primary health care systems (primasys) · case study from ethiopia 3 1. introduction to ethiopia...

Case study from Ethiopia

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Case study from Ethiopia


Morankar Sudhakar, Mirkuzie Woldie, Kiddus Yitbarek, Fira Abamecha, Abraham Tamirat

Jimma UniversityEthiopia


WHO/HIS/HSR/17.31

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CASE STUDY FROM ETHIOPIA

Contents

Abbreviations 1

Background to PRIMASYS case studies 2

1. Introduction to Ethiopia case study 3

2. Methods 3

3. Overview of Ethiopian PHC system 4

4. Timeline 7

5. Governance and structure of PHC in Ethiopia 9

6. Financing 14

7. Human resources 16

8. Planning and implementation 18

9. Regulatory processes 22

10. Monitoring and information systems 24

11. Challenges, ways forward and policy considerations 25

Annex 1. Study participants 26

Annex 2. Methods used to calculate expenditure indicators (see Table 1) 27

References 28

iv PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

FiguresFigure 1. Administrative structure of Ethiopian health system 10

Figure 2. PHC structure in Ethiopia 12

Figure 3. Ethiopian health expenditure, 2011 15

TablesTable 1. Key demographic, macroeconomic and health indicators of Ethiopia, 2016 4

Table 2.Relevance of key demographic, macroeconomic and health indicators for improved provision of PHC 5

Table 3. Barriers to and enablers of PHC provision in Ethiopia 8

Table 4. Health service organizations in Ethiopia by sector, and services provided 11

Table 5. Human resources for health in Ethiopia 17

Table A1.1. Study participants: clients, service users and service providers 26

Table A1.2. Study participants: managerial and policy-makers 26

1CASE STUDY FROM ETHIOPIA

Abbreviations

CBHI community-based health insurance

GDP gross domestic product

GTP Growth and Transformation Plan

HDA health development army

HDT health development team

HEW health extension worker

HMIS Health Management Information System

ICD-10 International Classification of Diseases and Related Health Problems, 10th Revision

IDSR Integrated Disease Surveillance and Response

IHP+ International Health Partnership

NGO nongovernmental organization

PHC primary health care

PHCU primary health care unit

RHB regional health bureau

TB tuberculosis

UNAIDS Joint United Nations Programme on HIV/AIDS

WASH water, sanitation and hygiene

WHO World Health Organization

2 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Background to PRIMASYS case studies

Health systems around the globe still fall short of providing accessible, good-quality, comprehensive and integrated care. As the global health community is setting ambitious goals of universal health coverage and health equity in line with the 2030 Agenda for Sustainable Development, there is increasing interest in access to and utilization of primary health care in low- and middle-income countries. A wide array of stakeholders, including development agencies, global health funders, policy planners and health system decision-makers, require a better understanding of primary health care systems in order to plan and support complex health system interventions. There is thus a need to fill the knowledge gaps concerning strategic information on front-line primary health care systems at national and subnational levels in low- and middle-income settings.

The Alliance for Health Policy and Systems Research, in collaboration with the Bill & Melinda Gates Foundation, is developing a set of 20 case studies of primary health care systems in selected low- and middle-income countries as part of an initiative entitled Primary Care Systems Profiles and Performance (PRIMASYS). PRIMASYS aims to advance the science of primary health care in low- and middle-income countries in order to support efforts to strengthen primary health care systems and improve the implementation, effectiveness

and efficiency of primary health care interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage of care, governance and organization, and monitoring and evaluation of system performance.

The Alliance has developed full and abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system, tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems in selected low- and middle-income countries. Furthermore, the case studies will serve as the basis for a multicountry analysis of primary health care systems, focusing on the implementation of policies and programmes, and the barriers to and facilitators of primary health care system reform. Evidence from the case studies and the multi-country analysis will in turn provide strategic evidence to enhance the performance and responsiveness of primary health care systems in low- and middle-income countries.


1. Introduction to Ethiopia case study

This case study provides a comprehensive, in-depth assessment of the national primary health care (PHC) system of Ethiopia. It presents the structures,

processes and outcomes of PHC systems in detail, while the last section brings out important gaps in policies and research.

2. Methods

Both quantitative and qualitative data were collected through secondary document review and key informant interviews. Key sources of data for quantitative information included websites (for published papers, policies, directions and plans) and grey literature (for policy guidelines and official reports from various health departments). The data were reviewed by a group of five researchers.

Qualitative data were collected through interviews with key informants and focus group discussions with health care providers. Respondents and key informants were selected from different segments of society and health systems in order to achieve maximum variability. Accordingly, interviews were carried out with women in antenatal care clinics and maternity waiting homes and health development army (HDA) leaders as direct users of PHC, and with

health extension workers (HEWs) and health care providers as service providers (Annex 1).

Similarly, interviews were undertaken with health care officials at different levels of the health care system (from district to national level), as either decision-makers or policy-makers with respect to PHC services. The selection process for some stakeholders, particularly at national level, followed informants’ recommendations (the “snowball sampling” technique). Attempts were made to contact all individuals recommended by informants by telephone to seek permission to interview them. Finally, in-depth interviews were conducted at the respective offices.

Information on all study participants is provided in Annex 1.


3. Overview of Ethiopian PHC system

Ethiopia is the second most populous country in Africa after Nigeria, with more than 90 million inhabitants. The male–female population distribution is approximately equal. The estimated population growth is 2.6% per year. The population of the country is mostly agrarian and rural, with a low per capita income (1). In recent years the life expectancy has been increasing, and is now 64 years at birth (2). Lower respiratory infections are the main cause of death in Ethiopia. The maternal mortality rate is 353 per 100 000 live births (3). Of

total health expenditure, 14.69% goes to finance PHC. Households contribute more than one third of the country’s health expenditure (4), and Ethiopian out-of-pocket health expenditure is more than double the government’s health expenditure. Table 1 presents information on key demographic, macroeconomic and health indicators for Ethiopia, while Table 2 shows the relevance of those indicators for improved provision of PHC and as a source of data for planners, policy-makers, managers, health service providers and also for the community in general.

