Health Sector Transformation Plan II - HSTP II 2020/21-2024/25 (2013 EFY - 2017 EFY)

3.1 Health status and economic gains ............................................................................................................. 20

3.1.1 The state of healthy life . ............................................................................................................................................. 20

3.1.2 Major causes of mortality and morbidity................................................................................................................ 20

3.1.3 Economic gain. ................................................................................................................................................................ 21

3.2 The status of health system performance . ............................................................................................... 22

3.2.1 Progress towards universal health coverage. ....................................................................................................... 22

3.2.2 Healthy lifestyle and practices................................................................................................................................... 22

3.2.3 Demand for health services........................................................................................................................................ 22 3.2.4 Health security, health system resilience, and lessons from the COVID-19 pandemic. .......................... 22

3.2.5 Health system responsiveness.................................................................................................................................. 23

3.3 Service Delivery............................................................................................................................................ 23

3.3.1 Service delivery platforms of the health sector.................................................................................................... 24 3.3.2 Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health (RMNCAYH). ............................. 24

3.3.3 Prevention and control of major diseases.............................................................................................................. 26

3.3.4 Health promotion........................................................................................................................................................... 28

3.4 The state of equity in the Ethiopian health system .................................................................................. 29

3.4.1 Geographic disparities in health. ............................................................................................................................... 29

3.4.2 Gender disparities in health........................................................................................................................................ 30

3.4.3 Socioeconomic disparities........................................................................................................................................... 30

3.5 Health system inputs .................................................................................................................................. 31

3.5.1 Health Workforce .......................................................................................................................................................... 31

3.5.2 Medical products and supplies . ................................................................................................................................ 31

3.5.3 Health infrastructure . .................................................................................................................................................. 32

3.5.4 Health financing. ............................................................................................................................................................ 32

3.5.5 Health information . ...................................................................................................................................................... 33

3.5.6 Community engagement ............................................................................................................................................ 34

3.6 Leadership, governance and multi-sectoral collaboration. ...................................................................... 34

3.6.1 Leadership and governance ....................................................................................................................................... 34

3.6.2 Multi-sectoral collaboration . ..................................................................................................................................... 35

3.7 SWOT Analysis . ........................................................................................................................................... 35

3.8 Stakeholder Analysis . ................................................................................................................................. 37

3.9 Summary of Lessons from HSTP-I implementation ................................................................................. 38 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 1 Chapter 4: Health Sector Transformation Plan II: Objectives, Targets, and Strategic Directions . .................... 40

4.1. Vision ........................................................................................................................................................................................ 41

4.2. Mission ..................................................................................................................................................................................... 41

4.3. Values ....................................................................................................................................................................................... 41

4.4. Objectives ................................................................................................................................................................................ 41

4.5. Targets . .................................................................................................................................................................................... 44

4.6. Strategic Directions .............................................................................................................................................................. 47

4.7. Priorities /Transformation Agendas of HSTP-II. .......................................................................................................... 66 Chapter 5: Costing and Financing . ......................................................................................................................... 67

5.1 Costing . ..................................................................................................................................................................................... 68

5.2 Financial space and costing analysis . .............................................................................................................................. 77

5.3. Financial Gap analysis . ........................................................................................................................................................ 84

5.4. The Financing Gap: Business as Usual . .......................................................................................................................... 85

5.5. Financing the Gap ................................................................................................................................................................. 86

5.6. Other Financing the Gap Options ..................................................................................................................................... 87 Chapter 6: Implementation Arrangement . ........................................................................................................ 89

6.1. Integration of initiatives . .................................................................................................................................................... 90

6.2. HSTP-II governance . ............................................................................................................................................................ 91

6.3. Planning and budgeting ...................................................................................................................................................... 92

6.4. Health service delivery arrangements . .......................................................................................................................... 94

6.5. Optimizing monitoring and review systems ................................................................................................................. 95

6.6. Multi-sectoral collaboration .............................................................................................................................................. 95

6.7. Public-private partnership . ................................................................................................................................................ 96

6.8. Fostering innovation through health technology assessment and adaptation ................................................. 97

6.9. Health diplomacy, Communication and visible leadership ....................................................................................... 97

6.10. Risks and Mitigation .......................................................................................................................................................... 98 Chapter 7: Monitoring and Evaluation Plan . ...................................................................................................... 99

7.1. Monitoring and Evaluation Framework . ..................................................................................................................... 100

7.2. Indicators . ............................................................................................................................................................................ 100

7.3. Index measurement in HSTP-II . .................................................................................................................................... 101

7.4. Transforming Data into Information and Action: The Data Cycle ........................................................................ 102

7.5. Evaluation . ........................................................................................................................................................................... 103

7.6. Dissemination and communication . ............................................................................................................................ 103

