADERSHIP AND GOVERNANCE
As a priority intervention, training of district heath management training has been supported
by government and previous global fund grants.
b. How the proposed Global Fund investment will encourage the commitment
of additional resources to the specific HSS areas being requested.
Most of these priorities areas were identified during disease specific concept and national
strategic plan developments which include different agencies of MoH, RHBs and Partners.
These HSS interventions have significant funding gaps even after considering partners
contribution. However, the partners and different stakeholders are convinced that without
well-functioning program specific investments will not have adequate return of investments
they are making. And these HSS interventions have also been priorities for HSDP and are
continued to be for the upcoming health sector strategy (HSTP), which have buy-in from
domestic and international partners and The stakeholder and development partners are
willing to invest more on HSS. In addition, the Global Fund modality of disbursing 15% of
the allocated amount ($90m) upon the domestic increment in investment (willingness-to-pay
(WTP)) is another encouraging investment on health system. This will increase the
domestic financing for health, in which areas to be financed with this increased financing
include prioritized HSS components.
c. The health system strengthening areas that have significant
funding gaps, and the planned actions to address these gaps
For those HSS intervention that prove to have significant funding gaps,
planned actions to address these gaps include
Health System Strengthening Concept Note 15 October 2014│ 25
Maximizing the community ownership and participation to improve the health
system.
Proactive resource mobilization from domestic and international
funding partners
prioritization of actions so that they are realized in a logical
sequencing, if need be, while not compromising the overall
effectiveness of the program in reaching its goals
Finally, reprogramming of available resources may be considered
as an option that could have greater impact on disease specific
targets.
Table 2: Summary Funding Landscape for priority HSS areas
Priority HSS areas Total Funding
need ($)
Commitment
($)
NFM
Allocation
($)
Funding
Gap ($)
Human Resource (For HEWs
upgrading, HIT training & IRT)
60,995,000 38,718,460 12,037,140 10,239,400
Supply chain management 17,023,730 3,889,000 8,694,319 5,140,411
Health Information System 18,043,986 3,469,960 10,367,826 4,206,200
Laboratory System Strengthening 29,511,190 10,259,000 8,618,145 10,634,045
Financial Management 6,063,590 3,000,000 3,063,590 0
District Health Management 3,213,522 300,522 2,913,000 0
Total 134,451,018 59,636,940 45,694,020 30,220,056
Health System Strengthening Concept Note 15 October 2014│ 26
SECTION 3: FUNDING REQUEST TO THE GLOBAL FUND
This section details the request for funding and how the investment is strategically
targeted to strengthen health systems and achieve greater impact on the diseases. This
section requests an analysis of the key programmatic gaps which in turn forms the basis
upon which the request is prioritized. The modular template organizes the request to
clearly link the selected modules and interventions to the goals and objectives of the
request, and associates these with indicators, targets, and costs.
3.1 Programmatic Gap Analysis
A programmatic gap analysis needs to be conducted for the three to six priority
HSS modules within the applicant’s funding request.
With respect to each of the three to six priority HSS modules within the funding request,
briefly describe (i) the types of programs currently in place, (ii) the populations or groups
involved where relevant, and (iii) the current funding sources and resource gaps.
If any of the three to six priority modules are easily quantifiable, complete a
programmatic gap table (Table1) instead of the narrative description below. Ensure
that the coverage levels for the priority modules selected are consistent with the coverage
targets in section D of the modular template (Table2).
2-3 PAGES
SUGGESTED
Six priority cross-cutting HSS modules are identified in this concept note based on the
reviews of the current health system performance and consultations with stakeholders on
HSTP and envisioning exercise and during disease specific concept note preparation
country dialogues and discussions. As the upcoming health sector strategy (HSTP) is
being developed, it is not easy to quantify the priority modules with exact figures. Hence,
the funding request is justified with the following qualitative gap analysis.
Human Resource
Resource need: $60,995,000
Commitment: $38,718,460
NFM Allocation: $12,037,140
Above Allocation: $10,239,400
Health System Strengthening Concept Note 15 October 2014│ 27
One of the focus areas in HRD is upgrading of HEWs to level IV with the aim of meeting
the increasing demand for quality health services. About 5000 HEWs were enrolled and
graduated as of 2013. Additional 5000 HEWs are expected to be enrolled in 2014/15. The
remaining 22,000 HEWs will be upgraded over the coming three years. It is anticipated
that GoE and MDG PF contributes to cover the cost of upgrading HEWs while this funding
request is to cover the remaining gap.
All the HEWs require refresher trainings on all IRT modules once every two years.
Previous grants of the Global Fund have supported the Integrated refresher training for
HEWs by leveraging resource from USG, UN agencies and other partners support. This
funding request will cover the training of modules I (ICCM), II (RMNCH), and IV (TB/HIV) of
the IRT for all HEWs.
To address the need for improved quality health information from increasing number of
health facilities, training and deployment of Health Information Technicians (HIT) among
the priorities of HRD. By the end of 2014, there will be total of 3,798 HITs with total need
of training more than 6000 HITs over the coming three years. This activity has been
supported by USG, CDC, MDG PF and government. In addition, previous GF grants
supported the training of these cadres and similar trend is expected with this funding
request.
Procurement and Supply Chain Management:
Resource need: $17,023,730
Commitment: $3,889,000
NFM Allocation: $8,694,319
Above Allocation: $5,140,411
As indicated earlier, the main gaps in procurement and supply chain management of the
health system are lack of reliable information flow in the forecasting and quantification,
procurement, storage and distribution of commodities, fund management, cost recovery
works of pharmaceuticals &medical equipment and limited capacity for bulk logistics
transport and storage at national level. This entails the need for completely efficient and
modern Integrated Pharmaceuticals Supplies Management Information System (IPFMIS)
to generate timely information which is required to ensure uninterrupted supply of essential
pharmaceuticals and supplies. Besides strengthening the logistics information system,
there is also a need to enhance the storage and distribution capacity at national and sub-
national levels. The Pharmaceutical Supply and Fund Agency (PSFA) has received funding
mainly from USAID, UNICEF, UNFPA, Clinton Health Access Initiative (CHAI), GAVI and
Health System Strengthening Concept Note 15 October 2014│ 28
Global Fund to improve its procurement, storage and distribution capacity.