Table 1. Key demographic, macroeconomic and health indicators of Ethiopia, 2016

Indicator Data Source of information

Total population of country 90 076 012 Health and health-related indicators, 2014/2015

Male–female sex ratio 101:100 Central Statistical Agency, 2013

Population growth rate 2.6% Ethiopian Demographic and Health Survey, 2011

Population density (per sq. km) 99.39 World Bank estimate, 2015

Distribution of population (urban–rural) 19.4% urban Health and health-related indicators, 2014/2015

Gross domestic product (GDP) per capita US$ 486.27 Trading Economics, 2015

Income or wealth inequality (Gini coefficient) 30 International Monetary Fund Country Report No. 15/326, Federal Democratic Republic of Ethiopia, 2015

Life expectancy at birth 64 years Health Sector Transformation Plan

Top five main causes of death (ICD-10 classification) Lower respiratory infections (10%)

Diarrheal diseases (8%) HIV (7%)

Tuberculosis (7%) Stroke (7%)

Centers for Disease Control and Prevention, 2013

Infant mortality rate 59 per 1000 live births Health and health-related indicators, 2014/2015

Under-5 mortality rate 64 per 1000 live births Ethiopia: World Health Organization (WHO) statistical profile, 2013

Maternal mortality rate 353 per 100 000 live births Trends in maternal mortality, WHO

Immunization coverage under 1 year (including pneumococcal and rotavirus)

86.4% Health and health-related indicators, 2014/2015

Total health expenditure as proportion of GDP 2.66% Health Sector Transformation Plan, 2015

PHC expenditure as % of total health expenditure (see Annex 2)

14.69% National Health Accounts, 2011/2012

% total public sector health expenditure on PHC (see Annex 2)



Indicator Data Source of information

Per capita public sector expenditure on PHC (see Annex 2)

11.57 Ethiopian birrs National Health Accounts, 2011/2012

Public expenditure on health as proportion of total expenditure on health


Out-of-pocket payments as proportion of total expenditure on health

36% National Health Accounts, 2011/2012

Voluntary health insurance as proportion of total expenditure on health

Data not available

Proportion of households experiencing catastrophic health expenditure

Data not available

Table 2.Relevance of key demographic, macroeconomic and health indicators for improved provision of PHC

Profile Summary Relevant areas for PHC Source of information

Demographic profile Of the population of over 90 million, 19.4% live in urban areas. The population density is approximately 99 per square kilometre. The ratio of males to females is 101:100. Population growth is about 2.6% per year.

• Enables planners to allocate resources and evenly distribute health infrastructure to ensure equity.

• Helps to identify the priority groups for PHC provision

• Helps in planning how the community can participate in PHC activities

• Facilitates decentralization of services• Provides basis for introduction of appropriate

technology• Assists in identifying the roles of other

development sectors and partners

Health and health-related indicators, 2014/2015Central Statistical Agency, 2013Ethiopian Demographic and Health Survey, 2011World Bank, 2015

Macroeconomic profile

GDP per capita is US$ 486.27 per year

• Enables identification of less advantaged groups

• Helps in planning equitable service provision for the poor

Trading Economics, 2015International Monetary Fund Country Report No. 15/326, Federal Democratic Republic of Ethiopia, 2015

Health profile Respiratory infections are the main cause of death. The infant mortality rate is 59 per 1000 live births, and the under-5 mortality rate is 64 per 1000 live births. The maternal mortality rate is 353 per 100 000 live births. Immunization coverage under 1 year is 86.4%.

• Helps to design preventive and promotive strategies

• Assists in identifying priority health problems• Provides basis for allocation of appropriate

resources to combat priority health problems

In previous years, health service access for communities was inadequate, especially in rural areas. Significant progress was made following the introduction of PHC services throughout the country, with access to primary health care units (PHCUs) greatly improved through the rapid expansion of health centres and health posts, and

increased deployment of the primary and mid-level health workforce. In relation to the PHCUs, the introduction and implementation of the Health Extension Programme in phase II of the Health Sector Development Programme was a significant factor in scaling up service provision. By the end of 2010, the Health Extension Programme had enabled


Ethiopia to increase PHC coverage to 90%. While there has been an expansion in the number of health facilities within accessible distance, available per capita measures of outpatient visits and hospital admission reports indicate low service utilization. Health service delivery is organized at household or family, community, and health facility levels, with major objectives including community ownership and adoption of positive health practices; improve maternal, neonatal, child, adolescent and youth health and nutrition; adoption of improved water, sanitation and hygiene (WASH) practices; and combating HIV/AIDS, tuberculosis (TB) and malaria and other communicable and noncommunicable diseases (2, 5).

The government is the main health service provider in Ethiopia. In public health facilities there is a waiver system that enables poor people to obtain health service and medicines free of charge. This system creates a de facto cross-subsidy between the poorest and the better off, who can afford drugs and medical services and assist the poor through their contributions to the Revolving Drug Fund. The Revolving Drug Fund system in Ethiopia has improved the availability and affordability of medicines, and has helped protect purchasers from higher drug prices in the private sector. However, there is still a shortage of essential drugs and services at public health facilities, and inadequate mechanisms to protect the poor from catastrophic health expenditure (6, 7).

The uneven distribution of health services and PHCUs, particularly between rural and urban areas, is a challenge for the expansion of PHCs. Inadequate health coverage is of particular concern in rural Ethiopia, where access to any type of modern health institution is limited at best. Health systems and roads are underdeveloped, and transportation problems are severe, especially during the rainy season. Reaching the poor and those in remote areas can be delayed due to weak infrastructure. Regional coverage and distribution of health facilities also remains uneven (8).

With regard to PHC services in Ethiopia, 69% of facilities, excluding health posts, offer any TB diagnosis, treatment or follow-up services. These services are universally available at hospitals regardless of type, health centres and government facilities. Gambella region has the lowest provision, with only 29% of health facilities offering any TB diagnosis, treatment or follow-up services. Maternal health services are available in about two thirds (65%) of all health facilities, excluding health posts. These services have much greater levels of availability in health centres (99%), primary hospitals (98%), general hospitals (93%) and referral hospitals (88%). However, less than half of the remaining health facilities offer normal delivery services (medium clinics 38%, higher clinics 30% and lower clinics 24%). Facilities run by nongovernmental organizations (NGOs) are more likely to offer normal delivery services (69%) than private for-profit or governmental facilities (27% and 3%, respectively) (9).


4. Timeline

Modern medicine was introduced to Ethiopia in the 16th century during the regime of Emperor Libne Dingel (1508–1540), and was enthusiastically promoted during the reigns of Emperor Menelik II (1889–1913) and Emperor Haile Selassie (1930–1974). Emperor Menelik invited travellers, missionaries and members of diplomatic missions to introduce medicines and provide medical services, mostly in Addis Ababa, and various programmes and interventions ensued. Emperor Haile Selassie established the Ministry of Public Health, and the first National Health Service, in 1947 (10, 11).

The Alma-Ata Declaration on Primary Health Care (1978), and its call for Health for All by the year 2000, was welcomed by the Ethiopian Government. However, it was clear that a national health policy based on the declaration alone was not sufficient, and in fact implementation of PHC policies was largely unsuccessful at first (12), for the following reasons:

• The policies and strategies for the specific elements of the PHC were not clearly defined at national level.

• Regions and health facilities had limited awareness of those elements as defined at the central level.

• There was lack of clarity on health policies in most regions as a result of poor and inadequate dissemination of information on the policies.