7.7. Coordination, Policy and Institutional Environment for Monitoring and Evaluation ..................................... 104 Annex 1: Indicators and Targets of HSTP-II ....................................................................................................... 106 ANNEX 2: Equity indicators and targets . ........................................................................................................... 111 Annex 3: References ...................................................................................................................................... ...... 112 2 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY FOREWORD Ethiopia has implemented the first Health Sector Transformation Plan (HSTP-I) from 2015/16 to 2019/20, during which significant achievements were registered in improving the health of our population and increasing access to and utilization of health services. Health outcome indicators have shown improvement, with a remarkable reduction in morbidity and mortality from major communicable diseases such as HIV, tuberculosis and malaria. Maternal and child health has also improved that resulted in saving the lives of millions of women and children. Despite significant improvements, mortality and morbidity from communicable diseases and maternal and child health conditions are still high. The prevalence of non-communicable diseases (NCDs) and injuries are on the rise creating a triple burden of diseases for the health system. There is a high disparity in service utilization and health outcomes among people in different geographical areas and socio-economic groups. The quality of health care is still sub-optimal. The health system is also challenged by emerging pandemics such as COVID-19. H.E.Dr. Lia Tadesse Minister of Health, The second health sector transformation plan (HSTP II) Federal Democratic Republic of Ethiopia is the sector’s five years strategic plan from 2020/21- 24/25. It aims at improving the health of our population through the realization of accelerating progress towards Universal Health Coverage (UHC), protecting people from emergencies, creating Woreda transformation and making the health system responsive to people’s needs and expectations. To measure progress towards these objectives, HSTP-II has set ambitious but realistic targets that are aligned with national 10 years development plan and international targets such as the Sustainable Development Goals (SDGs). The plan has identified 14 key strategic directions that define the major strategic areas and initiatives of the strategic period. The plan aspires to achieve UHC through expanding access to services and improving the provision of quality and equitable comprehensive health services at all levels. We will expand health services based on the recently revised Essential Health Services Package (EHSP), through which different high impact interventions will be made available for each respective level of care. Reproductive, Maternal, Newborn, Child, Adolescent and Youth health will continue to be the major focus areas. We will continue to strengthen the prevention and control of major communicable diseases such as HIV, Tuberculosis and Malaria. As NCDs and mental health problems are becoming public health concerns, we will give a special focus on the prevention and control of NCDs and mental health problems, mainly through integrating these services with the primary health care system. The health extension program (HEP) will be revitalized based on the newly revised HEP roadmap where more essential health services will be expanded to make services more accessible to the population. To protect the population from emergencies, we will focus on strengthening our public health emergency management system and work towards building a resilient health system. The plan also focuses on strengthening health investment areas such as medicines, information health workforce, health infrastructure, digital health and innovations in health. The plan also emphasizes on strengthening multi-sectoral collaborative approach through which we can tackle the social determinants of health. Strengthening the engagement of the private sector in the health sector priorities is also identified as a major strategic area. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 3 From the 14 strategic directions, we have identified five priority areas/transformation agendas, which will be the top priority issues of the sector. These include Quality and Equity of health Services, Information Revolution, Motivated, Competent and Compassionate Health workforce (MCC), Health Financing and Leadership. The first priority area, i.e, quality and equity aspires to improve the provision of quality and equitable services to the population. A national quality and equity strategy towards achieving narrowing health disparities is being developed and equity and quality will be mainstreamed in all of our health programs with regular measurement and improvement. Information revolution will continue to be the priority in HSTP-II as availability and use of quality data are key for informed evidence-based decision-making in the sector. The sector will focus on improving the production and use of quality of data, with a special focus on improving the routine health management information system (HMIS). As a key priority area, the sector will focus on creating a motivated, competent and compassionate health workforce, which will be one of the key inputs to provide quality and responsive health service. To accelerate progress towards UHC by protecting our people from financial hardship, health financing will be one of the priority areas. The sector will work towards sustainable health financing by implementing different health financing interventions such as insurance schemes, rigorous resource mobilization and different innovative financing mechanisms. The fifth priority area is leadership, which will play a pivotal role in policy and strategy development, creating and strengthening transparency and accountability in the health system, promote coordination and inter-sectoral collaboration and overall guidance of the health system. The HSTP-II builds on the successes and challenges of the first HSTP. Although different challenges are anticipated from the impact of the COVID-19 pandemic and other political instabilities, I believe Ethiopia will continue to build on the successes achieved so far, and mitigate the challenges that hinder progress and continue the path towards transforming the health system and improve the health status of the population, which is the backbone to develop a productive and prosperous nation. The objectives of the plan can only be successful through the dedication of health workers, the continued political commitment, collaboration and concerted effort of all stakeholders. I hope that our collaborative efforts with the community, CSOs, development partners, donors, line ministries, academia, associations, the private sector and other stakeholders will continue to transform the health sector and achieve the ambitious targets set in the plan. Looking forward to working with you all towards the successful implementation of the HSTP-II and realization of the vision. Lia Tadesse, M.D., MHA Minister of Health, Federal Democratic Republic of Ethiopia 4 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY LIST OF ACRONYMS AHRI Armauer Hansen Research Institute AIDS Acquired Immunodeficiency Syndrome ALOS Average Length of Stay AMR Ant-Microbial Resistance ANC Antenatal Care ANC4 Antenatal Care Fourth Visit APR Annual Performance Report APTS Auditable Pharmaceutical Transaction and Service ARM Annual Review Meeting ART Antiretroviral Therapy ARV Antiretroviral BEmOC Basic Emergency Obstetric Care CASH Clean and Safe Health Facilities CBHI Community Based Health Insurance CEmOC Comprehensive Emergency Obstetric Care COC Certificate of Competence COVID-19 Corona Virus Disease-19 CPD Continued Professional Development CPR Contraceptive Prevalence Rate CRC Compassionate Respectful and Caring CRVS Civil Registration and Vital Statistics CSA Central Statistical Agency CSC Community Scorecard CSO Civil Society Organization DALYs Disability Adjusted Life Years DHIS2 District Health Information System DMAT Disaster Management Assistant Team DPCD Disease Prevention and Control Directorate DQA Data Quality Assessment DR TB Drug resistance Tuberculosis ECD Early Childhood Development eCHIS Electronic Community Health Information System EDHS Ethiopia Demographic and Health Survey EFDA Ethiopia Food and Drug Authority EFY Ethiopian Fiscal Year EHAQ Ethiopian Hospitals Alliance for Quality EHIA Ethiopia Health Insurance Agency EHRIG Ethiopian Hospital Reform Implementation Guideline EHSP Essential Health Services Package EHSTG Ethiopian Hospital Services Transformation Guideline EmONC Emergency Obstetric and Neonatal Care ENBC Essential New-Born Care EOC Emergency Operations Center EPAQ Ethiopian Primary Health Care Alliance for quality EPHI Ethiopian Public Health Institute EPHIA Ethiopia Population Based HIV Impact Assessment EPI Expanded Program on Immunization EPSA Ethiopia Pharmaceutical Supply Agency HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 5 EPTB Extra Pulmonary Tuberculosis ETB Ethiopian Birr FMOH Federal Ministry of Health FP Family Planning GBD Global Burden of Disease GBV Gender Based Violence GDP Gross Domestic Product GGE General Government Expenditure GGHE General Government Health Expenditure GGI Good Governance Index GII Gender Inequality Index GMP Growth Monitoring and Promotion GTP Growth and Transformation Plan HALE Healthy Life Expectancy HAPCO HIV/AIDS Prevention and Control Office HBV Hepatitis B Virus HCF Healthcare Financing HCI Human Capital Index HCMIS Health Commodity Management Information System HCs Health Centers HCV Hepatitis C Virus HDI Human Development Index HDSS Health and Demographic Surveillance System HEHD Hygiene and Environmental Health Directorate HEP Health Extension Program HEPHD Health Extension and Primary Health Directorate HERQA Higher Education Relevance and Quality Agency HEW Health Extension Workers HF Health Facility HHM Health Harmonization Manual HiAP Health in All Policies HIS Health Information System HIT Health Information Technician HITD Health Information Technology Directorate HIV Human Immunodeficiency Virus HMIS Health Management Information System HP Health Post HPV Human Papilloma Virus HRD Human Resource Directorate HRH Human Resource for Health HRIS Human Resources Information System HSTP Health Sector Transformation System HSTQ Health Service Transformation in Quality HTA Health Technology Assessment