Through support of this funding request, the pharmaceuticals and logistics information
system will be strengthened by installation of Enterprise Resource Planning /ERP/ software
at regional hubs, training of end-users on the new IPFMIS software. More than 500 end
users will receive change management and end-users training on the software with the
support of funding through this concept note.
Storage and distribution capacity of PFSA will be further enhanced through procurement of
heavy trucks with Trailers, Medium Trucks, Forklifts, GPS equipment for all trucks, and
equipping newly constructed PFSA warehouses. Total of 17 Heavy Trucks to deliver
pharmaceuticals from Center to 17 Branches each with 250 quintals, 85 Medium Trucks to
deliver pharmaceuticals from PFSA 17 Branches to Health Facilities with 100 quintals
capacity, 17 forklift to unload from Truck one for each Branch and GPS for 270 vehicles
are required in this concept note period and 15 trucks need to be replaced. Five heavy
trucks, 17 medium trucks and 9 forklifts were procured by the GAVI, GF and UNFPA are
procuring respectively. And 48 medium trucks are in the process of procurement through
the GF. Hence, the gaps are requested in this concept note.
Besides, quality assurance of health commodities will carry out by FMHACA through
strengthening its quality assurance laboratory, awareness creation and reporting of
Adverse Event of Drugs.
These interventions will assist in meeting the goal of PFSA and FMHACA to deliver quality
assured health commodities to all public health facilities in the grant period of this funding
request which in turn improves the supply management system of the country.
Health Information System
Resource need: $18,043,986
Commitment: $3,469,960
NFM Allocation: $10,367,826
Above Allocation: $4,206,200
The health information technology initiative of the MoH covers a wide range of applications
including electronic HMIS (e-HMIS), The national health management information system
(HMIS) has been revised recently with inclusion of additional indicators and will be reported
electronically. Training of health care workforce and program staffs across the health tier
system on the e-HMIS recording and reporting tools has begun with funding from GoE.
However, there is a financial gap to train adequate number of health care providers and
program staffs on the revised HMIS and e-HMIS. Besides, this funding request would be
Health System Strengthening Concept Note 15 October 2014│ 29
an opportunity to attract more funding to Community health information system (CHIS) by
covering some of the cost of tablet computers and operational trainings for digitizing the
family folder. More resources will be mobilized from GoE and development partners to go
for full scale up of digitizing family folder covering more than 16,000 health posts in the
grant period.
Service Delivery: Laboratory System Strengthening
Resource need: $29,511,190
Commitment: $10,259,000
NFM Allocation: $8,618,145
Above Allocation: $10,634,045
The health care system in Ethiopia relies upon a tiered network of laboratories and
reference laboratories, with an increasing degree of specialization at each tier. As part of
this design, specialized instruments have been placed at various laboratories throughout
the country, including Culture systems, TB liquid culture facilities, automated analyzers for
hematology, chemistry, and CD4; molecular diagnostics like DNA-PCR; and additional
molecular diagnostic laboratories. In order to utilize this network effectively, it is essential
that communications and data systems are established between laboratories.
An efficient laboratory network requires that samples be transported from small
laboratories (e.g. district, health center) to larger laboratories (Regional or National) for
specific tests. A system for reliable and safe sample collection, transport, and delivery will
be established for all sites that require tests to be conducted at other laboratories. Sample
stability has a significant influence on the design of a transportation system. In addition to
this unavailability of advanced Laboratory test at each heath facility level, poor
communication between the upper and lower level laboratories; and postal office, lack of
awareness on sample transportation for advanced specific testing and using postal office
(for both health professional and postal officers) and lack of follow up at regional and
federal level
Also, logistics systems must be in place to ensure that samples requiring specialized
testing can be referred from one tier to the next. In the event of an instruments breakdown
or sample backlogs, nearby laboratories must be able to refer samples to others where
back-up services are provided. Sample transportation services have been implemented at
some levels of the system, but they have not been uniformly effective throughout. They
have also been implemented with varying degrees of effectiveness. In order to upgrade
laboratory networking, strengthen the sample referral network, and facilitate laboratory
Health System Strengthening Concept Note 15 October 2014│ 30
activities information flow the following activities will be implemented:
Among the challenges in laboratory services is suboptimal focus on infection control. There
is a need to renovate the laboratories of high volume facilities from the infection control
perspective. Frequent laboratory equipment breakdowns, weak sample referral and weak
laboratory information system has been among the key gaps affecting priority health
programs such as HIV/AIDS, TB and Malaria.. There is a national plan to improve medical
and laboratory equipment maintenance through establishment of regional maintenance
workshops, training and deployment of biomedical technicians and engineers. With the
support of GAVI funding in MDG PF, 12 maintenance workshops with tools will be
established. Initiatives to improve laboratory information system and laboratory networking
have also begun to be implemented with the domestic resources and with some support
from US Government (USG) partners. Close to 50 laboratories in high volume hospitals are
enrolled to be accredited through Strengthening laboratory Management Towards
Accreditation (SLMTA). Specimen transportation and EQA system is being supported by
(USG) implementing partners. However, there is no adequate resource to renovate
laboratories of high volume hospitals to improve infection control, patient flow and quality of
laboratory services. In this concept note, renovation of 50 high volume laboratories and
support to specimen referral system are requested,
Financial Management
Resource need: $6,063,590
Commitment: $3,000,000
NFM Allocation: $3,063,590
Above Allocation: $0
Despite very good progresses in resource mobilization for health, the current financial
management capacity of the health sector is challenged by delayed liquidation of funds,
poor at regional and lower levels. This requires for financial management reforms/initiatives
with focus on improvements in the financial information system and grant management
capacity. The rollout of Integrated Financial Management Information System (IFMIS) is
aimed at addressing the gaps. The funding source for this program is the GoE so far.
