Health Sector Development Programme, the Ethiopian Case

1
Health Sector Development Programme, the
Ethiopian Case

• May, 2007
• For GAVI Board

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Outline of the presentation

• Background
• Health Policy and health sector development plan
• Health care financing
• Progress on EPI and Major communicable diseases
• Challenges and the way forward

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Country Profile

• 1.1 million sq.km
• 77.3 million population
• Population growth rate 2.7 /year
• Rural population85
• Federal government
• 9 Regional States, and 2 City Administration
• 624 Woredas (districts)
• 15,000 kebeles (villages)

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Main focus of Health policy of Ethiopia

• Decentralized health system
• Capacity building
• Social mobilization
• Universal access to primary health care
• Development of the preventive and promotive
  components of the health service
• Maternal and Child Health
• HIV/AIDS, TB and Malaria
• Harmonization

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How the health system works?

• A four-tier health delivery system
• Comprised of health posts (HEP) and Health
  centers Primary health care unit (PHCU)
• Followed by District, Zonal and Specialized
  hospitals
• PHCU Unit is planned to serve 25,000 people
• District and Zonal hospitals are expected to
  serve 250,000 and 1,000,000 people respectively.

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Summary of HSDP III Outcomes and Targets
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Three scenarios

• Scenario 1 US 4.8 per capita per year over 5
  years
• Full implementation of the HEP
• access to health post 100 (13,635 health post,
  human resource, essential inputs)
• access to health center 80 (2,229 health center,
  human resource, essential inputs, functional
  B-EOC)
• Scenario 2 US7.5 per capita per year over 5
  years
• HEP plus expansion of first referral clinical
• Scenario 3 US13.3 per capita per year over 5
  years
• No resource constraints
• access to health center 94 (3,153 health center,
  human resource, essential inputs, functional
  C-EOC
• High coverage targets for clinical care e.g. 80
  ARV
• All health MDGs achieved

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Main Vehicles for HSDP III Implementation

• Health Extension Program (HEP)
• Health as a product produced by a HH
• GoE flagship program to improve access and equity
  to preventive essential health interventions
• 16 packages of promotive, preventive and basic
  curative services
• 2 HEWs and a HP in each village of 5000
  population
• High school grads with 1 year certificate
  training
• Accelerated expansion of PHC facilities
• 1 Health center for 25,000 population
• Need is gt 3,000 health centers (existing 670)
• Headed by HO (total need 5,000 health officers)
• Focus mainly on curative services as a back-up to
  HEP

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Health Extension Workers Profile

• Recruitment Female high school graduates
• Duration of training 1 year
• Venue of training TVET Centers
• Deployment two HEWs per villages
• Employment per government scale
• Accountability accountable to the DHOs
• Supervision supervised by DHOs
• Logistic supplies provided by DHOs and Health
  Centers

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Major HEP Categories

• Family health
• Communicable diseases prevention and control
• Hygiene and environmental health
• Health education

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Components

• HIV/AIDS
• Malaria
• Maternal Health
• Child Health
• Adolescent reproductive health
• Vaccination
• Nutrition
• Solid and liquid waste

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Components

• Housing
• Latrine
• Insect control
• Food sanitation
• Water sanitation
• Personal hygiene
• First Aid
• Health education

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Action Steps

• Discuss with administrators and association
  leaders and reach consensus
• Conduct base line survey
• Select model families (30-45 households at once)
  on voluntary basis
• Train selected households for 96 hours
• Graduate trained households in 2-3 months (Oath)
• Monitor progress after graduation (HEW and CHWs)
• Enforce environmental law and penalize community
  members who practice otherwise (Social court)
• Complete (HH) and minimum package
• Activities are harmonized with Education and
  Agriculture

• m

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Achievements to date and challenges

• Challenges
• 17,430 health extension workers trained and
  deployed until December 2007
• Over 7200 HEWs enrolled in January 2007
• gt 6,800 Health Posts constructed to date
• Results from areas where HEWs are deployed are
  encouraging immunization contraceptive use
  personal and environmental hygiene HCT malaria
  etc..
• Challenges
• Systems (shortage of supplies and weak support
  system)
• Structure (dedicated unit and Supportive
  supervision)
• Human resource (low confidence in some skills)

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Progress 2000 to 2005 Child Health

• Infant mortality 77/1000 from 97 in 2000
• Under five mortality 123/1000 from 160 in 2000
• DPT 3 coverage 80 from 38 in 2000