ICMNCI Integrated Community Case Management of Newborn & Childhood Illness ICT Information Communication Technology ICU Intensive Care Unit IDP Internally Displaced People IHR International Health Regulation IMNCI Integrated Management of Neonatal and Child Illness 6 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY IMR Infant Mortality Rate INVEA Immigration, Nationality and Vital Event Agency IR Information Revolution JCCC Joint Core Coordinating Committee JCF Joint Consultative Forum JRM Joint Review Mission JSC Joint Steering Committee KM Knowledge Management KMC Kangaroo Mother Care KPI Key Performance Indicators KPP Key and Priority Populations LAN Local Area Network LIP Leadership Incubation Program LLINs Long-Lasting Insecticidal Net LMIS Logistic Management Information System LQAS Lot Quality Assurance Sampling M&E Monitoring and Evaluation MCC Motivated, Competent and Compassionate MCH Maternal and Child Health MCV Measles Containing Vaccine MDG Millennium Development Goals MFR Master Facility Registry MHM Menstrual Hygiene Management MMR Maternal Mortality Ratio MNH Maternal & Newborn Health MOE Ministry of Education MOH Ministry Of Health MPDSR Maternal and Perinatal Death Surveillance and Response MSWT Multi-Sectoral Woreda Transformation MTCT Maternal to Child Transmission MTR Mid-Term Reviews NAPHS National Action Plan for Health Security NCDI Non-Communicable Diseases and Injuries NCoD National Classification of Disease NGO Non-Governmental Organizations NHA National Health Account NHDD National Health Data dictionary NICU Neonatal Intensive Care Unit NNMR Neonatal Mortality Rate NNP National Nutrition Programme NNT Neonatal Tetanus NTD Neglected Tropical Diseases ODF Open Defecation Free OHT OneHealth Tool OOP Out of Pocket OPD Out Patient Department ORS Oral Rehydration Salt PCD Partnership and Cooperation Directorate PHC Primary Health Care PHCU Primary Health Care Unit HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 7 PHEM Public Health Emergency Management PLHIV People Living with HIV PMT Performance Monitoring Team PMTCT Prevention of Mother to Child Transmission of HIV PNC Postnatal Care PPP Public-Private Partnership QI Quality Improvement QUALY Quality-Adjusted Life-Year RDQA Routine Data Quality Assessment RDT Rapid Diagnostic Test RED Reach Every District RHBs Regional Health Bureau RHD Rheumatic Heart Disease RIS Regulatory Information System RMNCAYH Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health RMNCH Reproductive, Maternal, Neonatal and Child Health RRT Rapid Response Team SALTS Saving Life Through Safe Surgery SARA Service Availability and Readiness Assessment SDGs Sustainable Development Goals SHI Social Health Insurance SPA Service Provision Assessment SPM Strategic Planning and Management SRH Sexual and Reproductive Health STH Soil Transmitted Helminthiasis STI Sexually Transmitted Infections SUD Substance Use Disorders SWOT Strengths, Weaknesses, Opportunities and Threats TB Tuberculosis TF Total Fertility TFC Treatment Followup Centers TFR Total Fertility Rate THE Total Health Expenditure TICs Treatment Initiating Centers TVET Technical Vocational Educational Training U5MR Under 5 Mortality Rate UHC Universal Health Coverage USD United States Dollar VLBW Very Low Birth Weight VMMC Voluntary Medical Male Circumcision VPN Virtual Private Network VSD Very Sever Disease WASH Water, Sanitation and Hygiene WBHSP Woreda Based Health Sector Plan WDG Women Development Group WHO World Health Organization WoHo Woreda Health Office ZHD Zonal Health Department 8 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY EXECUTIVE SUMMARY This is the second Health Sector Transformation Plan (HSTP-II) covering the period between Ethiopian fiscal years 2013 and 2017 (July 2020–June 2025). HSTP-II was developed as the first part of a 10-year health sector plan. It was prepared based on an in-depth situational analysis and performance evaluation of HSTP-I; it takes into consideration the country’s global commitments and aligns with its overall macro-economic development framework. HSTP-I (July 2015–June 2020) achieved significant achievements despite ongoing challenges, such as internal conflicts leading to population displacement and the COVID-19 pandemic. The HSTP-I period was marked by encouraging improvements in life expectancy at birth. This included notable reductions in maternal mortality (decreased 676 deaths per 100,000 live births in 2011 to 401 in 2017). In addition, under-5 mortality and infant mortality per 1000 live births decreased from 123 and 77 in 2005 to 59 and 47, respectively, in 2019. However, over the years, there have been no significant reductions in neonatal mortality (33 deaths per 1,000 live births in 2019). Morbidity and mortality from common communicable diseases, including malaria, HIV, tuberculosis (TB), and vaccine- preventable diseases, declined dramatically during HSTP-I. However, the same period witnessed a substantial rise in the prevalence of non-communicable diseases. Although the burden of neglected tropical diseases (NTDs) is decreasing, the proportion of people affected remains considerable. In terms of disease risk factors, there has been a relatively high level of reduction in unsafe sex behaviour. The prevalence of stunting, underweight, and wasting have also diminished from 51% to 37%, from 33% to 21%, and from 12% to 7% respectively, between 2005 and 2019.However, risks from water, sanitation, and hygiene (WASH) and dietary factors, alcohol use, and high blood glucose level showed a lower rate of reduction. The performance of major health programs has improved, as seen by an increase in the utilization of certain health services. For instance, in 2019, 41% of married Ethiopian women were using contraception compared to just 27% in 2011 and 35% in 2016 (the unmet need remains considerably high at 22%). Antenatal care visit 1 (ANC1) coverage also improved from 62% in 2016 to 74% in 2019, although only 43% of pregnant women had four or more visits. Skilled birth delivery has increased from 28% in 2016 to 50% in 2019. The mean availability of tracer items for basic emergency obstetrical care (BEMOC) stands at more than 85% for hospitals, 74% for health centers (HCs) and 55% for higher-level clinics. Access to safe abortion services and post-abortion care has also expanded. In terms of child health, in 2019, the proportion of children receiving three doses of pentavalent vaccine and all basic vaccines reached 61% and 43%, respectively. There has also been impressive progress in prevention and control of major communicable diseases. Ethiopia is on track to achieve one of the three targets of the Global End TB Strategy; TB incidence has declined by 21% from the HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 9 2015 estimate (as compared to a targeted decline of 20%). TB case notification has been improving, with a detection rate of 71% in 2019/20. TB treatment success and cure rates also reached 95% and 80%, respectively in 2019/20. There has also been progress towards achieving two of the 90-90-90 targets for HIV: 90% of people who know their status were on ART, with 91% achieving viral supersession. Furthermore, in 2019/20, 91% of eligible mothers received services for antiretroviral therapy and prevention of mother-to-child transmission were available in 84% of public health facilities. Malaria control initiatives have been on track. Between 2015 and 2019, malaria deaths dropped from 3.6 to 0.3 per 100,000 among populations at risk. Malaria case incidence has dropped from 5.2 million in 2015 to under 1.6 million in 2019/20. Several interventions have been implemented to enhance financial risk protection in accessing essential health services. These include provision of high-impact interventions free of charge through an exemption program; subsidization of more than 80% of the cost of care in public health facilities; implementation of community-based health insurance (CBHI) schemes; and full subsidization of the very poor through fee waivers for both health services and CBHI premiums. A revised health care financing strategy was developed within the framework of achieving the goal of universal health coverage. To address the social and environmental determinants of health, the Government of Ethiopia has taken steps to strengthen engagement with key local and international sectors and stakeholders, for example in the nutrition and WASH programs. There have been multi-sectoral collaborative activities and interventions to improve the status of food security and nutrition, including the high-level government commitment platform, - the “Seqota” Declaration to end child under-nutrition by 2030. The government implemented major strategic initiatives to improve hygiene and environmental health, such as- urban sanitation, scale up of community-led and school-led total sanitation and hygiene, sanitation marketing, and actions to build adaptation and resilience to climate change into the health sector. The three-tier health system—primary, secondary and tertiary—continues to be the backbone of health service delivery. The primary health care infrastructure has expand enormously, with potential coverage reaching more than 90% in 2019. The Health Extension Program continues to make significant contributions towards improved health indicators in the country. In the second- and third-tier facilities, implementation of strategic initiatives and reforms has strengthened pre-hospital and hospital clinical care. Overall, outpatient attendance rate increased from 0.27 to 0.9 per capita per year between 2000 and 2019. In 2019, the Essential Health Service Package (EHSP) was revised and endorsed with emphasis on service availability, accessibility, acceptability, and affordability. The 1993 Health Policy has undergone revision and is currently being finalized. Based on the HSTP-I M&E (monitoring and evaluation) framework, the health information system was strengthened to generate data to the monitor the performance and various components of the plan. An effective leadership and governance system further strengthened the legal and regulatory framework for the implementation of HSTP-I. In addition, stakeholder engagement and partnership with the health sector was strengthened through such platforms as the Joint Steering Committee meetings with Regional Health Bureaus, the Executive Committee Meetings with agencies; and the regular meetings of the Joint Consultative Forum and the Joint Core Coordinating Committee. Four transformation agendas were implemented during HSTP-I: 1) Woreda Transformation, 2) Information Revolution, 3) Transformation in Quality & Equity, and 4) Compassionate, Respectful, and Caring Health Workers. Leadership at all levels prioritized and closely monitored these agendas; and the agendas were successful in mobilizing resources and strengthening health sector’s efforts to achieve the positive results described above. HSTP-II aims to build on the successes of the HSTP-I period, incorporating the lessons from its implementation. HSTP-II is aligned with the country’s overall macro-economic development framework. The plan was developed in a consultation with the National Plan and Development Commission by employing Strategic Planning and Management tool, and using an inclusive and active participatory process led by the health sector. The process included iterative gathering of feedback during which different versions of the Plan were shared with a wide range of stakeholders, including government sectors and agencies, regional health bureaus, academia, professional associations, the private sector, civil service organizations, and development partners. The overall objective of HSTP-II is to improve the health status of the population–by accelerating progress towards universal health coverage, protecting populations during health emergencies, transforming woredas, and improving the health system’s responsiveness. 