The development of PHC in Ethiopia under three political systems – monarchy, socialism and democracy – was characterized by both modification of health policies and strategies from one administration to the next, and the maintenance of a number of deeply ingrained attitudes and practices. A major constraint was placed on PHC development by the heavy emphasis on central, top-down approaches that failed to consider cultural diversity, disease ecology-specific and appropriate strategies, and true community participation, and

by the persistence of predominantly urban-based, curative and technocratic health care systems. Basic health needs are strongly influenced by cultural and geographical diversities and must be addressed by adaptable and acceptable health strategies (10).

Ultimately, the success of PHC in Ethiopia depends not just on policy statements, resource reallocations and expansion of health infrastructure but also on a fundamental change in attitudes and values regarding the development of human resources and the equitability of social services. It remains to be seen whether the existing Ethiopian Government can maintain momentum in the continuing decentralization and democratization processes, and create a sociopolitical environment conducive to bottom-up PHC development. A plan to achieve universal access to PHC was prepared and embedded in the Health Sector Development Programme III in 2005. This plan aimed to address shortcomings of service coverage within the health system through accelerated expansion and strengthening of PHC services (10, 13).

Table 3 presents barriers to and enablers of the future provision of PHC services in Ethiopia.


Table 3. Barriers to and enablers of PHC provision in Ethiopia

Successes or failures Barriers Enablers Source of information

Improvement in provision of equitable health services

– Initiation of PHCU structure up to kebele level

Respondent from Federal Ministry of Health

Health services became accessible to the majority of the population and the community became a participant in the health care delivery process

– The existing Ethiopian Government is striving to maintain momentum in the ongoing decentralization and democratization processes, and to create a sociopolitical environment conducive to bottom-up PHC development

Implementation of Ethiopia’s Health Extension Programme, 2002

Improved access to health services

– Introduction of Health Extension Programme

Health Sector Development Programme III

Improved access to disease preventive and health promotive services

– Commitment of the government to decentralized leadership,HDA introduction

Respondents from Federal Ministry of Health

Implementation of PHC was largely unsuccessful during early introduction periods

The policies and strategies for the specific elements of PHC were not clearly defined at national level

– Health Planning and Management, 2004

Regions and health facilities had limited awareness of those elements defined at the central level


There was lack of clarity on health policies in most regions as a result of poor and inadequate dissemination of policy information


Uneven distribution of PHC services

Infrastructure problems, especially in rural areas – Research article on poor access to health services, 2007

Catastrophic expenditures Lack of some services and essential medicines in public health facilities

– Research article on poor access to health services, 2007

Service provision challenges in health posts and health centres, and at the community level

High turnover and lack of motivation in HEWs – Respondent from Oromia Regional Health Bureau

Lack of commitment from health development team (HDT) leaders

– HDT leader interview

Inequitable distribution of health professionals between urban and rural settings

– Respondent from Federal Ministry of Health

Problems in quality of PHC service

Poor skills, and lack of client-centred health service

– Respondents from clients (community side)


5. Governance and structure of PHC in Ethiopia

Ethiopia is divided into nine ethnically based administrative regional states and two city administrations. The Ethiopian Federal Ministry of Health is at the top of the hierarchy for health sector administration in the country. Each of the 11 administrative units has its own regional health bureau (RHB). The states are further subdivided into zones, each with a zonal health department, with the exception of Harari regional state, which has no zonal divisions. There are 558 woredas (districts), each with a woreda health office. Each woreda comprises a number of neighbourhoods or kebeles (the smallest administrative unit in Ethiopia, at village level), which number over 15 000. The effort to expand access to and quality of health care services in Ethiopia has focused a great deal on delivery and organization at the kebele level (14).

These health administration bodies stand at different tiers of a decentralized system. The Ministry of Health is responsible for major policies and guidelines, provision of policy and technical guidance, and coordination of donor support. Its relationship with the RHBs in the decentralization process is still evolving. The RHBs are under regional administration, with authority emanating from the regional council. Regional policies and plans are developed by the regional councils, which also decide what budget is allocated to the regional health activities. General and primary hospitals are the responsibility of RHBs. Zonal health departments are essentially administrative branches of the RHBs. The zonal health department is accountable to the zonal administration under the zonal council. At the woreda level, the woreda health offices are accountable to the woreda administration, in the form of the woreda council, an elected body. Woreda health offices have only a technical link with the RHB or zonal health department. The woreda health office is expected to oversee the PHCUs in the woreda, and is responsible for the planning, implementation and evaluation of all district health activities (15).

In the health system of the country, the working entities at each level are required to plan their activities periodically, though they do not engage in that process autonomously. The Federal Ministry of Health and RHBs guide the development of the plans by the lower bodies in the administrative structure. The Oromia RHB study participant said: “Targets are provided from the regional health bureau and Federal Ministry of Health to the lower levels in the hierarchy. The woredas and health centres develop their plans in line with the regional and Federal Ministry of Health.” Even the woredas develop their own financial plans annually, though the allocation of financial resources to the system is determined by the higher-level entities in the hierarchy.

The country’s health service has been restructured into a three-tier system, with primary, secondary and tertiary levels of care. The primary level of care includes primary hospitals, health centres and health posts. The PHCU comprises five satellite health posts (the lowest-level health system facility, at village level) and a referral health centre. It is the point at which PHC services are provided and facilitated under the health service delivery structure. A primary hospital provides inpatient and ambulatory services to an average population of 100 000 people. In addition to the services provided by a health centre, a primary hospital provides emergency surgical services, including caesarean sections, and blood transfusion services. It also serves as a referral centre for health centres within its catchment area, and a practical training centre for nurses and other paramedical health professionals. A primary hospital has an inpatient capacity of 25–50 beds and is staffed by an average of 53 health workers (2, 16).

Figure 1 illustrates the administrative structure of the Ethiopian health system.


A general hospital provides inpatient and ambulatory services to an average of 1 million people, and is staffed by an average of 234 professionals. It serves as a referral centre for primary hospitals and as a training centre for health officers, nurses and emergency surgeons. A specialized hospital serves an average of 5 million people and is staffed by an average of 440 professionals. It serves as a referral centre for general hospitals (Figure 1) (2).

Various types and levels of health service providers are also found in the private sector, which can be broadly subdivided into private for-profit and private not-for-profit subsectors. The private for-profit

subsector can be further subdivided into providers of formal health services and products, and providers of informal health services and products. The formal providers include health care providers operating in hospitals and clinics; diagnostic laboratories and diagnostic imaging facilities; and pharmacies, drug stores and rural drug vendors. The private hospitals provide a range of services similar to those provided by the public hospitals. Private clinics (higher clinics) often have both inpatient and outpatient services, and most have some diagnostic laboratory services. In contrast, informal providers include traditional healers, traditional birth attendants, and vendors of herbal and or alternative medicines (Table 4) (17, 18).