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EPI Coverage 2001 - 2006, Ethiopia
GAVI
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Distribution of zones by coverage category
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Trends in Child Health Impact Indicators
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Support provided from GAVI to Ethiopia 2002 to
2007
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Additional children reached for DPT3 and GAVI-
ISS Award since the start of GAVI support
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Number of children reached for DPT3 and GAVI- ISS
Award
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A year ago 85 of the ART patients were male (fee
based) Hospitals filled with male
patients Today with free ART program females
exceeded the male patients b/c it is freely
available for economically poor and vulnerable
women and their children
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Malaria

• 10 million households in malarious area in 2
  years, by August 2007 20 million ITNs required
• So far, 15.8 million ITNs distributed and
  remaining ITNs are secured and in the pipeline
• Gap to be filled with ITNs already on procurement
• Early diagnosis and treatment by HEWs
• Social mobilization for malaria picking
• IRS coverage increasing
• MAC campaign

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Yearly Malaria Epidemics Recorded, ETHIOPIA (July
2000 June 2006)REMARK no data incorporated
from Benishangul Gumuz and Dire Dawa Regional
States for the year 2005 - 2006
Source data collected from Regional Health
Bureaus, FMOH
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Health Human Resource

• Health extension workers 17,400 (58 of the
  required 30,000)
• Physicians (including HOs) 2,790
  (Ratio126,906)
• Health Officers (trained in 5 years)776
• Nurses (senior and junior) 17,845
• (Ratio14,207)

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Harmonization and Alignment

• Code of conduct was signed in September 2005
  between Government and health partners
• GAVI signed the code of conduct recently and the
  first contributor to the MDG PPF
• Establishment of TA Health Pool Fund
• Revised HSDP Harmonization Manual (HHM) endorsed
  in April 2007 (One Plan, One budget and one
  report)
• Procurement of consulting firm for HSDP resource
  mapping underway

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Logistic Master Plan

• Assessment of the Health Commodity Supply System
• Selected option Drug revolving fund managed by
  PHARMID
• Total funding required amounts slightly over 110
  million USD in 4years
• First year implementation started in 2007

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HMIS

• National HMIS reform under way, based on
• common set of indicators
• standardized procedures
• focus on information use for decision making
• Involving all the stakeholders
• Based on regional and woreda experiences and best
  practices and BPR Principles
• Assessment conducted, indicators selected tools
  and formats developed ready for pilot testing

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Health Financing Status

• Funds flow in 3 channels to the health sector
• Block grants to regional states, allocation to
  sectors based on priorities at district level
• Low per capita total health expenditure
• US5.6 in 2000
• In 2004 total health expenditure increased to
  US7.8 per capita(3rd NHA)
• Domestic revenue (23 of GDP) and government
  expenditures (29 of GDP) higher than average
  SSA .
• HSDP envisages establishment of Health Insurance
  (social and community) country experiences
  consolidated, options of implementing HI being
  developed, design phase begins once the
  appropriate option is selected

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HSDP Financing GAP (preliminary data)
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Funding Distribution by Programs
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GAVI HSS Contribution to HSDP

• Three main areas for GAVI HSS support
• all focusing on strengthening health systems
  functions at district level and below and still
  not exclusive.
• Health workforce mobilization, distribution and
  motivation
• Supply, distribution and maintenance systems and
  infrastructure for PHC
• Organization and management of health services at
  the district level and below
• GAVI HSS a potential support to filling the
  critical gap in HSDP
• GAVI HSS promotes harmonization by channelling
  the fund through MDG PPF

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HSDP Governance

• Central Joint Steering Committee chaired by
  Minister of Health
• Federal MOH-Health Population Nutrition donors
  consultative forum Co-chaired by State Minister
  of Health and head of HPN
• Joint Core Central Committee chaired by Planning
  Programming Department of MOH
• Joint Review Mission /Annual Review Meeting
• Mid term and final evaluation of HSDP

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Challenges

• High turn over of skilled health professionals
  brain drain
• Ineffectiveness of HMIS in supporting planning,
  decision making, and monitoring and evaluation
  process.
• Weak logistic and medical equipment maintenance
  and management system.
• harmonization and alignment manual finalized
  getting into action is a huge challenge.
• Speed and Volume are picking but there is still a
  huge challenge in Quality.
• Underfunding of key areas such as health systems

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gaps still large form child health, malaria and
health systems even for Scenario 1
Source Health Care Financing Study
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The way forward

• high production and retention with focus on low
  and mid-level professionals
• Focus on health systems strengthening identify
  new sources
• Accelerate HMIS and LMIS reform
• Ensure implementation of the newly endorsed
  Harmonization manual build partner confidence
• Keep the balance on quality while maintaining
  high speed and big volume
• Accelerate Resource mobilization reform to tap
  both domestic and international resources