10 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY HSTP-II has targets to measure its objectives and performance that are developed by considering baseline, national and international standards and anticipated resources. For instance, HSTP-II has set ambitious targets to reduce the maternal mortality rate to 279 per 100,000 live births and to reduce under-5 and neonatal mortalities to 44 and 21 per 1,000 live births, respectively. In terms of service uptake, targets include increasing skilled delivery attendance to 76%, coverage of ANC 4 to 81%, and coverage of pentavalent (3), TB detection rate and ART coverage to 90%, 81%, and 95%, respectively. The list of all indicators with the corresponding targets appears in the “Targets” section. The Government of Ethiopia developed 14 strategic directions, along with their major activities, to achieve the targets laid out in HTSP-II: § Enhance provision of equitable and quality comprehensive health service § Improve health emergency and disaster risk management § Ensure community engagement and ownership § Improve access to pharmaceuticals and medical devices and their rational and proper use § Improve regulatory systems § Improve human resource development and management § Enhance informed decision-making and innovations § Improve health financing § Strengthen governance and leadership § Improve health infrastructure § Enhance digital health technology § Improve traditional medicine § Enhance health in all policies and strategies § Enhance private engagement in the heath sector Five priority issues were identified as part of the transformation agenda for HSTP-II. Key interventions will be implemented to address these priority issues to transform the health system and to achieve health for all. The transformation agenda are: 1. Quality and Equity: Ensuring equity in delivery of quality health services by creating high-performing primary health care units, ensuring active engagement of the community in service delivery, and continually improving clinical care outcomes. 2. Information revolution: Significantly improving methods and practices for collecting, analyzing, presenting, using, and disseminating information that can influence decisions. 3. Motivated, competent, and compassionate health workforce: Ensuring equitable distribution and availability of an adequate number and skill mix of health workers who are motivated, competent, and compassionate to provide quality health services. 4. Health financing: Reforming public financial management and health financing to improve efficiency and accountability, while pursuing the agenda of sustainable domestic resource mobilization for health. 5. Leadership: Enhancing leadership and governance mechanisms at all levels of the health system to drive attainment of the national strategic objectives through activities to ensure alignment and harmonization, thereby creating an enabling environment for the translation of plans into results. The overall costing for HSTP-II implementation was computed using OneHealth Tool (OHT), a tool based on the WHO’s six health system building blocks framework. Accordingly, U.S. dollars $21.88 billion and $ 27.55 billion at base and high-case scenario respectively is required for the five years to be covered in the plan, while the available financial resources during that period are projected at $18.7 billion, $19.7 billion, and $21.9 billion for low-, medium-, and high-case scenarios, respectively. HSTP-II will be cascaded to all levels of the health system, and will be translated into annual operational plans using the woreda-based health sector annual plan. Its implementation will be regularly monitored using the agreed monitoring framework in a coordinated manner. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 11 Chapter 1 INTRODUCTION 12 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Ethiopia has accomplished the second growth and transformation plan (GTP-II, June 2015 – June 2020), marked by several positive results and achievements. However, this period was also marred by internal conflicts, resulting in large displacement of populations and creating additional burden to the health system. In addition, the COVID-19 pandemic posed a clear threat to ongoing reforms and relatively strong economic growth, with wide-ranging, serious impacts across the country. Nevertheless, the country has still managed to achieve impressive progress in transforming the socioeconomic status of its people. The first Health Sector Transformation Plan (HSTP-I) was the health chapter of the GTP-II and the first phase of the “Envisioning Ethiopia’s Path towards Universal Health Coverage through Strengthening Primary Health Care by 2035.” The performance of HSTP-I has been critically reviewed through annual performance reviews and ad hoc assessments, including routine Health Information Management System (HMIS) assessments, mid-term reviews, Joint Review Mission reports, and various population- and facility-based surveys. These reviews show that Ethiopia has achieved the goals of the GTP despite the challenges mentioned above. These achievements were made possible due to the implementation of high-impact interventions, primarily through flagship community-based programs such as the Health Extension Program (HEP). Through the implementation of the four Transformation Agendas (1. Woreda Transformation, 2. Information Revolution, 3. Transformation in Quality & Equity, and 4. Compassionate, Respectful, and Caring Health Workers), the health sector has developed momentum to address critical health system bottlenecks. The health sector has also ardently advocated for multi-sectoral collaboration to address the social determinants of health. However, the COVID-19 pandemic caused an important setback and threatened to unwind these gains and achievements. The second Health Sector Transformation Plan (HSTP-II) is the next five-year national health sector strategic plan, which covers the period between 2013–2017 Ethiopian fiscal years (July 2020–June 2025). During this strategic period, the sector envisions building on the successes and consolidating the gains of HSTP-I to build a resilient, sustainable, high-quality, equity-based health system. Thus, the preparation of HSTP-II was informed by in-depth situational analysis of the performance of the health sector during HSTP-I. The plan also took into account the nation’s long-term socioeconomic strategic directions and priorities, the global situation and country’s commitments to sustainable development goals, and the dynamics of social determinants of health. The Ministry of Health (MOH) and Regional Health Bureaus (RHBs) used an active participatory process to develop the HSTP-II. The health sector first identified the nation’s long-term strategic goals in consultation with the National Plan and Development Commission, using the Strategic Planning and Management tool. A series of consultations were held with the private sector, academia, professional associations, other government sectors and development partners. These consultations were instrumental in developing a comprehensive plan and ensuring commitment and shared vision among all stakeholders, and the resulting feedback was incorporated in the plan. HSTP-II’s objectives and strategic directions were developed based on the situational analysis of the HSTP-I; and the baseline and targets were developed using data from recent surveys and in consultation with program experts. Costing and target setting was developed using a OneHealth tool designed to inform national strategic health planning in low- and middle-income countries by linking strategic objectives and targets of health programs to the required investments in health systems. The six chapters that follow give a comprehensive overview of HSTP-II. Chapter 2 covers the country context; Chapter 3 describes the situation analysis; Chapter 4 outlines the objectives, targets, and strategic directions of HSTP-II; Chapter 5 details the costing and financial gap analysis; Chapter 6 describes the implementation arrangement; and Chapter 7 covers the monitoring and evaluation (M&E) plan. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 13 Chapter 2 COUNTRY CONTEXT 14 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Geography Ethiopia is located in the North-Eastern part of Africa, also known as the Horn of Africa. It is bordered by Sudan and South Sudan on the west, Eritrea and Djibouti on the northeast, Somalia on the East and Southeast, and Kenya on the south. Ethiopia lies between the Equator and Tropic of Cancer, between the 30oN and 150oN Latitude and 330o E and 480o E longitude. The country occupies an area of 1.1 million km2 and water bodies occupy 7,444 km2. Ethiopia is a country with rich geographical diversity that includes rugged mountains, flat-topped plateaus, deep gorges, and river valleys. Over the ages, erosion, volcanic eruptions and tectonic movements have contributed to the nation’s diverse topography. More than half of the geographic area of the country lies 1,500 m above sea level. The highest altitude is at Ras Dashen (4,620 m above sea level) and the lowest altitude is at Danakil (Dallol) Depression (148 m below sea level). Demographic Profile With a population of about 101 million in 2020, Ethiopia is the second most populous country of Africa and ranks 12th in the world. Ethiopia is the home to various ethnicities, with more than 80 different spoken languages. The country is characterized by rapid population growth (2.6%), young age structure, and a high dependency ratio, with a high rural-urban differential. Ethiopia has a high total fertility rate of 4.6 births per woman (2.3 in urban areas and 5.2 in rural areas) and a corresponding crude birth rate of 32 per 1000 in 2016. The average household size is 4.6. By 2024, the population is projected to reach 109.5 million (Central Statistics Agency, Juy 2013) and will reach 122.3 million by 2030 (See Figure 1 below). Children under age 15 years and individuals in the age group of 15-65 years account for 47% and 49% of the population, respectively. Only 4% of the population is above the age of 65 years. The sex ratio between males and females is almost equal, and women of reproductive age constitute about 23% of the population. Nearly 80% of the population lives in rural areas mainly depend on subsistence agriculture (Central Statistics Agency, Juy 2013). population by age and sex (percent) 2020 2029 80 80 75-79 MALE FEMALE 75-79 MALE FEMALE 70-74 70-74 65-69 65-69 60-64 60-64 54-59 54-59 50-54 50-54 45-49 45-49 40-44 40-44 35-39 35-39 30-34 30-34 25-29 25-29 20-24 20-24 15-19 15-19 10-14 10-14 5-9 5-9 0-4 0-4 6 4 2 0 2 4 6 6 4 2 0 2 4 6 Figure 1. Ethiopian population by age and sex (percent) Demographic shift/dividend Ethiopia’s population age structure has the potential to yield demographic dividends since the majority of the population is young. However, harnessing this dividend will depend on the country’s ability to scale up human capital investments and address existing inequalities. With enhanced efforts to reduce health and education inequalities between urban and rural areas and among regional states, Ethiopia can benefit from accelerated economic growth and improve citizens’ quality of life. Strategic investments in health, education, economic policy, and governance will be crucial to achieve substantial gains from the demographic dividend. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 15 Socioeconomic situation Ethiopia is engaged in rapid, comprehensive development activities to transition from poverty to sustainable, reliable growth and prosperity. Since 1991, the country has implemented several macroeconomic policies, including a market-based and agriculture-led industrialization. The government has introduced initiatives to ensure successful transformation from an agrarian to industry-led economy. The country has registered commendable achievements on Millennium Development Goals (MDGs) mainly in reducing poverty head count, achieving universal primary education, narrowing gender disparities in primary education, reducing child and neonatal mortality, and combating HIV, TB, and malaria. Ethiopia is a low-income country with a gross domestic product (GDP) per capita (current US$) of $772 in 2018, up from about $340 in 2010. It is one of the fastest-growing economies in Africa, experiencing an average annual growth of about 10% between 2004 and 2014. The main contributors to the economic growth are agriculture, industry, and service sectors. According to Ethiopia’s poverty assessment report, household poverty rate has diminished remarkably, by around 20%, between 2011 and 2016 (World Bank 2019). However, despite its significant economic growth, the country remains one of the world’s poorest. Women’s empowerment has been an important feature of Ethiopia’s economic reform. The Ethiopian Constitution recognizes the principle of equality of access to economic opportunities, employment, and property ownership for women. According to a report by the Central Statistical Agency (CSA), the national income inequality coefficient increased from 0.298 in 2010/11 to 0.328 in 2015/16. Between 2000 and 2017, Ethiopia’s Human Development Index value increased from 0.283 to 0.463, an increase of 63.5%. However, it remains below the average of 0.504. According to the 2019 World Bank report, Ethiopia’s Human Capital Index is 0.38, making Ethiopia 135th of 157 countries (The World Bank, 2019). The road coverage has increased by six-folds compared to 1990, with total road length reaching 105,000 kms. Under the Universal Rural Road Access Program, about 10,765 rural kebeles are now connected, creating better access to health care for millions of mothers and children. Connectivity via modern communication devices has improved tremendously, with 32 million mobile phone subscribers, which expands opportunities for digital health. Humanitarian impact and needs Ethiopia is prone to natural and manmade shocks and stresses. The country experiences cyclical hazards that affect households, infrastructure, and system resilience. The periodic occurrence of regular outbreaks such as measles, yellow fever, and cholera poses a challenge to the health system, and the global COVID-19 pandemic has further tested the health system’s resilience. In 2020, an estimated 8.4 million needed humanitarian assistance (UNOCHA, 2020). Of these, women and children are disproportionately affected. For the health sector specifically, 5.9 million people are estimated to have humanitarian needs, including 1.2 million women and girls needing family planning and maternal health services. Among internally displaced people (IDPs), unmet need for health services for pre-existing and new disease conditions, physical and mental trauma, and sexual and gender-based violence (GBV) remains high. IDPs put additional pressure on local health systems, straining the health care work force and stocks of medicines and other essential supplies. Position of the health sector in the country context Population health is both the means and outcome of development. A healthy population is an engine for economic growth. Investment in health can reduce poverty and catalyse wider cycle of economic growth. Investment in health is also an outcome, as good economic status of a nation allocates more resource to keeping their people healthy. The latter depends on the country’s policies and strategies for safeguarding health. The Ethiopian health sector, alongside other sectors, is playing its part as a means of economic growth. The contribution of the sector towards national socioeconomic development is critical, as equitable human development well-being relies on the health status and well-being of individuals and communities. Investing in health is an investment in current and future generations, and towards sustainable development. Health is also a measure of inclusive growth that should be commensurate with economic development. Otherwise, economic growth without equitable social development may not be sustainable. The health sector should therefore be viewed as a conduit to development, and as a means to ensuring social justice and sustainable economic development. 16 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Chapter 3 PERFORMANCE OF HEALTH SECTOR TRANSFORMATION PLAN I – SITUATION ANALYSIS HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 17 This section provides a comprehensive overview of the progress made in achieving the Ethiopian health sector’s goals and objectives. The section also presents some of the key lessons from the implementation of HSTP-I, including strengths, weaknesses, opportunities, and threats (SWOT) and stakeholder analysis of the Ethiopian health system. The Ethiopian health system framework (Figure 2), adapted from the WHO African region framework, is used to analyze and structure the situation analysis. Vision: To see a healthy, productive and prosperous society Mission: To promote the health and wellbeing of the society through providing and regulating a comprehensive package of health services of the highest possible quality in an equitable manner Impact Improved Health Status Economic Gain Efficiency Universal Health Coverage Woreda Transformation Intermediate Health System Responsiveness Protect People from Health Results Emergencies Quality Service Delivery Processes Equity & Quality Health Promotion, Disease Prevention, Curative, Polliatuve & Rehabilitative Services Health Health Community Medical Health Health Products & Infrastructure Information Financing Workforce Inputs Supplies Principles Governance, Multisectoral Collaboration Figure 2. Ethiopia’s health system framework (adapted from the WHO African regional framework) Overall, while HSTP-I was successful on some fronts, the performance on certain domains in the health system framework, as measured by key performance indicators from its M&E framework, was in general sub-optimal. Table 1 summarizes the baseline, targets, and achievements of HSTP-I on key performance indicators. Details on specific topics are presented in subsequent sub-sections. 18 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Table 1. Summary of performance for HSTP-I key performance indicators 2015 Domain Indicator HSTP-I Target Achievement baseline Life expectancy at birth (in years) 64 69 65.5 Maternal morality ratio 420 199 401 Under five mortality (per 1,000 live births) 64 30 59 Infant mortality (per 1,000 live births) 44 20 47 Neonatal morality (per 1,000 live births) 28 10 33 Health status Stunting (under five years old) 40 26 37 Wasting (under five years old) 9 4.9 7 HIV incidence rate (per 1,000) 0.03 0.25 0.16 TB incidence rate (per 100,000) 224 156 151 TB mortality rate (per 100,000) 32 17 22 Malaria death rate (per 100,000) 0.6 0.32 Contraceptive prevalence rate 42 55% 41% Unmet need for FP 24 10% 22% ANC (at least four visits) 95% 43% Skilled birth attendance 90% 50% Postnatal care coverage 95% 34% Still birth rate (per 1000 live births) 18 10 15 CS rate as proportion of births 2.2 8 4 ART to prevent MTCT of HIV 59% 95% 91% Status of Priority Three doses of pentavalent immunization 98% 61% Health Programs Exclusive breast feeding at six months 72% 59% ART coverage – Adult >=15 years 82% 90% 75.8% TB case detection rate 61% 87% 71% TB treatment success rate 92% 95% 95% Proportion of women screened for cervical Ca 0.6% 20% 5% % of HHs with safe water source 35% 28% OPD attendance per capita 0.48 2 0.9 Average length of stay 4.3 5 days 4.5 days Health emergency risk management Proportion of emergency affected people Health Security 36% 95% 84% provided rehabilitation Proportion of epidemics controlled NA 85% 80% Health workers per 1,000 population 0.84 1.6 1.74 Proportion of Woredas with CBHI 15% 80% 70% OOP as a proportion of THE 33.7% 15% 31% Health System % of HCs with BEmONC 56% 100% 74% Investments % of hospitals with CEmONC 83% 100% 85% Essential medicines availability at PHC 90% 100% 48% Report completeness 72% 90% 89% HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 19