Through this concept note, the pace of IFMIS project implementation at federal and
regional level will be speed up through end-users training on IFMIS, procurement and
installation of IT supplies, mentoring and supervision of its implementation. Technical
assistance through deployment of regional and zonal grant/finance officers and financial
management trainings will enable the roll out of IFMIS in a much faster rate than
implementation by Ministry of Finance and Economic Development (MOFED). MOFED
has already procured the IFMIS software which is oracle based application and is paying
Health System Strengthening Concept Note 15 October 2014│ 31
more than a million dollar annually for maintenance. The health sector is one of the few
sectors selected by MOFED in earlier phase of phased-in implementation at federal level.
However, the pace of implementation by MOFED is slow as there are many sectors at
federal and lower level to roll out the system. Hence, the MoH in collaboration with MOFED
would accelerate the implementation of IFMIS in the health sector through this funding
request.
Leadership and Governance:
Resource need: $3,213,522
Commitment: $300,522
NFM Allocation: $2,913,000
Above Allocation: $0
Strengthening District Health Management is essential in the decentralized health system
where PHC is the main approach in service provision. The district health offices are
responsible to implement essential health service programs by developing operational
plans, allocating resources, monitoring and evaluating progresses with their PHCUs.
Hence, the leadership and governance skill of district health mangers need to be
capacitated to meet the expectation. The district health system is where most of the PHCU
and community based activities are consolidated to maximize impact. When a considerable
size of woredas (districts) is transformed, the country as a whole will be transformed in
which equity will be addressed. Hence, institutionalizing district health management
capacity building efforts will be instrumental to continuously train and provide supportive
supervision to district health managers. GoE and partners such as WHO and GF are
supporting trainings of district health managers so far. GF is requested to continue
supporting this training in this funding request. MOH is building a training center in which
trainings of such kind will carried out in a well-established training institution to ensure
sustainability.
Health System Strengthening Concept Note 15 October 2014│ 32
3.2 Applicant Funding Request
Provide a strategic overview of the applicant’s funding request, including both the
proposed investment of the allocation amount and the request above this amount. The
overview should give a clear description of the health system strengthening objective(s) of
the request, how these are linked to the national health strategy priorities, and how they
address the gaps and constraints described in sections 1, 2 and 3.1. If the Global Fund is
supporting existing programs that will continue into the requested funding period, explain
how they will be adapted to maximize impact on the objectives of the program.
4-5 PAGES SUGGESTED
The following six main objectives will be addressed through this cross-cutting HSS
Concept Note funding request:
1. Improve human resource capacity that enhance community and health information
system
2. Improve pharmaceuticals supply chain management system
3. Strengthen national health management information system
4. Improve service delivery through strengthening the laboratory services
5. Improve financial resources management system
6. Improve leadership and governance of district health management
1. Human resource development
In this funding request, $12,037,140 million is requested mainly to contribute for
Upgrading of more than 22,000 HEWs to level IV, refresher training of 30,000 HEWs and
more than 6000 HITs. The global fund contribution covers a quartet to a third of the
estimated costs.
Prioritized Intervention 1.1: Upgrading of health extension workers
HEP was introduced 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.
Health System Strengthening Concept Note 15 October 2014│ 33
The increased health seeking behavior of the communities as a result of improved
educational status of the community, economic growth and health programs such as the
HEP has created additional demand for community health services. This has indicated the
need to improve the capacity of HEWs through upgrading to level IV competency. In the
past two years, Global fund round 8 and 9 grants supported the training of 3,638 level 4,
3,943 level 3 and 1210 urban HEW. In this funding period (2015-17), about 22,000 Level
III HEWs will be upgraded to level IV. The Global Fund is requested in this concept note to
leverage resources with GoE and other development partners.
Prioritized Intervention 1.2: Integrated refresher training for health extension
workers
Following the initial rounds of pre-service trainings for HEWs (EFY 1996/7), gaps in HEW
skill and service delivery were identified. It was seen that the pre-service training need to
be refreshed periodically to keep the core competencies of the HEWs expected by HEP.
The MOH and RHBs periodically coordinates and provide a standardized IRT for HEWs to
avoid frequently pulled out of HEWs from their posts for various trainings required by
various programs including HIV/AIDS, TB and malaria. This training has alleviate the
uncoordinated training effort by our partners to support the HEWs and improved
efficiency. Partners supporting the HEP pool resource to conduct IRT in an integrated and
coordinated manner in modular forms.
Previous GF grants supported these trainings. All the HEWs will be trained during this
concept note period and close to $28 million is required to train all HEWs. The TOT and
some of the cascading training will be covered by USG and MDG PF. This funding
request will cover a portion of the cascade trainings by leveraging resources with GoE and
development partners.
The HEP is the pillar of the primary health care in Ethiopia. Hence, the IRT training
improves the competency of the HEWs to provide quality HEP packages which will
contribute in improved coverage of high impact interventions.
Prioritized Intervention 1.3: Pre-service training for health information technicians
Information quality and use remain sub-optimal within the health sector, particularly at the
peripheral levels, The HMIS 12 strategic plan depicts the need to improve quality
information use (Annex_3). A number of initiatives are in place to address data quality
12 HMIS strategic plan
Health System Strengthening Concept Note 15 October 2014│ 34
including use of technologies, regular data quality assessments, training of health workers
and data mangers on revised HMIS, CHIS and supportive supervision. Building the
capacity at all levels particularly at the lower levels of the health sector in quality, timely
and complete data collection, analysis and use for local decision-making is found to be
critical. This could be carried out through short term need based training of health workers
and increase the number of health information technicians through training of additional
level 4 trainees. Health Information Technicians (HITs) play a pivotal role in ensuring data
are captured electronically in a timely manner, analyzed with relevant program focal
persons and present reliable information to decision makers at the point of data collection
and beyond. HIS are deployed at health centers and hospitals and 10,500 HITs are
needed to cover all health centers and hospitals. 2,532 are currently deployed in health
facilities. The premier activity is being supported by different partners including GF and
the training of additional health information technicians (HIT) is included to be part of this
HSS Concept Note funding request. This request includes the training of additional 1,500
level 4 HITs training out of 6000 required to be trained in three years and deploying them
in Zonal and Woreda health office level based on the need. Global Fund, through Round 8
HSS grant, has supported the training of 600 Level 4 HIT. This funding request considers
continuation of the Global Fund in contributing resource in HIT training.