Figure 1. Administrative structure of Ethiopian health system

Source: Ethiopian health sector transformation plan, 2015.

Specialized hospital 3.5-5.0 million

Tertiary level health care

Woreda health office

(WorHO)

Kebele administration

Health centre (15 000-25 000 people)

Health post (3 000-5 000 people)

Health development team (20-30 families)

One-to-five network (6 families)

Household

Secondary level health care

General hospital (1-1.5 million people)

Primary hospital (60 000-100 000 people)



Health centre

(40 000 people)

URBAN RURAL

Primary level health care

Ethiopian health tire system Primary health care unit (PHCU)


Table 4. Health service organizations in Ethiopia by sector, and services provided

Type of facility

Mode of employment Range of services provided Source of information

Private sector

Specialized hospitals

Salaried permanent

• Serve up to 5 million people• Referral for general hospitals• Serve as training centre for medical, medical specialty and health students

Health Sector Transformation Plan, 2015

General hospitals

Salaried permanent

• Inpatient services and ambulatory services for 1 million people• Referral centre for primary hospitals• Training centre for health officers, nurses and emergency surgeons


Primary hospitals

Salaried permanent

• Inpatient capacity of 25–50 beds• Referral centre for health centres• Staffed by an average of 53 health professionals• Provides inpatient and ambulatory services to an average population of

100 000• Provides emergency surgical services, including caesarean sections, and

gives access to blood transfusion services


Health centres

Salaried permanent

• Referral for health posts• Serve up to 25 000 population in rural areas and up to 40 000 in urban

areas• Impatient capacity of up to five beds


Health posts Salaried permanent

• Staffed by average of two HEWs• Provides services for an average of 5000 people• Mostly preventive services

Health Development Army Guidelines, 2005

Private for-profit, private not-for-profit sectors

Private hospitals

Both salaried permanent and part time

• Inpatient and outpatient services• Laboratory services

Public-Private Partnership in Health Strategic Framework for Ethiopia, 2013

Clinics Both salaried permanent and part time

• Inpatient and outpatient services• Higher clinics offer some laboratory services

Assessment of Readiness of Private Higher Clinics, 2008

Drug vendors


• Supply of essential drugs usually for rural community• Supply of medical supplies and instruments

List of medicines for rural drug vendors, 2011

Pharmacy Both salaried permanent and part time

• Supply of essential drugs mostly in urban settings• Supply of medical supplies and instruments

Assessment of the Pharmaceutical Sector in Ethiopia, 2003

Diagnostic laboratories


• Treating patients • Deciding health priorities and allocating resources• Monitoring the development and spread of infections pathogens as well

as status of non-infectious acute or chronic diseases or their markers; tumour markers, hormones, cancer cells, etc.

• Investigating preventable premature loss of life

Health Laboratory Management and Quality Assurance, 2004

There is demand among communities for linkages between the formal health system, particularly the PHC system, and community-level networks. This has been ensured through the introduction of health development armies (HDAs). Organizing a

functional HDA requires the establishment of health development teams (HDTs) that comprise up to 30 households residing in the same neighbourhood. The HDT is further divided into smaller groups of six members (households), commonly referred to as


“one-to-five” networks. HDA implementation started in 2011, since when considerable progress has been made in the organization and formation of a network of HDAs and HDTs. In Ethiopia there are currently 442 773 HDTs, within which are 2 289 741 one-to-five networks. The HDA network enables mobilization of the community through participatory learning and action meetings (2).

In that regard, the PHCU coordinator of Oromia RHB said:

At kebele (village) level there is a command post led by the kebele leader, with members from development sectors like health, education and agriculture. This command post follows up the development groups’ developmental work every two weeks. The development group controls the one-to-five networks’ activities each week, and the one-to-five networks follow up each household’s performance three days per week. Since its implementation, this structure has become fruitful; the results can be seen especially in improving institutional delivery. Mothers help each other in their one-to-five networks and development groups, which support mothers with food provision during the latter stages of pregnancy.

The leaders of the HDTs and the one-to-five networks are selected by the team members. The main criteria for selection of the leaders are their status as model family members, and their trustworthiness as community mobilizers. A model family can obtain community recognition when they implement all the packages of the Health Extension Programme, or perform with distinction among the group members. There is also the possibility of changing leaders (19). As one study participant from the Oromia RHB coordination unit said: “Other members of the HDT or one-to-five network have the chance to become the leader whenever they implement health extension packages better than the former leader. This creates a sense of competition among the members.”

The formation of the HDTs and the one-to-five networks is facilitated by HEWs and the kebele

administration. The HDT leaders, who operate as unpaid volunteers under the supervision of HEWs, carry out a number of tasks, including helping during immunization campaigns, keeping track of pregnancies and illnesses, and relaying messages between households and HEWs (20–22).

The PHCU is the smallest division in the Ethiopian health tier system, and is the unit most accessible to the general population (Figure 2). As previously mentioned, it is composed of a health centre and five satellite health posts. The health post is the first level of Ethiopian health service delivery, and provides services at kebele level. On average 5000 people are served by a single health post, and two HEWs serve at each health post. The health posts are accountable to the health centre and kebele administration (20).

Health centres provide services to approximately 25 000 people. A health centre is staffed by an average of 20 health personnel, and provides both preventive and curative services. It serves as a referral centre and practical training institution for HEWs. A health centre normally has an inpatient capacity of five beds (2).

Figure 2. PHC structure in Ethiopia

Woreda health office

(WorHO)

Kebele administration



Health development team (20-30 families)

One-to-five network (6 families)

Household

Primary health care unit (PHCU)


The PHC service is designed to include preventive, promotive and basic curative services. The Ethiopian Government introduced its Health Extension Programme in 2002 to enhance PHC services, especially for the rural population. The Health Extension Programme, which focuses on the preventive and promotive aspects of health care, includes 16 packages under four main programme categories (13, 23):

• Hygiene and environmental sanitation: (a) proper and safe excreta disposal system; (b) proper and safe solid and liquid waste management; (c) water supply safety measures; (d) food hygiene and safety measures; (e) healthy home environment; (f ) arthropods and rodent control; and (g) personal hygiene.

• Disease prevention and control: (a) HIV/AIDS prevention and control; (b) TB prevention and control; (c) malaria prevention and control; and (d) first aid.

• Family health services: (a) maternal and child health; (b) family planning; (c) immunization; (d) adolescent reproductive health; and (e) nutrition.

• Health education and communication.