3.1 HEALTH STATUS AND ECONOMIC GAINS

3.1.1 The state of healthy life Life expectancy at birth increased from 58 years in 2007 to 65.5 years in 2017, with an annual rate of increase ranging from 1.98% in 2007 to 0.7% in 2016. Despite encouraging improvements in life expectancy at birth, premature death and suboptimal quality of life still constitute major health and development challenges in Ethiopia. Although health-adjusted life expectancy at birth (57.5 years) is above the average for low-income countries (54.9 years), it is still lower than the global average (63.3 years) and that of low- to middle-income countries (59 years).

3.1.2 Major causes of mortality and morbidity Ethiopia is currently facing triple burden of diseases (communicable and non-communicable diseases or NCDs, mental health, and injuries) that affects all age groups, with a disproportionately higher burden among children and women in their reproductive age. In 2019, 58% of disability- adjusted life years (DALYs) were due to maternal and neonatal conditions, communicable diseases, and malnutrition (Figure 3). Over the past two decades, the share of NCDs has increased from 17% to 35%. Relative share of dalys in Ethiopia, 1999 to 2019 120% 100% 80% 60% 74% 70% 58% 40% 20% 17% 24% 35% 0% 9% 6% 7% 1999 2009 2019 Injuries NCD RMNCH-N and communicable diseases Figure 3. Relative share of categories of diseases for DALYs lost in Ethiopia, 1999-2019 Ethiopia has documented notable achievements in improving the health status of women and children in the last two decades. Between 1990 and 2015, child deaths have diminished by two-thirds. The under-5 mortality rate decreased from 123 per 1,000 live births in 2005 to 59 in 2019. Similarly, the infant mortality rate decreased from 77 per 1,000 live births to 47 in 2019. However, maternal and neonatal mortalities remain high. The decline in maternal mortality declined was modest: from 871 deaths per 100,000 livebirths in 2000 to 401 in 2017. Similarly, neonatal mortality declined modestly, from 39 deaths per 1,000 livebirths in 2000 to 33 in 2019. (Figure 4) 20 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Trends in Childhood Mortality Rates in Ethiopia, 2005-2019 140 123 120 100 88 80 77 67 59 59 60 48 47 40 39 37 33 20 29 0 2005 EDHS 2011 EDHS 2016 EDHS 2019 EDHS Neonatal Mortality Infant Mrtality Under-five Mortality Figure 4. Trends in childhood mortality rates, 2005 – 2019 In the last two decades, morbidity and mortality from common communicable diseases such as HIV, drug susceptible TB and vaccine preventable diseases like measles has decreased, including during the HSTP-I period. Due to the lack of comparable data, it has been difficult to measure the impact on mortality from NCDs. However, data from the Global Burden of Disease (2019) suggests that an increasing trend in the proportion of deaths is attributable to NCDs (Institute for Health Metrics and Evaluation, 2019). Injuries, accidents, and mental health problems are becoming growing concerns. The 2016 Ethiopia Demographic and Health Survey (EDHS) showed that 3% of households reported having at least one member who was injured or killed in the 12 months before the survey (CSA [Ethiopia] and ICF Macro [USA], 2016). As per WHO estimates, road traffic accidents caused 27 deaths per 100,000 population in 2016 (WHO, 2018). The burden of neglected tropical diseases (NTD) is decreasing, even though a considerable number of people in Ethiopia are still affected. In 2017, NTDs caused 547,599 DALYs annually (1.4% of the total DALYs lost from any cause), and 3 deaths per 100,000 population, accounting for 0.6% of the total deaths in the country in the same year.

3.1.3 Economic gain The Ethiopian government has made significant investments to improve the health outcomes of its population. The country reaped cascading benefits from its investments up to now, in terms of the improved health of millions of Ethiopians. At the same time, the country’s macro-economy has improved rapidly, achieving a yearly per capita growth of more than 8% and elevating many out of poverty. As population health improved, school attendance increased dramatically. Control of major infectious diseases like HIV/AIDS and malaria has increased productivity, as better health leads to increased worker capacity, lower rates of absenteeism, and less workforce turnover. During the same time, life expectancy increased, which led to increased incomes and encouraged people to save more for retirement—which in turn boosted the economy-wide capital available for increased investment. Nevertheless, further investment is critical to sustain these gains and improve access to services and quality of care. A study found that in 2015 there were 8 million avoidable premature deaths due to lack of access to quality care, leading to $6 trillion in annual economic loss (Harvard Medical School, 2018). Inadequate access to high-quality health care results in significant mortality and imposes a macroeconomic burden that is inequitably distributed, with the largest relative burden falling on low-income countries like Ethiopia. It is estimated that COVID-19 will shave 2.9 percentage points off this fiscal year’s economic growth in Ethiopia. Poor-quality care can also lead to important waste and inefficiency. Health-care waste includes the overuse of unnecessary care or ineffective approaches, medical errors, unsafe care, incoordination of care, misuse (including inappropriate hospital admissions and bypassing), fraud, and abuse. The World Health Report (2010) estimated that about 20-40% of all health sector resources are wasted and highlighted leading sources of inefficiency (WHO, 2010). According to a study done in public health facilities in Ethiopia, the average number of outpatient equivalent visits per clinical staff per day in primary hospitals was 2.54 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 21 in 2016. This is slightly lower than output production found among health centers in Ethiopia, at 3.7 outpatient equivalent visits per clinical staff per day (Peter Berman, 2016). The average pure technical efficiency score among the inefficient primary, secondary, and tertiary hospitals and health centers were 68%, 66%, 61%, and 79%, respectively, implying that on average, these same facilities could reduce their inputs by 32%, 44%, 39%, and 21%, without reducing outputs. Those efficiency reports indicate some areas where improvements in resource allocation and use improve the efficiency of health services.

3.2 THE STATUS OF HEALTH SYSTEM PERFORMANCE

3.2.1 Progress towards universal health coverage As a signatory to the Alma Ata Declaration and UN political declaration on universal health coverage (UHC) UHC, Ethiopia is committed to achieving UHC through primary health care (PHC). This has led to growing investment in expanding health services, infrastructure, and health workforce. As a result, although access to primary health coverage has potentially increased from 50.7% in 2000 to more than 90% in 2019, the UHC service coverage index remains at 43%. Additionally, outpatient attendance rate has increased from 0.27 to 0.9 per capita per year during the same period (MOH, 2019). With respect to financial risk protection, according to the National Health Account (NHA)-7, out-of-pocket (OOP) spending on health remains high at 31% of Total Health Expenditure (THE) in 2016/17, with a significant proportion of households (4.2%) facing catastrophic health expenses (Ministry of Health of Ethiopia, 2019).

3.2.2 Healthy lifestyle and practices In Ethiopia, behavioral risk factors including malnutrition, dietary risks, unsafe sex, alcohol use, and tobacco use constitute five of the top 10 risk factors contributing to the most DALYs lost. Lifestyle-related risk factors for chronic diseases tend to be more prevalent in the younger age groups, resulting in higher premature mortality compared to the developed world (Ethiopian Public Health Association (EPHA), 2012). Sedentary lifestyles are common among adolescents (Mohammed OY, 2020). Almost half of patients with cardiovascular diseases have sub-optimal knowledge about cardiovascular risk factors (Negesa LB, 2020). Modification of lifestyle and health-related behaviors remains low overall. According to the 2019 National Assessment of the HEP, only half of rural households adopted healthy behaviors related to family health, disease prevention and control, and hygiene and environmental sanitation (Teklu AM, 2020).

3.2.3 Demand for health services In Ethiopia, use of health services is low, especially among rural dwellers, socioeconomically deprived groups such as pastoralist communities, and those without formal education (Alene M, 2019). Numerous factors combine to limit service use. Misperceptions regarding the causes, outcomes, and remedies of diseases contribute to low health-seeking behavior. Diverse sociocultural beliefs and practices also greatly influences decisions regarding use of health facilities. Facility-related factors such as poor client satisfaction and disrespectful treatment, low trust in the health service provided, poor geographical accessibility, stock outs of medical supplies and equipment, lack of cleanliness at facilities, and long waiting times limit use of health services. General low health system literacy, where a community is not fully aware of available services at different system levels, also contributes to the low demand and utilization of health services.