2. Strengthening Supply Chain Management
$8,649,319 is requested for this module mainly focusing on ICT plat forms to
improve supply management information system, enhance storage and distribution
capacity and strengthen pharmacovigilance activities.
Prioritized Interventions 2.1 Improve supply management system through
ICT platforms
Introduction of Enterprise Resource Planning (ERP) is being carried out at PFSA
which involves procuring hardware and software, assessing the existing situation
in terms of IT infrastructure and HR, end-users training and capacity building to IT
staff and managers of PFSA. Some of the expenses are covered by the US
government funded implementing partners while this request and GoE is
anticipated to cover the remaining costs.
Enterprise resource planning (ERP) systems are designed to address the problem
of fragmentation of information or “islands of information” in business
organizations. ERP systems promise to computerize an entire business with a
suite of software modules covering activities in all areas of the business.
Health System Strengthening Concept Note 15 October 2014│ 35
Furthermore, ERP is now being promoted as a desirable and critical link for
enhancing integration between all functional areas within the enterprise, and
between the enterprise and its upstream and downstream trading/business
partners13. ERP provides an integrated view of core business processes, often in
real-time, using common databases maintained by a database management
system. ERP systems track business resources—cash, raw materials, production
capacity—and the status of business commitments: orders, purchase orders, and
payroll. The applications that make up the system share data across the various
departments (manufacturing, purchasing, sales, accounting, etc.) that provide the
data 14 . ERP facilitates information flow between all business functions, and
manages connections to outside stakeholders.15 Hence, the application of this
system is expected to significantly improve the performance of PFSA and then the
country’s health commodity management at large.
Other interventions that help to improve the supply chain management system
such as distribution and tracking of commodities, monitoring stock out and
capacity building activities are being supported by government, USG/ Deliver,
UNICEF, UNFPA and MDG PF.
Prioritized Interventions 2.2 Enhance pharmaceutical storage and
distribution capacity
The other rationalized activities to address the gaps on warehousing, inventory
management and distribution will be procuring of heavy trucks with trailers,
medium trucks, forklift, procurement and installation of GPS and related
equipment for all trucks, procurement of CCTV security camera and adoption of
Bar-code for all warehouses and, procurement of warehouses auxiliary materials.
It is also propose to strengthen transportation means for delivering essential health
commodities to HC to strengthen the PHCUs. GoE’s and GF’s support with regard
13 International Journal of Operations & Production Management Vol. 23 No. 8, 2003; pp. 850-87
14 http://searchsap.techtarget.com/definition/ERP
15 Jump up^ Bidgoli, Hossein, (2004). The Internet Encyclopedia, Volume 1, John
Wiley & Sons, Inc. p. 707.
Health System Strengthening Concept Note 15 October 2014│ 36
is complimented by other development partners including USG, UNICEF, UNFPA
and other partners of MDG PF.
Prioritized Interventions 2.3 Strengthen pharmacovigilance
With the support of this funding opportunity, FMHACA’s laboratories will have
sufficient equipment and supplies as well as inspectors of Good Manufacturing
Process Practice (GMP) will be well trained and prepared to carry out QC at all
levels. Reporting of Adverse Events of Drugs will be strengthened through
awareness to health workers and the public.
3. Improving health information system
The PR requests $10,367,826 to strengthen the health information system mainly to
digitize the family folder, scaling up e-HMIS and capacity building efforts of health
information technology initiatives.
Prioritized Intervention 3.1: Strengthen the CHIS through digitizing Family
Folder
Availability of reliable, relevant, comprehensive and timely health information is widely
recognized and recounted as an essential foundation for any public health interventions.
Improved data and monitoring tools are also crucial for devising appropriate policies and
interventions needed to achieve the Millennium Development Goals16. The HMIS reform
was initiated by FMOH in collaboration with other health partners in 2008 all over the
country after piloted with few sites. The family folder was developed as a data collection
tool to be used at the health post level to collect household health data. It was designed
as a comprehensive data collection and documentation tool to be used by HEWs17. This
reform moved the multiple registers to a family folder based community health
information system. Prior to the reform, there were many registers ranging from 7 to 12
to document different health services as indicated in one of the assessments published
in Journal of Health Informatics18. The family folder coverage has now reached 64.5% in
2013/14. Digitizing the folder using tablet computers is expected to transform the CHIS
in particular and the HIS in general. In this funding request, procurement of tablet
16 ] World Health Organization (WHO), Millennium Development Goals. 2013, http://www.who.int/topics/millennium_development_goals/about/en/index.html 17 FMOH. Health Management Information System (HMIS)/Monitoring and Evaluation (M&E) Strategic Plan for Ethiopian Health Sector. Federal Ministry of Health, Addis Ababa, Ethiopia, 2008 18 Zufan D, and Amsalu S. , Journal of Health Informatics in Developing Countries, Vol. 7 No. 2, 2013 (www.jhidc.org)
Health System Strengthening Concept Note 15 October 2014│ 37
computers to HEWs is requested alongside solar chargers and operational trainings.
Financial support in scaling up e-HMIS and supportive supervision are among the
requests in this funding opportunity. Global Fund through previous grants, partners of
MSG PF, USG and GoE are among the partners that leverage resources in HIS.
Prioritized Intervention 3.2: Improve data quality through supportive supervision
and Regular Data Quality Assessment (RDQA)
Data quality is critical to generate health information to base decisions upon. Hence, a
number of data quality improvement mechanisms are in place including use of technology
in collecting and analyzing data. Regular supportive supervision and systematic data
quality assessment are among the data quality assurance activities of the MoH that needs
to be strengthened substantially. Hence, funding for Regular Data quality Assessment
(RDQA) is requested in this concept note.
4. Service Delivery: Laboratory strengthening
$8,618,145 is requested in this concept note to contribute for strengthening the service
delivery through renovation and upgrading 5o high volume hospital laboratories, improving
the laboratory maintenance system, enhancing the laboratory information system and
networking and specimen referral.