The Health Extension Programme initially focused on rural settings. However, preventive and promotive services are vital in the urban areas of the country. Since most of the country’s health problems are attributed to preventable infectious and communicable diseases, a 24-package urban health extension programme has been established (4). HEWs in the rural areas have completed 10th grade, while health extension professionals in urban areas hold clinical nursing diplomas. The clinical nursing diploma holders are given three months’ pre-service training on the basics of the Health Extension Programme and the 24 packages (24). On the matter of the rural and urban health extension programmes, an informant from the Federal Ministry of Health PHC and Health Extension Programme Directorate said:

Until now the urban health extension programme has not been as effective as the rural one. Using clinical nurses as HEWs in the urban setting was

one of the problems. Consequently we are starting a generic programme for urban HEWs. The first batches are being enrolled at Menelik Health Science College and regions are on the way to start this programme. Through the programme, females who have completed 10th grade get three years’ training, essential for the Health Extension Programme.

The Ethiopian health system uses a “harmonization and alignment” mechanism, with the major objective of streamlining planning, financing and reporting by having one plan, one budget and one report. The Ethiopian Government and development partners work together to achieve this objective. Moreover, Ethiopia is a signatory of the International Health Partnership (IHP+) Global Compact, and was the first country to develop and sign a country-based IHP+ compact. The health sectorwide strategic plan – the Health Sector Development Programme – is the product of substantial consultations between the Ministry of Health and health development partners. One of the most important refinements in Health Sector Development Programme III was the inclusion of woreda-based health sector planning, which created a platform for joint planning by all stakeholders at all levels of the health system, including health development partners (25).


6. Financing

Ethiopia’s health sector has multiple financing sources, including the government Treasury (federal, regional and woreda/district levels), bilateral and multilateral donors, household out-of-pocket expenditure, international and local NGOs, private and parastatal employers, and insurance companies. Nearly half of Ethiopian health care expenditure comes from the rest of the world, followed by household expenditure and government expenditure (Figure 3) (4).

A key informant from the Federal Ministry of Health Resource Mobilization Directorate provided more detail on the sources of funds for the Ethiopian health system:

Most of the financial resources for health care come from the government Treasury and revenue, the rest of the world, and household out-of-pocket payments. The resources from the rest of the world come from both loans and donations. Since they are repayable to the creditors, loans are considered as government money. Donor money comes through three channels. Channel 1 comprises resources that come directly from donors to the Ministry of Finance and Economic Cooperation. These can be of two types: marked resources, which are resources targeted to one specific programme, and unmarked resources, which are financial resources allocated according to the Federal Ministry of Health. Channel 2 comprises resources that come from donors and go directly to the Federal Ministry of Health. Channel 3 comprises resources from donors that go directly to NGOs that have connection with the donors. Out-of-pocket payments are collected as government revenue and reallocated to the health service. Even when health institutions raise financial resources, it is considered as government revenue.

The “one budget” approach has enabled the Federal Ministry of Health and health development partners

to jointly design their revenue and expenditure accounts for health services in the country. A joint financing arrangement, signed by the government and development partners, has enabled the Federal Ministry of Health to access and make use of pooled funds (25).

Out-of-pocket health expenditure in the country is 35.8% of total health expenditure. There is a fee waiver system to protect the poor from catastrophic health expenditure, but due to shortages of health services and medicines in health facilities, the poor often have to result to private sector suppliers, resulting in high out-of-pocket health expenditure. For PHC services, out-of pocket-expenditure again accounts for the highest proportion. Of the total health expenditure by the government, 26.73% is allocated to primary-level health care (Table 1) (26). This is greater than the proportion of government

35.8% Households

Rest of the world 46.8%

Others

0.9%

Government 16.5%

Figure 3. Ethiopian health expenditure, 2011

Source: Ethiopian National Health Accounts (4).


expenditure for the overall health system, possibly indicating greater focus on PHC provision.

Government health facilities were major recipients of the 2010/2011 spending of health care financial resources, accounting for nearly 34% of total health expenditure. Public PHCUs, which include government health centres and health posts, received nearly 15% of total health expenditure. In addition, the Ethiopian Government has embarked on implementing community-based health insurance (CBHI) schemes in the country, which cover an estimated 83% of the population. The scheme was implemented as a pilot in selected districts of the four biggest regions: Oromia, Amhara, the Southern Nations, Nationalities and People’s Region, and Tigray (4, 26).

Currently, CBHI has been extended to 377 districts nationally. Among these, 205 districts have started delivering health services based on the insurance

scheme, to the extent that 36% of the population in those districts is covered by the scheme. Nationally, CBHI has 15% coverage. The representative of a health insurance agency observed: “Initially this CBHI was designed to deliver health services at the PHCU level. But later it was modified to enable clients to obtain referral services at the secondary and tertiary levels of the health system.”

In addition to these sources of finance, as the information from Oromia RHB indicated, there are other mechanisms to support PHC services at the regional level. At the HDT level, members of the team can make a financial contribution to cover their health issues. But there is no fixed amount of contribution that is officially determined – the members themselves agree on their contributions. The contributions of the households are collected legally, depending on the regional financing guidelines. These resources are used to finance the health affairs of the community.

Figure 3. Ethiopian health expenditure, 2011


7. Human resources

In this era of rapid and continuous change, human resources management is one of the organizational domains that can provide support for employees dur-ing internal change processes and help managers and leaders identify and implement processes for change (27). As a large and diverse country, Ethiopia presents daunting challenges to human resources develop-ment. That challenge has increased with the growth in population, from 28.7 million in 1976 to 80 million in 2010, and the growing urban population (28).

Currently, the New Medical Education Initiative has been expanded to 13 medical schools, contributing to the increase in intake of medical students. Despite these positive developments, the sector still faces formidable challenges, including the huge burden of maternal mortality. Even though appropriate strategies and initiatives are in place, there are serious shortages of the required trained human resources, and there are also cultural, social and economic barriers to be overcome (29).

To improve the staffing number and composition at various levels, taking into account the human resources for health requirement for universal PHC coverage by the end of the Health Sector Development Programme III period, the focus has been on scaling up the training of community and mid-level health professionals. With regard to community-level professionals, a total of 31 831 HEWs have been trained and deployed to meet the human resources for health requirements of the Health Extension Programme. In addition, to increase the human resources for comprehensive emergency obstetric care and other emergency surgery services at PHC level, a curriculum for a master’s programme on emergency surgery has been developed and training has started in five universities (25).

Given the need to improve the quality of the licensure examination to assure a competent health workforce and safe, high-quality health care, and its congruence with the scope and expertise requirements of the Human Resources for Health Project, opportunities were explored for collaboration

with state occupational assessment and certification agencies, federal and state technical and vocational education and training systems, and the Ministry of Health. Among other things, the project is mandated with improving the quality of education and training of health workers and improving human resources for health policies, regulations, and practices (30).

A report of the Human Resource Development Directorate of the Ethiopian Ministry of Health states the aims of training and supplying qualified health workers of different categories governed by professional ethics, and designing new systems of human resource development and retention. The directorate also recognizes that although great progress has been made in the recruitment and training of low-level health care providers such as HEWs, there is a human resource crisis at higher levels, particularly among physicians (14).