3.2.4 Health security, health system resilience, and lessons from the COVID-19 pandemic In the Joint External Evaluation conducted in 2016 by MOH and WHO using the International Health Regulations (IHR) framework, Ethiopia scored 2.6 out of a possible 4 points (highest scores for national legislation and policy, and lowest score for chemical and radiation events). Overall, public health emergency management in Ethiopia has been effective, including outbreak investigations and timely responses. During the period of the HSTP-I, rehabilitation services were provided to 84% of people affected by 22 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY public health emergencies. The proportion of epidemics controlled within acceptable mortality rates also increased from 40% in 2015/16 to 80% in 2017/18. In terms of laboratory confirmation of outbreaks, the performance has remained consistently above 80% between 2015 and 2018. However, certain challenges remain, such as limited surveillance capacity at the lower levels, poor functionality of emergency operations centers (EOCs), poor documentation of rumors and a limited verification system, suboptimal laboratory-based surveillance, inadequate emergency funds, inadequate preparedness for pandemics such as COVID-19, and conflicts that lead to many internally displaced people (IDPs). The COVID-19 pandemic offered a number of lessons on the need to continue investing in and improving public health to build a resilient health system. The experience points these priority needs:- § Improve emergency health management: Strengthen the public health emergency management (PHEM) system at all levels of the health system. Decentralization of PHEM functions is critical for timely detection and containment of outbreaks and emergencies. Operationalizing PHEM at all levels will requires identification of a dedicated PHEM team with strong linkages to a robust community surveillance system. Strengthening of everyday preparedness and integration of clinical and public health response at each level is crucial. § Establish an emergency funding source: To respond to the need for additional flexible funds to respond to emergencies, a contingency fund should be established. In addition, a pre-defined financial, human, infrastructure, and supplies mobilization scheme should be considered to cover acute periods of such emergencies. § Develop an emergency supply plan: Prior planning to manage stocks of the medicines, supplies, and medical devices needed to maintain essential and pandemic health services at each level of health care is critical. This should take into consideration possible supply and transport disruptions during a pandemic. § Strengthen governance: Strong leadership and governance are paramount for an effective response. This should include multi-sectoral coordination mechanisms, at national and local levels, among government ministries, competent authorities, nongovernmental organizations, and non-state actors involved in preparedness and response activities. Health care leaders should implement actions to strengthen health sector coordination and communication mechanisms with preparedness, response and recovery partners (e.g., national emergency management and other government agencies, and the health care sector at subnational and local levels). § International solidarity: The COVID-19 pandemic has underlined the need for global solidarity. No country can tackle the pandemic and overcome its economic and social impact alone.

3.2.5 Health system responsiveness HSTP-I launched many interventions to improve patient satisfaction in the care provided. Improved satisfaction will lead better trust and care uptake. The agenda for compassionate, respectful, and caring CRC) health workers was launched as a transformation agenda under HSTP-I, and a movement was created around it. Unfortunately, measuring CRC is difficult since it is an emerging area, and there were no indicators to assess progress. Measuring clients’ satisfaction to evaluate quality of care has not been found useful in many other low- and middle-income countries. Satisfaction is generally measured using other aspects of care like accessibility, costs, health status, expectations, immediate outcomes of care, and gratitude. According to WHO-AFRO report, the health system’s score for responsiveness and satisfaction in Ethiopia is 0.52, which is slightly above the average for the African region (0.47). Access to social support has the highest score, at

1.0. Other aspects, such as autonomy, prompt attention, and choice of care provider have lower scoring: 0.25, 0.27, and 0.31, respectively (WHO Regional Office for Africa, 2018). Contributing factors for the low scores include long waiting time, lack of clean toilets, lack of privacy in examination rooms, absence of directions and communications on post-visit care, lack of laboratory and radiologic services, and other facility characteristics. Health workers’ lack of respect for patient privacy is a common main reason for low satisfaction with outpatient services (Fufa BD, 2019). By contrast, good communication and attitude from health staff improve client satisfaction (Kumsa A, 2016).

3.3 SERVICE DELIVERY Ethiopia has made significant efforts to make high-quality essential health services available, accessible, acceptable, and affordable to the community. In 2005, the first essential health services package (EHSP) was defined. It included a set of health promotion, disease prevention, curative, and rehabilitative services. This was revised in 2019 to include 1,019 interventions that are now included in the EHSP. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 23

3.3.1 Service delivery platforms of the health sector Health services are provided by a network of health facilities arranged in a three-tier health care delivery model. (Please refer to the section on implementation for further details). The status of these service delivery platforms is described below.

3.3.1.1 Primary Health Care/Health Extension Program Primary Health care units (PHCUs (17,550 health posts and 3,735 health centers) are the main source of primary care services, especially for rural communities in Ethiopia. The Health Extension Program, or HEP, provides a package of 18 primary care packages for family health, health promotion and disease prevention, hygiene, and environmental sanitation. Findings from the 2019 national HEP assessment suggest that the program has contributed to improvements in health indicators, especially family health. HEP has helped to reduce maternal and child mortality by increasing service utilization among mothers (MERQ Consultancy, 2020). Nevertheless, PHC facilities continue to face challenges such as lack of access to basic amenities (water, electricity, communication equipment, and sanitation facilities), shortage of skilled and committed leadership, high staff attrition, and low staff motivation and competencies. The national assessment of the HEP also identified a number of areas for improvement. Priority areas include expanding the HEP service package to meet the ever-growing needs of the community, addressing gaps in quality of care provided by health extension workers (HEWs), revising the number and mix of health professionals, strengthening HEP infrastructure to allow the provision of more comprehensive and improved services, improving the functionality of community structures and its engagement, strengthening HEP leadership, and revising information system to allow effective monitoring and evaluation of the program. Also, the current HEP service packages, delivery modalities, and service delivery points were found to be inadequate, leading to marginalization of males and youth.

3.3.1.2 Hospital-based services Hospital-based services are provided by 353 hospitals that are categorized into primary, general, and specialized hospitals. During HSTP-I, actions were undertaken to strengthen pre-hospital and hospital-based clinical care services—for example, purchasing over 3,000 ambulances, building community capacity in first aid, rolling out wide-scale basic emergency care training and assembling disaster medical assistant teams (DMATs) nationally and in all regions. Provision of specialized clinical care services at intensive care units (ICUs) was another major initiative. There are currently 53 ICUs all over the country and the ICU mortality rate stands at 29.4%. To improve emergency care, two more trauma centers and four more burn care centers were established during HSTP-I. Private hospitals also prove services to the population. However, numerous continuing challenges persist: poor coordination and referral linkages, inefficient facility management and weak accountability, weak ambulance management system, low staffing in and client satisfaction, and a need for more ICUs and ICU equipment—among others. In addition, rehabilitative and palliative care services were limited, as were specialty and subspecialty clinical services.

3.3.2 Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health (RMNCAYH)

3.3.2.1 Family Planning Family planning services are available in almost all public health facilities in Ethiopia, ranging from 99% in health centers to more than 93% in general and referral hospitals. About 82% of private health facilities also provide family planning services (FMOH and EPHI, 2018). In 2019, 41% of married Ethiopian women were using contraception, compared to just 29% in 2011 and 36% in 2016. In terms of method mix, the share of long-acting/permanent method users has increased in the past six years, from 17.9% in 2014 to 35.5% in 2019 (PMA 2019). These proportions are far below the targets for 2020(55% for contraceptive prevalence rate). In addition, there is still a high unmet need (22% in 2016, compared to a target of 10%) (EDHS 2016). There is also significant variation in total fertility rate, desired family size, and contraceptive prevalence among regions and different socioeconomic groups. In addition, there was consistent decline in percentage of women who were counseled on three key aspects of their chosen method; told 24 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY about other methods, counseled on side effects, and counselled on what to do if side effects occur since 2015 (PMA 2019). Younger women are having sex later, getting married later, having births later and starting contraceptive use earlier than older women. On average, rural women give birth to two children before starting contraception for the first time, while urban women start contraception after their first birth (PMA 2019).