Prioritized Intervention 4.1 Strengthening Service delivery through renovation of
high volume health facilities and maintenance of laboratory equipment
The service delivery of priority diseases and health conditions through improving the
laboratory service provision of high volume health facilities is one of constrains of the
health care delivery system. The priority facilities will also serve as a referral and back up
laboratories for peripheral laboratories as well as conduct regular External Quality
Assurance programs to their respective catchment health facilities. Among the priority
activities requested in this concept note include renovation of the laboratories from
infection control perspective, specimen referral and networking through laboratory
information system. The rest of the laboratory components will be covered by the GoE,
Global fund in diseases specific grants and the USG.
Prioritized Intervention 4.2: Strengthen laboratory information system and
laboratory networking and specimen referral system
An effective referral system ensures a close relationship between all levels of the referral
system and helps to ensure people receive the best possible care closest to home. It also
assists in making cost-effective use of regional laboratories, laboratories of hospitals and
primary health care services. Support to such system helps build capacity and enhance
Health System Strengthening Concept Note 15 October 2014│ 38
access to better quality care.
Infection control is among the critical components in transporting samples. All patient
specimens should be treated as potentially hazardous and handled accordingly. Hence,
the request in this concept note is geared towards improving transportation and infection
control through procuring transportation means and equipment for specimen handling.
Electronic LIS enables laboratories to efficiently capture, store, analyze, interpret and
communicate laboratory information. LIS greatly improves laboratory workflows and
efficiency of processes. LIS, as an important component of Hospital Information System
(HIS), is an ideal tool to enhance interdepartmental communications through interfacing
with other administrative and technical software packages like Electronic Medical Record.
Furthermore, laboratories with functional electronic LIS can be easily networked along or
across tiers facilitating information flow within the network which is particularly important
for the improvement of referral testing services and collection of laboratory related
program indicators at different levels of management thus favorably augmenting the
function of the bigger Health Management Information System.
5. Improve financial management capacity
The funding request to this component is $3,063,590 to improve capacity of grant
management and speed up rollout of IFMIS.
Prioritized Intervention 5.1: Scale up of the Integrated Financial Management
Information System (IFMIS) initiative
The Integrated Financial Management Information System (IFMIS) is one of the
major financial reform programs in the public sector, which is expected to come up
with an enhanced financial information system for all public bodies in a uniform
platform. Full rollout of the IFMIS is expected to automate the financial reporting at
all levels and creates a system that financial utilization and reporting status at
different level can be monitored centrally. In order to speed up the rollout of
EFMIS, training of the end users and procuring related inputs such as computers
and their accessories are required.
IFMIS will ultimately improve and create real-time timely financial utilization
reporting so as to decrease the rate of non-liquidated advances at regional and
district level. Therefore, the following key activities will be implemented to scale
up the IFMIF initiative at different levels;
i. Conduct end users training and change management orientation
Health System Strengthening Concept Note 15 October 2014│ 39
session on IFMIS
ii. Procurement of computers, accessories and other networking
supplies for IFMIS implementation at regional level
iii. Purchase Woreda net internet fee and conduct IT infrastructure
assessment
Prioritized Intervention 5.2: Improve grant management capacity through
technical assistance at different levels
Effective grants management is a process of adequate oversight and monitoring of
grants from pre-award stage until close out stage of the grant that includes a cycle
of activities related to planning, implantation coordination, program and financial
reporting and grant closeout.
The newly established grant management unit has conducted a rapid assessment
to identify the challenges related to coordination of the grant implementation
between program and finance departments at different levels; Federal, regional,
Zonal and Woreda level.
The current experience has demonstrated there is sub optimal coordination
between Program and finance units with regard to properly and timely liquidation
and reporting of the grant funds.
The ultimate effect of sub optimal coordination and communication coupled with a
need to understanding about the principles of grant management has created
delayed fund liquidation of grants. Hence, there is a need to provide technical
assistance
Majority of the grant funds are being utilized at the Woreda level where the
financial system operates in a pooled system. The district finance Bureaus are
responsible to financial management of all sectors in the district. Inadequate
staffing, both in number and quality, of the regional finance department is the other
bottleneck contributing for delayed financial reporting and high un-liquidated
advances. The financial reporting sent from the Woredas to the RHBs are not
being timely sent to the FMOH finance as the small number of finance staffs at the
RHB level is always busy with other urgent day to day activities related to handling
the daily transaction. Hence, providing technical assistance by deploying grant
Health System Strengthening Concept Note 15 October 2014│ 40
management and finance officers to the zonal and regional level facilitates
coordination of Zonal and Woreda Finance with Zonal and Woreda Health offices
to timely liquidate and report grants according to the grant agreement.
The financial recording and reporting of all grant funds at Federal Ministry of
Health level is based on software packages like Peachtree. Only 5 of the 11
regional Health bureaus and one of the four agencies use software packages for
financial recording and reporting. The other regions and agencies uses manual
recording and excel based recording.
A total of 80 technical assistance are requested to be deployed; 54 of them at
zonal level to mentor finance officers of districts. The regional zonal health offices
will be further supplied with electronic equipment (Eg. Computers, financial
recording software’s, fax machines, etc) needed for timely financial reporting.
6. Leadership and governance
Intervention 6.1. Training of district health management
$2,913,000 is included in this concept note for supporting the training of district
and PHCU program managers. Being the main implementers at the grass root
level, building the capacity of the district health management team will significantly
improve program planning, implementation and reporting. This will address the
health system constrains and gaps through proper planning and implementation
of health programs. This training has been supported through GF round 9 HSS
grant. The district health management team will be oriented and trained on the
general sector strategies and program strategies. This will create a platform
where there will be a sector wide understanding the set targets and strategies and
expected outcomes.