Stated objectives of human resource policy include deployment of relevant and qualified health workers of different categories for the whole sector and improving the management of human resources within the public sector in order to enhance the efficiency of health workers, retaining them within the sector and maintaining a high level of professional ethics (31). The need is highlighted by a member of the Medical Service Directorate at the health bureau of the Southern Nations, Nationalities and People’s Region (SNNPR):

There are instances where we go for supportive supervision to the zones from the SNNPR regional health bureau. In various zones that we visited, they are telling us that there is high attrition of health professionals from district health institutions, especially laboratory and pharmacy technicians. There are even health centres without laboratory technicians and pharmacy technicians, which makes the services incomplete.

Table 5 presents data on human resources for health in Ethiopia.


Table 5. Human resources for health in Ethiopia

Indicator Number

Number of physicians per 1000 population 0.2 per 1000

Number of nurses per 1000 population 2.3 per 1000

Number of community health workers per 1000 population (HEWs) 0.41 per 1000

Relative geographical distribution (rural/urban) of doctors, nurses, community health workers Data not available

Informal providers and practitioners of traditional complementary and alternative medicine as proportion of total health care workforce

Data not available

Source: Geresu et al. (32).


8. Planning and implementation

Ethiopia’s health plans are developed and implemented within the wider context of the country’s major development plan – the Growth and Transformation Plan (GTP). The GTP is a five-year strategic plan that is directed towards achieving Ethiopia’s long-term vision and sustaining rapid and broad-based economic growth. The first GTP was started during 2011/2012 and ended successfully in 2014/2015 (33). The second phase (GTP II) was developed in 2015/2016 and will be implemented over the next five years, up to 2019/2020. The development of GTP II took cognizance of and built on the lessons learned from GTP I (34).

Over the last 20 years, the five-year health-specific development plan – the Health Sector Development Programme – has been used to guide the planning and implementation of health-related policies and programmes in Ethiopia. The country has successfully completed four consecutive phases of the Health Sector Development Programme since its inception in 1997/1998. Records of each phase of the plan – Health Sector Development Programme I, II and III – showed encouraging successes in both health service coverage and the utilization of services at all levels of the health care system in Ethiopia. Health Sector Development Programme IV of 2010/11–2014/15 has been completed but is yet to be evaluated exhaustively (25).

The national implementation of PHC strategies and expansion of infrastructure have also been carried out successfully over the past 20 years, with 16 440 health posts, 3547 health centres and 311 hospitals constructed. In parallel with the construction of health facilities, investment in human resource development and management has been scaled up (2).

Despite the impressive progress made, Ethiopia still has high rates of morbidity and mortality from preventable causes. The latest five-year health plan

– termed the Health Sector Transformation Plan – was developed in August 2015, in line with the country’s GTP II. The plan sets ambitious goals to improve equity, coverage and utilization of essential health services, improve quality of health care, and enhance the implementation capacity of the different components of the health sector (35). To help achieve this ambition, the Health Sector Transformation Plan includes administrative decentralization to RHBs and district-level health offices.

In order to track and measure disease prevalence in the general population for improved reporting, Ethiopia has implemented the Integrated Disease Surveillance and Response (IDSR) system since 1998, and the Health Management Information System (HMIS) since 2005 (36, 37). The IDSR system was established with the aim of identifying and reporting priority diseases and outbreaks for decision-making and providing feedback within and across levels of the health care system (36, 38). The flow of information in the IDSR system is from the health facility, where diseases that have epidemic potential and are thus targeted for eradication and elimination are reported, to district health offices. The district health offices receive data from the health facilities, compile them, and send them to the higher levels (RHB and Federal Ministry of Health) for decision-making (39).

Similarly, the HMIS was developed in accordance with the priority plans and objectives of the Health Sector Development Programme III. It was formulated as part of the attempt to harmonize the national, local, and international efforts for the continuing improvement of the health of the population, in line with the principle of having a single common plan, budget, and monitoring and evaluation system, which is a cornerstone of the Health Sector Development Programme III. A similar principle – the “Three Ones” principle – has been formally adopted by the Joint United Nations Programme on


HIV/AIDS (UNAIDS). The HMIS will accordingly act in conjunction with the Monitoring and Evaluation Strategic Plan to support the aim of establishing a single shared monitoring and evaluation system in Ethiopia (40).

The Public Health Emergency Management Centre is responsible for anticipating, preventing, preparing for, detecting and responding to public health crises, such as epidemics, emerging infectious diseases, and nutritional emergencies (41).

While Ethiopia has made progress in developing conducive policies and programmes, several challenges remain, including unsustainable financial resource strategies, inadequate training and high turnover of peripheral staff, unreliable feedback, lack of supervision from higher authorities, and weak laboratory capacities. These challenges are exacerbated by a scarcity of support mechanisms and materials, such as case definitions, reporting formats, and adequate communication and transport systems. In addition, the lack of availability of a cadre of professionals sufficiently trained in surveillance is a major systemic hindrance to successful implementation of the IDSR system (36).

With respect to the HMIS and Monitoring and Evaluation Strategic Plan, the current core process is weak in terms of staffing, including formal assignment of staff with job descriptions and assigned tasks, and established training modalities. In Ethiopia, there are no standard instruments to collect information when patients interact with caregivers. In addition, public health emergency preparedness capabilities are weak, including putting in place the necessary logistics and funding, building the essential systems specific to protection, prevention and response, and equipping public health personnel and respondents with the required knowledge.

Ethiopia also has policies supporting the deployment of primary care teams with clearly identified roles. The country has a decentralized federal structure with nine regional states, two city administrations, 817 districts, and 15 000 villages (kebeles). Under

the new structure, the Federal Ministry of Health is responsible for issuing policies, setting national targets and monitoring implementation of programmes. The RHBs are run autonomously by the member states of the federation. Previously, the centralized administration resulted in a poor organizational and management structure within the health sector, with inadequate support for PHC staff. Following a change of government in 1991, a new health policy was developed and implemented in 1993, stimulating many reforms in the Ministry of Health (42).

Recently, the referral system has been reorganized and the management structure of the health sector has changed considerably. The size of the Ministry of Health has been reduced, delegating more responsibilities and power to the RHBs, and decentralization has expanded to the district level, where health service delivery is managed by woredas (districts). The woredas have also been responsible for budget allocation, hiring and firing.

The Health Extension Programme was conceived with the principle and philosophy that health is a service that can be self-managed by individuals, families, and communities, given appropriate devolution of responsibilities to community level. The process of developing the Health Extension Programme commenced with the creation of a training programme for HEWs, construction of new health posts, improved supply chains for medicines and drugs, and development of a framework to engage communities. Starting in 2004, about 38 000 female HEWs in rural areas and 4000 HEWs in urban areas have been trained. About 400 male HEWs were trained because in some pastoralist communities females were not sufficiently educated to enrol in the HEW programme. The initial intention was that female HEWs would be recruited and trained, and would spend 75% of their time interacting with women and mothers in their homes (25).