Summary of allocated budget for HSS
New Funding Model cross-cutting Health System Strengthening Allocated budget
Total allocated $53,265,094
On pipeline from Round 9 HSS $2,571,074
Reallocated for HIV/AIDS $5,000,000
Allocated for the Concept note period $45,694,020
Health System Strengthening Concept Note 15 October 2014│ 41
Summary of Funding Request per module
Priority Module Interventions requested to be
covered through HSS Concept note,
allocation amount
Amount of Funding
request ($)
Human resource Upgrading of HEWs
IRT
HIT Pre-service training
12,037,140
Supplies chain
management
IPFSIS Rollout
ERP Supplies
End-user training
Storage and distribution capacity
Pharmacovigilance
8,694,319
Health Information
System
e-HMIS scale up
Supervision
Training on CHIS
Printing of HMIS&CHIS
materials
10,367,826
Laboratory system
strengthening
Renovation of laboratories of
high volume health facilities
Equipment maintenance
Strengthening LIS
Strengthening laboratory
networking and specimen
referral
8,618,145
Financial Management Scale up of IFMIS project:
IFMIS Supplies
End-user training
Supervision
Grant management:
Deployment of grant officers
Training &
Supervision
3,063,590
District health
Management
District health management training 2,913,000
Total 45,694,020
Health System Strengthening Concept Note 15 October 2014│ 42
Health System Strengthening Concept Note 15 October 2014│ 43
3.3 Modular Template
Complete the modular template (Table2). To accompany the modular template, for both
the allocation amount and the request above this amount, briefly:
a. Explain the rationale for the selection and prioritization of modules and
interventions.
b. Describe the expected impact and outcomes, referring to evidence of effectiveness
of the interventions being proposed.
c. Explain the additional gains expected from the funding requested above the
allocation amount.
3-4 PAGES SUGGESTED
a. Explain the rationale for the selection and prioritization of modules and
interventions.
The modules selected for funding under the allocated amount reflect a prioritization based
on expected degree of impact of the interventions to achieve the targets set by MoH.
Ethiopia has a decentralized health system and decision-making and community
empowerment and participation is the main goal of the health system. Improving the health
system enables to establish and maintain the confidence of communities that the
community needs are appropriately met and addressed. The modules selected reflect, as
priority, reinforcement of this approach and provision of essential services. Availability of
well-trained and knowledgeable health workers at the grass root level will improve delivery
of quality health services and improve community health seeking behaviour and help the
community own their health issues
Investing on pharmaceutical supply chain management is also selected as a priority
module in this concept note as quality supply system is very critical as programs without
products are not able to achieve their set targets. During this concept note period,
initiatives on supply and regulation of pharmaceuticals and other health products will be
given high priority to deliver quality services to the community. This will ensure that the
communities get appropriate treatment, care and support.
Improving and transforming health information system plays pivotal role for timely
generating of quality data for appropriate decision making and taking appropriate actions.
This ensures that the resources are invested based on evidence generated at local level.
Hence strengthening the information system is one of major priority of the health sector
Health System Strengthening Concept Note 15 October 2014│ 44
and because the significant fund gas, it is also identified as a priority module for this
funding request.
Service delivery through strengthening laboratory system is critical for proper identification
of disease which leads to getting prompt and accurate treatment. Renovating and
upgrading high volume hospital laboratories, maintenance of laboratory equipment,
strengthening laboratory networking and specimen and strengthening laboratory
information system are critical to improve quality of diagnosis and referral linkage.
strengthening specimen transportation to effectively utilize available high-tech diagnostic
facilities; implementation of electronic technologies to capture, store, analyze and interpret
laboratory service information to be used for local decision making and working towards
decreasing laboratory instrument downtimes significantly improves health care delivery
and reduces the burden of major health problems such as HIV/AIDS, TB and malaria.
Accountability and transparency are notions of the health system in Ethiopia. Improving
the financial management system through implementing an efficient electronic based
financial recording and reporting and improving the capacity and workforce of finance and
grant management to improve resource mobilization, utilization and liquidation can not
only help to achieve resource need of the health system, but also improve transparency
and accountability at different levels of the health system. In addition, having good
leadership and governance play an important role for proper implementation of health
programs. So having well-trained and updated program managers on health strategies
and interventions at different levels helps to improve planning, implementation and
reporting of health programs. This will in turn increase the return of investments and
improve program impacts.
Good leadership and governance are important for improving the implementation of health
system plans. Then having well-trained and capable program managers at all levels of the
health system plays critical role in achieving the set goals and targets of HSPD and
upcoming health sectors strategy, HSTP. Training of district health managers is selected
as priority interventions for this effect.
b. Describe the expected impact and outcomes, referring to evidence of
effectiveness of the interventions being proposed.
The main priority goals of the health sector are significantly reducing under-five, maternal
mortality and significantly reduce burden of HIV/AIDS, TB and Malaria to meet the MDG
targets and beyond among other goals. Proposed modules/interventions are have proved
to have greater impact and outcome in achieving the set goals. Investing of community
Health System Strengthening Concept Note 15 October 2014│ 45
level health extension works and upgrading their capacity will impact on quality service
delivery proper management of health problems. Strengthening pharmaceutical and other
health products supply system is critical to avoid stock outs, overstocks, and expires and
wastages and helps to avail quality assured pharmaceutical to the community in need of
such services. Hence improving this will profound impact of reducing the aforementioned
health outcomes.
Generating accurate and timely data can be achieved through scaling up and transforming
the health information system. Having an automated and timely data and information helps
to improved timely decision making and taking actions. This in turn improves positive
health outcomes through targeted delivery of appropriate interventions based on evidence
Improving service delivery through strengthening laboratory system is also important for
accurate and timely diagnosis and treatment of patients. Having well renovated and
equipped laboratories, properly functioning laboratory equipment maintenance, and
networking and specimen referral supported with an electronic laboratory information
system can enhance the service delivery and help reduce the major health problems
c. Highlight the additional gains expected from the funding requested above the
allocation amount.
Ethiopia has decentralized and community based health system and investing more on
this system to significantly improve the health outcomes and improve community
ownership and participation. If the above allocation amount is funded, there will be
significant improvement and this will encourage the community to invest on the health
system which is very critical for sustainability.
Health System Strengthening Concept Note 15 October 2014│ 46
3.4 Focus on Underserved Populations and/or Highest Impact Interventions
This question is not applicable for Low Income Countries.
Describe whether the focus of the funding request meets the Global Fund’s Eligibility and
Counterpart Financing Policy requirements as listed below:
a. If the applicant is a Lower-Middle Income Country, describe how the funding
request focuses at least 50 percent of the budget on underserved populations
and/or highest-impact interventions.
b. If the applicant is an Upper-Middle Income Country, describe how the funding
request focuses 100 percent of the budget on underserved populations and/or
highest-impact interventions.
½ PAGE SUGGESTED
SECTION 4: IMPLEMENTATION ARRANGEMENTSAND RISK ASSESSMENT
4.1 Overview of Implementation Arrangements
Provide an overview of the proposed implementation arrangements for the funding
request, including use of existing country systems and oversight mechanisms. In the
response, describe:
a. If applicable, the reason why the proposed implementation arrangement does not
reflect a dual-track financing arrangement (i.e. both government and non-
government sector principal recipients).
b. If more than one principal recipient is nominated, how co-ordination will occur
between PR(s).
c. The type of sub-recipient management arrangements likely to be put into place
and whether sub-recipients have been identified.
d. How coordination will occur between each nominated principal recipient and its
respective sub-recipients(s).
e. How representatives of women’s organizations, people living with the diseases and
other key populations will actively participate in the implementation of this funding
request.
1-2 PAGES SUGGESTED
a. If applicable, the reason why the proposed implementation arrangement does
Health System Strengthening Concept Note 15 October 2014│ 47
not reflect a dual-track financing arrangement (i.e. both government and non-
government sector principal recipients).
Proposed implementation arrangements do not reflect a dual-track financing arrangement.
Harmonization and alignment strategy, while harnessing the resources of a broad
representative partnership, seeks nevertheless to empower governments to address their
priorities through mutual accountability. Besides majority of the interventions includes in
this concept note are planned to strengthen initiatives under the government
implementation arrangements. Although the proposed implementation arrangements do
not reflect dual track financing, it is possible that sub-recipients, drawn from technical
panel partners, including civil society organizations (CSOs) will be used for targeted
interventions. Besides, FMOH is the PR of the funding for this Concept Note, in-country
partners and other sectors also contribute to achievement of the goals.
b. If more than one principal recipient is nominated, how co-ordination will occur
between PR(s).
Only one PR has been nominated.
c. The type of sub-recipient management arrangements likely to be put into
place and whether sub-recipients have been identified.
The CCM has agreed for one government PR and there are no sub-recipients (SRs)
identified.
d. How coordination will occur between each nominated principal recipient and
its respective sub-recipients(s).
Selected SRs will be required to report periodically on implementation based upon clear
and agreed targets for achievement, established timelines and related financial
parameters.
e. How representatives of women’s organizations, people living with the
diseases and other key populations will actively participate in the implementation
of this funding request.
Majority of the funding request under this concept note support are targeted on HEP
through deployment, skill development training of two community-based HEWs in each of
the health posts in nearly all of the estimated 16,000 kebeles/communities. This is
believed to empower the community and actively participate in implementation of the
funding request.
In addition, the health system strengthening modules included in this request will ensure
the procurement and distribution of drugs and supplies for HIV/AIDS, TB, Malaria and
other disease and people living with the three diseases are members of CCM where the
Health System Strengthening Concept Note 15 October 2014│ 48
oversight of this grant implementation effected.
4.2 Ensuring Implementation Efficiencies
Complete this question only if the Country Coordinating Mechanism (CCM) is
overseeing other Global Fund grants.
Describe how the funding requested links to existing Global Fund grants and to any other
funding requests being submitted by the CCM.
In particular, from a program management perspective, explain how this request
complements (and does not duplicate) any human resources, training, monitoring and
evaluation, and supervision or other Global Fund financed activities.
1 PAGE SUGGESTED
The pursuit of an integrated approach to grant implementation in this Concept Note builds
on the achievements of previous grants and maintains the gains they have provided. The
strategy is significantly dependent upon the HEP and the Health System that was
established with funding from the government and was further supported by the Global
Fund and other development partner grants.
Extensive opportunities have been realized to coordinate budgeting and assure that there
is no overlap or duplication of activities, and to maximize efficient use of resources. The
strategic and annual planning processes are very consultative and participatory. The
integration starts at the federal level and extends all the way to the community level.
The Government conducts an annual resource mapping exercise to inform annual
planning. Developing the map helps to rationalize use of resources, identifies synergies
and avoids overlap. Similarly, promotion of the three ones – one plan, one budget and
one reporting mechanism (HSDP), helps to assure a coordinated effort across multiple
parameters.
By empowering communities, the Concept Note links closely with other disease
components at the crucial intersection of communities and takes maximum advantage of
the integrated approach within the Ministry. The workers are trained to address integrated
primary health care solutions in proximity to communities, where it can be most relevant
and effective. Support to the HEWs at the Woreda/District level takes advantage of cross-
discipline training, comprehensive monitoring and evaluation and integrated supervision.
4.3 Minimum Standards for Principal Recipient (PR) and Program Delivery
Complete this table for each nominated PR. For more information on Minimum
Health System Strengthening Concept Note 15 October 2014│ 49
Standards refer to the Concept Note Instructions.
PR 1 Name
Ministry of
Health
Sector Public
Does this principal recipient
currently manage a Global Fund
stand-alone cross-cutting HSS or
a disease component grant(s)?
Yes
Minimum Standards CCM assessment
1. The principal recipient
demonstrates effective
management structures and
planning
FMOH demonstrates effective management structures and
rigorous planning process. Since GF Round 1, FMOH has
been PR for 7 GF grants and has had no major issues
regarding management of GF grants.
2. The principal recipient has the
capacity and systems for
effective management and
oversight of Sub-Recipients
(and relevant Sub-Sub-
Recipients)
There is a long-standing, internal system for effective
management and oversight in the FMOH, including sub-
recipients. The current strategy relies on the structure of
the Ministry extending down to the regions and beyond
(see accompanying implementation structure). The
structure demonstrates clear lines of authority and
establishes organizational responsibilities for
implementation at all levels. Each level is effectively held
accountable for commitments to internal and external
partners. While administrative authority is decentralized for
efficiency, technical coordination remains with the FMOH
to assure coordinated action.
3. The internal control system of
the principal recipient is
effective to prevent and detect
misuse or fraud
There is a strong internal control system to prevent and
detect any misuse or fraud at all levels of the health
system. FMOH conducts internal and external audits
annually down to the regional level and subsidiary levels
are audited down the reporting structure. The system has
proven to be effective in detecting and avoiding misuse or
fraud.