To ensure the highest level of community participation, the HEWs are supported by volunteer “model families”, called HDA leaders, which are


recognized by the district office as exemplary family units in their community. As one of the Federal Ministry of Health key informants noted: “These people are non-paid volunteers. We believe they are motivated because they are serving their community and their families, and they need recognition.”

Through gradual and continuous evolution, the Ethiopian health care delivery system has developed to the present three-tier health care system. To support this process, health workers of different categories have been trained to staff the different tiers of the system, from HEWs at the lower level, through mid-level health professionals, to higher-level specialized workers (25).

These health cadres are expected to work to the best of their professional standards based on guidelines indicating the required standards and competencies for health practitioners and regulations of professional practice. The general public is informed of the services that health workers are qualified to provide (43). However, as observed from the qualitative results, there are problems with the quality of educational curricula, resulting in deficient professional knowledge, skills and even behaviour, as observed by a key informant from the Ministry of Health:

We have a number of problems with our professionals’ skills, as we already noticed from a preliminary study we had with stakeholders. We want to further investigate the quality of health sciences education and maybe educational curriculums guiding education in colleges or universities.

In another reform, hospitals are now managed by boards, which decide internally on the allocation of resources. However, the “brain drain” of high-quality physicians has been a serious problem in Ethiopia. In order to incentivize high-calibre physicians to continue practising in Ethiopia, a private wing incentive package has been created within government facilities. In the private wing, doctors

work on a fee-for-service basis, and can be paid up to 10 times the salary of doctors in public hospitals.

The Federal Ministry of Health has prioritized the provision of quality emergency and critical care medicine in the national health care system. To this end, procurement and distribution of ambulances and other emergency and critical care equipment, launch of the Addis Ababa emergency coordinators’ team, publication of the national ambulance guidelines, development of a referral manual, and initiating postgraduate studies in emergency medicine all indicate progress. The Federal Ministry of Health has procured and distributed 1247 ambulances to all regions after signing a memorandum of understanding with all the relevant stakeholders (44).

Although the referral system, as it is structured, emanates from the community and passes through health posts, health centres, primary hospitals and then to specialized hospitals, referral decisions are not usually patient centred. Hindrances to the referral system include insufficient skills and knowledge of health workers, inadequate data with regard to available resources and services, poor attitude of health workers, and absence of proper communication mechanisms. Lack of transportation means that patients often face difficulties reaching higher-level facilities if they are referred, and on arriving at the hosting hospitals they face further therapeutic and referral challenges (44).

Despite the aim of simplifying the health care delivery system along the lines of the three tiers, proper administration of the supply chain and referral system has proved to be challenging. Since Ethiopia is a large country with limited access to road networks in many cases, it is difficult to maintain a constant supply of medicines and commodities to every part of the country (45).

Ethiopia has been promoting civic engagement in the context of decentralization of authority to lower levels as an important policy instrument for addressing local needs effectively and situating


the power for public service delivery closer to the people. In Ethiopia, up to 2012, a total of 1056 new charities and societies had been registered and received certificates. Overall, as of February 2012, the charities and societies registered at federal level were implementing over 1139 projects in the social, economic and governance-related spheres. In terms of the kind of initiatives that the charities and societies are engaged in, the data indicate that health and health-related projects account for over 19.8% of interventions (46).

Taking the Ethiopian reality into consideration, the mechanisms for social accountability are intended to ensure that ordinary citizens, who are the users of public services, (a) voice their needs, preferences and demands for improved and effective service delivery and policies; and (b) hold policy-makers and service providers accountable for weak performance or non-delivery of services. In 2004, a local network of civil society organizations –the Poverty Action Network of Civil Society Organizations in Ethiopia – piloted the use of the citizen report card to assess access to, use of, and satisfaction derived from delivery of key services in different regions of the country (47).

Social accountability falls under the scope of governance, and only approved Ethiopian charities and societies have the right to engage in that area. Corruption, weak accountability systems and a lack of responsiveness on the part of government are often cited as the basis for growing disillusionment of citizens with government at all levels. A weak culture of public action, lack of assertiveness, and deficient public policy advocacy are challenges, even under ideal conditions. There are also potential risks that advocacy approaches pose to those individuals or organizations that speak out. For instance, some attribute the restrictions on certain NGOs following the 2005 election to the fact that some of the organizations were critical of the manner in which the election was conducted (46).


9. Regulatory processes

Health care provision depends on efficiently combining financial resources, human resources and supplies, and delivering services in a timely fashion and with equitable spatial distribution throughout a country. Good governance is a critical factor in making such a system function. While governance indicators have been developed for countries in the aggregate, governance indicators for specific sectors, such as health, are often not readily available. Consequently, it is necessary to look for proxies that reflect the quality of health sector governance (48).

The “Quality of health services” component of the Health Sector Development Programme IV applies a three-pronged approach to improving the quality of health services. These comprise supply-side interventions, demand-side interventions and regulatory measures. The supply-side interventions include providing adequate numbers of skilled and motivated professionals, and strengthening the supply chain management system to ensure an adequate and uninterrupted supply of pharmaceuticals at the point of service delivery. An internal quality assurance mechanism would help ensure effective implementation of performance monitoring and quality improvement standards and tools at all levels of the health system. Other plans include placement of community members on health facility governance boards; development of a patients’ rights charter; and conducting regular surveys on client satisfaction (25).

The health policy of Ethiopia emphasizes training of community-based, task-oriented front-line and mid-level health workers. As a mechanism to retain health workers, the policy supports development of an attractive career structure, proper remuneration and incentives for all categories of workers within their respective systems of employment (49). The basis for accelerated improvement in health has been the rapid growth in the construction of health

facilities, the training of health professionals and the allocation of budgetary resources to the sector (50).

Standards applied by accrediting entities continue to draw on the expertise of provider organizations, health professionals, purchasers, health planners, consumers, and measurement experts, while being mindful of the burden placed on providers. Through regulatory processes, overseeing provider organizations and facilities should continue to monitor providers, ensure feedback and accountability, and strengthen patient safety and quality improvement (51).

A key principle of health sector business process re-engineering is improving the quality of health services through institutionalizing accountability and transparency. The Health and Health-Related Services and Products Regulatory Agency has a mandate to undertake inspection and quality control of health and health-related products, premises, professionals and health delivery processes in an integrated manner (25).

Regulations pertaining to quality may define specific standards and require that health providers comply with certain requirements, but they can also allow health care or professional organizations to prescribe their own rules. The degree of specificity of a quality regulation depends in large part on the perceived competence of provider institutions and on regulators’ confidence that the desired ends of regulation will be achieved (52).