4. The financial management
system of the principal
recipient is effective and
accurate
FMOH designed a new grant management system and
established a grant management unit at federal and
regional levels. The new grant management system has
been working to improve the coordination and
implementation of grant between different departments at
Health System Strengthening Concept Note 15 October 2014│ 50
federal and regional levels. In addition, FMOH has started
to scale up Integrated Financial Management System
(IFMIS). The system provides multiple advantages for
performance improvement –
Timely, accurate and consistent data for management
and budget decision-making.
Information for budget planning, analysis and
government-wide reporting.
Facilitates reporting and auditing.
Closer linkages between FMOH, Regions and
implementing partners.
5. Central warehousing and
regional warehouse have
capacity, and are aligned with
good storage practices to
ensure adequate condition,
integrity and security of health
products
All warehouses are now strategically placed within
reasonable radius of all locations in the country for
assuring timely distribution of health products and
eliminating stock outs and avoiding treatment/program
disruptions.
6. The distribution systems and
transportation arrangements
are efficient to ensure
continued and secured supply
of health products to end
users to avoid treatment /
program disruptions
All warehouses are now strategically placed within
reasonable radius of all locations in the country for
assuring timely distribution of health products and
eliminating stock outs and avoiding treatment/program
disruptions.
7. Data-collection capacity and
tools are in place to monitor
program performance
There is a health management information system (HMIS)
and a logistics management information system (LMIS).
The HMIS and LMIS provide some data and reports that
are valuable for monitoring malaria program performance.
The Public Health Emergency Management (PHEM)
Directorate at Ethiopian Public Health Institute (EPHI)
assures the availability of data-collection capacity and
tools. It is within the responsibility of PHEM to provide
surveillance data and emergency response, for which it
must assure ongoing monitoring of program performance.
8. A functional routine reporting
system with reasonable
There is a routine paper based and electronic reporting
system from the community (health post level) up to the
Health System Strengthening Concept Note 15 October 2014│ 51
coverage is in place to report
program performance timely
and accurately
central level.
9. Implementers have capacity
to comply with quality
requirements and to monitor
product quality throughout the
in-country supply chain
The Food, Medicine and Health Care Administration and
Control Authority (FMHACA) is charged with quality
assessment of all health inputs and holds accountable
concerned bodies if there are lapses in quality. In addition,
measures are proposed in this HSS support to further
improve capacity in quality assurance issues among
implementers.
4.4 Current or Anticipated Risks to Program Delivery and Principal Recipient(s)
Performance
a. With reference to the portfolio analysis, describe any major risks in the country, and in
the implementation environment, that might negatively affect the performance of the
proposed interventions including external risks, principal recipient and key
implementers’ capacity, past and current performance issues.
b. Describe the proposed risk mitigation measures (including technical assistance)
included in the funding request.
1-2 PAGES SUGGESTED
a. With reference to the portfolio analysis, describe any major risks in the country
and implementation environment that might negatively affect the performance of
the proposed interventions including external risks, Principal Recipient and key
implementers’ capacity, and past and current performance issues.
The modules selected to be included in this HSS request are emanated from the recently
conducted Health sector development program IV performance evaluation. The HSDP
performance evaluation has clearly indicated for the need to keep and build on the good
progresses made with regard to the major building blocks of the Health system including;
human resource for Health, Health Information management, laboratory, pharmaceutical
and supply system, pharmacovigilance, financial management and governance and
leadership.
The review has also pointed the challenges that the system is facing with regard to health
care financing. The 2010/11 USD 20 per capita health expenditure is way less than the
WHO recommendation USD 60 by 2015. This indicates the need to mobilize more
Health System Strengthening Concept Note 15 October 2014│ 52
resource in to the sector. The issue of predictability of donor funds in light of high donor
funded programs and the fact that households also incur lingering out of pocket expenses
is believed to pose a risk that needs to be addressed in the coming period.
b. Describe the proposed risk-mitigation measures (including technical assistance)
included in the funding request.
Efforts to mitigate the above risks related to Health Care Financing are seriously
considered during the preparation for the next chapter of health/HSTP (2015 – 2020). A
new Health Care Financing Technical working group has been established and the
revision of the health care financing strategy has already started. The revised Health care
financing strategy is expected to address the financial barriers of the community from
accessing the health services through different health insurance schemes.
To address the challenges of high out of pocket payments, the community and social
health insurance schemes are already in place. In 2014, the community health Insurance
schemes have scaled up in to 160 districts from the 13 only districts in the Agrarian region.
All the necessary preparation for implementation of the social insurance has also been
carried out.
Improving accountability and efficiency in the resource management is also highlighted to
be a priority to be strengthened during the period of this concept note as one of the steps
to maintain the predictability of donor funds. Appreciating the gaps in the financial
management, FMOH designed a new grant management system and established a grant
management unit at federal and regional levels. The new grant management system has
been working to improve the coordination and implementation of grants at federal and
regional levels. In addition, FMOH has started to scale up Integrated Financial
Management System (IFMIS). The system provides multiple advantages for performance
improvement, including timely, accurate and consistent data for management and budget
decision-making; information for budget planning, analysis and government-wide reporting;
and facilitates reporting and auditing and closer linkages between FMOH, Regions and
other implementing partners.
In general, there are mitigation measures developed for all the identified potential risks and
effort is being made to address those potential risks at the minimal during the
implementation of the concept note period.
Health System Strengthening Concept Note 15 October 2014│ 53
CORE TABLES, CCM ELIGIBILITY AND ENDORSEMENT OF THE CONCEPT NOTE
Before submitting the concept note, ensure that all the core tables, CCM eligibility
requirements and an endorsement of the concept note, as shown below, have been filled
in using the online grant management platform or, in exceptional cases, attached to the
application using the offline templates provided. These documents can only be submitted
by email if the applicant receives Secretariat permission to do so.
☐ Table1: Programmatic Gap Table(s)
☐ Table2: Modular Template
☐ Table 3: List of Abbreviations and Annexes
☐ CCM Eligibility Requirements
☐ CCM Endorsement of Concept Note