Recently, components of quality of care have been identified as a combination of access and effectiveness in the areas of clinical care and interpersonal care (53). The Federal Ministry of Health has prioritized the provision of quality emergency and critical care medicine in the national health care system. To this end, ambulances and other emergency and critical care equipment have been procured and distributed (44). A female health


worker from North Bench woreda, Southern Nations, Nationalities and People’s Region, observed:

People are always complaining at this health centre [North Bench health centre] because of the shortage of drugs. One of my neighbours, whom I had advised to visit the health centre because of her health problem, told me that the health professional prescribed for her a drug that was not in the health centre’s pharmacy, and the druggist working there told her to buy outside the pharmacy from the private drug stores, which was more expensive. I heard other individuals also complaining about the shortage of drugs.


10. Monitoring and information systems

The organizations at each level of the PHC system, and the first-level entities under each kebele (for example the HDTs and one-to-five networks), share their information, thus maintaining the structural linkages between these bodies. HDT leaders collect reports from the one-to-five networks; similarly, HEWs in each health post at kebele level receive reports from HDT leaders, and compile these reports with their own activities to send to health centres.

Ethiopia has three sources of health monitoring data relevant for universal health care measurement: the HMIS, administrative reports, and surveys. The Federal Ministry of Health is attempting to strengthen the HMIS in Ethiopia, which, in general terms, represents a combination of health services-based data sources. The HMIS was established to support informed strategic decision-making by providing quality data that help managers and health workers plan and manage the health service system (54).

Major HMIS challenges and weaknesses include the absence of an implementation strategy and guidelines; the shortage of human resources and high staff turnover; inadequate skills for gathering and analysing data among health care staff at lower levels; unsatisfactory quality of data in the reports, reducing the ability to make informed decisions; and fragmented information flows, including parallel reporting system channels, resulting in increased workloads (55).

HMIS reports are being used for various decision-making processes, including woreda-based planning, which is now the formal planning process in most regions. Planning is taking place at different levels and involving a widening range of stakeholders, including heads of health centres, community representatives, NGOs, community leaders, administrative leaders and development partners (25).

Health care informatics has been identified as a critical area in need of extensive improvement and

reform. A stated purpose of the reform is to create a simplified, standardized and integrated national health information system. The reform covers a wide range of activities that will be implemented in phases with the intention of producing vital information for planning, monitoring, and decision-making. These activities include management of individual medical records, abstraction of data for quarterly-based reporting, and indicator review for activity monitoring and performance improvement (14). A medical service officer at North Bench woreda health office stated:

As woreda medical service officer, I think that information gives us the power to plan for the limited resources that we have at hand. At the department, we collect reports from the health centres and the health post on regular basis, that is, monthly. The performance review team discusses whether the key performance indicators were implemented as planned or not. Then the performance review team provides feedback on the indicators. At the end of the year, an aggregate of the data obtained from the institution serves as the basis for the woreda base plan for the coming fiscal year.


11. Challenges, ways forward and policy considerations

The following challenges and problems were identified:

• Shortage, high turnover and lack of motiva-tion of HEWs. There is no career and educational development structure for HEWs in the Ethiopian education system, due to a lack of awareness of the need for future development in that regard. However, the Federal Ministry of Health, in collaboration with RHBs and universities, is developing a curriculum for educational and career development of HEWs. One Federal Ministry of Health respondent said: “We have started level 4 training for HEWs. To date, more than 8000 have graduated at level 4. There is also a career mechanism for their development. They can be BSc or master’s holders and can even become family physicians.”

• Lack of commitment from leaders of HDTs and one-to-five networks. One HDT leader said: “You know, I am extremely busy with my own routine activities as well as this work, and there is no incentive attached to this job.”

• Lack of quality of health professionals. In addition to the low ratio of health professionals to population, the general lack of quality and competency among health professionals has drawn the attention of federal and regional health officials, as well as the communities being served. One respondent from the Federal Ministry of Health stressed the need to conduct quality and competency assessments for both the educational curriculum and the employees in service.

• Inequitable distribution of health profes-sionals. The health workforce is inequitably distributed across urban and rural areas. As one individual from the Federal Ministry of Health observed: “High-level specialized doctors and master’s holders live and serve in urban areas.” There are few disaggregated data on the number of professionals working in rural and urban areas.

• Lack of decentralized planning. Districts still have inadequate responsibility for their work and financial plans, and very limited autonomy regarding allocation and utilization of financial resources.

• Limited supplies. Difficulties arise from the lack of medical equipment and medicine, and deficient supply chain management and quality assurance.

• Capacity-building for monitoring and evaluation. At all levels, correct methodologies for applying financial indicators for PHC have to be developed, in line with international standards. Capacity-building is needed at both individual and organizational levels.

• Assessment of community-level health contributions. At community level, health development armies collect voluntarily contributed resources – money, grains, teff (local staple food), coffee – and deposit them at health posts. This mechanism of community distribution and utilization of resources to contribute to their own health remains unstudied scientifically. Similarly, the effectiveness of communities’ contribution towards maternal waiting homes remains unstudied.

• Need for additional data. Further studies are needed of the following: (a) motivation to work; (b) impact of in-service training; and (c) effect of health infrastructure on health service accessibility for the general public, as well as people with particular challenges, such as disabilities. The Federal Ministry of Health needs to create indicators where data are not available.


Annex 1. Study participants

Table A1.1. Study participants: clients, service users and service providers

Descriptor Main areas of expertise Main constituency represented Number Remarks

Women at antenatal care clinics

– Public or community side 3 Key informant

Women at maternity waiting homes for delivery

– Public or community side 1 Key informant

Health development army – Public or community side 8 Key informant

HEWs Health care workers Service provider side 6 Key informant

health care providers Different categories of health care provider (nurse, pharmacist, midwife, laboratory assistant, etc.)

Service provider side 2 Focus group discussions (12 persons)

Table A1.2. Study participants: managerial and policy-makers

Descriptor Main constituency represented

Level of health system at which active Number

District HEW supervisors Health care manager District/local 2

Regional PHC Directorate Decision-maker Regional 3

National PHC and Health Extension Programme Directorate

Policy-maker National/federal 1

National Human Resources for Health Directorate Policy-maker National/federal 1

National Health Care Financing Directorate Policy-maker National/federal 1

National Health Insurance Agency Policy-maker National/federal 1


Annex 2. Methods used to calculate expenditure indicators (see Table 1)

PHC expenditure as % of total health expenditure =total PHCU expenditure

total health expenditure× 100

% total public sector expenditure on PHC =public health expenditure on PHCU

total PHCU expenditure× 100

Per capita public sector expenditure on PHC =public health expenditure on PHCU

total population


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This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system, tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points to strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems in selected low- and middle-income countries.

primary health care systems (primasys) · case study from ethiopia 3 1. introduction to ethiopia...

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