3.3.2.2 Maternal, Neonatal and Child Health Coverage of reproductive, maternal, neonatal, and child health services (RMNCH) increased during HSTP-I. ANC1 coverage improved from 28% in 2005 to 74% in 2019 (EPHI and ICF, 2019). However, only 43% of pregnant women had four or more visits, and only 20% of women started ANC visit at the recommended time. Only 50% of women delivered in a health facility in 2019. Quality of care also remains a concern. For instance, only 10.6% of mothers received iron for 90 days or more during their pregnancy. In addition, only 14% of expected deliveries took place in functioning emergency obstetric and neonatal care (EMONC) facilities. The rate of caesarean delivery remains low at 4%, with large regional disparities (ranging from 25% in Addis Ababa to less than 1% in Afar and Somali). Coverage of PNC remains low despite marginal increase from 17% in 2016 to 34% in 2019 (EPHI and ICF, 2019). According to SARA 2018, 75% of hospitals, and no health centers provided comprehensive EMONC services. Mean availability of tracer items for basic emergency obstetric care was more than 85% for all the three types of hospitals, 74% for health centers, and 55% for higher-level clinics. Efforts have been made during the period of HSTP-I to expand access to safe abortion and post-abortion care. Despite the encouraging reduction in under-5 mortality rate, it is still estimated that 189,000 under-five children die from preventable childhood diseases every year with more than half happening during their neonatal period. Many more children suffer illnesses and face long-term disabilities due to complications of neonatal and childhood diseases. Neonatal disorders, diarrhoea and lower respiratory infections remain the major killers of under-five children contributing for 40.7%, 13.2% and 10.3% of total deaths respectively. Injury, measles, and malaria are also major killers of under five children (Institute for Health Metrics and Evaluation, 2019) . Malnutrition remains to be a major contributor to child mortality contributing for nearly half of under-5 deaths. The progress of Ethiopia in preventing childhood deaths has been less successful in the prevention of neonatal mortality. The proportion of neonatal deaths from the total under-five deaths increased from 43% in 1990 to 55% in 2019 (EPHI and ICF, 2019). In addition, equivalent numbers of stillbirths occur, representing a “silent epidemic”. Close to half of stillbirths occur during the process of labour and delivery. More than 80% of all newborn deaths are caused by preventable and treatable conditions. Congenital anomalies are also becoming notable contributors to neonatal mortality, morbidity and disability. Generally, half of neonatal deaths occur in the first day of life, and some three quarters of all neonatal deaths occur within the first week of life. Despite increasing accessibility of services, uneven distribution of health resources, sub-optimal quality of care, low child health care seeking behaviour of communities, low coverage of Kangaroo mother care (KMC) services, and shortage of essential health commodities and equipment at service delivery points remain to be key challenges contributing to high rates of neonatal mortality.

3.3.2.3 Immunization In 2019, coverage with three doses of pentavalent vaccine and all basic vaccines among children under 1 year of age reached 61% and 44%, respectively. However, about 19% of children had no vaccination at all. There is also high vaccination dropout rate with a national dropout of 13% from pentavalent 1 to measles, with high regional variation. Factors in low immunization coverage include inadequate cold chain infrastructure, data inconsistency among different reports, inadequate service delivery and behavioral change communication, and sub-optimal overall management of the Extended Program on Immunization.

3.3.2.4 Adolescent and youth health Adolescents and youth constitute 42% of the population in Ethiopia (Central Statistics Agency, Juy 2013). However, about 20% of adolescent girls aged 15-19 years are anemic and underweight. Most young people in Ethiopia lack comprehensive knowledge on sexual and reproductive health (SRH), often engaging in risky behavior. Wide HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 25 urban-rural disparities in comprehensive knowledge about HIV and HIV testing persist. About 37% of girls and 43% of boys aged 15-19 year consume alcohol. About 57% of boys also chew Khat. Despite high prevalence of health problems and risk factors among adolescents and youth, access to and utilization of health services is limited; and health education and life skills trainings for youth are often fragmented.

3.3.3 Prevention and control of major diseases

3.3.3.1 HIV/AIDS Progress towards the 2020 90-90-90 targets for HIV was suboptimal for the first 90 with only 78.5% of estimated people living with HIV (PLHIV) knowing their HIV status. Achievements were better for the second and third 90’s: 90% of PLHIVs who know their status were on ART and 91% of those on ART had viral suppression (MOH, 2019/20). About 90% of the annual incident HIV infections in children under 15 are still due to mother-to-child transmission (13.4%, according to UNAIDS 2019). In 2019, among the estimated HIV-positive mothers that need ART for prevention of mother-to-child transmission (PMTCT), 74% received antiretroviral therapy (ART). PMTCT service is available in 84% of public health facilities, but only in 5% of private facilities (SARA 2018). In 2019, 64% of HIV-exposed infants born to HIV-positive women received virological testing for HIV; but proportion of infants born to HIV-positive mothers who received antiretroviral prophylaxis is low, and requires further effort. Major challenges and gaps in Ethiopia’s response to the HIV epidemic include suboptimal HIV case finding, especially in pediatric and adolescent age groups and in key and priority populations; and gaps on overall quality of services for prevention, diagnosis, care, and treatment.

3.3.3.2 Tuberculosis and Leprosy Prevention and Control services Ethiopia is on track to achieving one of the three targets of the global End TB Strategy: TB incidence has declined by 21% from the 2015 estimate (was against a target of 20%). However, progress in reducing TB mortality was only 15% (target was 35%) under HSTP-I. As there is no nationally representative estimate of the catastrophic costs for TB-affected households, the status of progress on the third milestone is not known. TB case notification has been improving, with a detection rate of 71%. In 2019/20, TB treatment success and cure rates also reached 95% and 80%, respectively (MOH, 2019). According to the mid-term review of the national TB and Leprosy strategy in 2018, among health facilities having TB smear microscopy, 74% participated in external quality assurance (EQA) schemes and the concordance rate was 96%. According to SARA 2018, 50% and 39% of health facilities (excluding health posts) offered TB diagnosis by sputum smear microscopy examination and clinical symptoms, respectively. Multi-drug-resistant (MDR) TB is a public health concern as the number of cases increase in Ethiopia. Since 2009, a cumulative of 4,906 drug-resistant TB (DR TB) patients were detected and enrolled on second-line drug treatment. As of 2019, there are 59 DR TB treatment initiative centers, and more than 700 treatment follow-up centers providing DR TB treatment services. The prevalence of leprosy has sharply declined, from 20 per 10,000 population in 1983 to 0.34 per 10,000 population in 2018/19. The number of leprosy cases detected in 2011 Ethiopian Fiscal Year (EFY) (2018/19) was higher than the number detected in the last two years. A total of 3,383 new leprosy cases were detected in 2018/19, mainly from Oromia and Amhara regions (MOH, 2019). Increasing case detection, addressing MDR TB, accelerating response to TB/HIV, increasing financing to close resource gaps, and intensifying research and innovations remain some of the main priorities for prevention and control of TB and leprosy.

3.3.3.3 Malaria Prevention and Control Services In the past five years, mortality and morbidity from malaria has declined dramatically. Between 2015 and 2019, malaria deaths dropped from 3.6 to 0.3 per 100,000 population at risk, and malaria case incidence dropped from 5.2 million in 2015 to less than 1 million in 2019. In 2017/18, a malaria elimination program was launched, with activities carried out in 239-targeted woredas. The government has started a sub-national elimination program to comprehensively interrupt local transmission of the disease by 2030. The 2019 World Malaria Report indicated that Ethiopia is on track for a 40% reduction in incidence and mortality by 2020. However, high-level resistance of malaria vectors to insecticides, sub-optimal usage of interventions by target 26 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY communities, complacency in maintaining the momentum, delay in implementing the national case management guidelines, and shortage of complete and timely data for evidence-based decision-making are remaining challenges that need close attention.

3.3.3.4 Hepatitis C Virus and Hepatitis B Virus Most patients in Ethiopia (85% to 95%) do not know their hepatitis B or C infection status and fewer than 5% access treatment. The hepatitis prevention and control program remains under-resourced, which accentuates the challenges of access to diagnosis, treatment, and preventive measures. In addition, low coverage of hepatitis vaccine for newborn babies, the high cost of diagnostics, stock outs of pharmaceuticals, the slow scale up of diagnosis and treatment services are among the major challenges for the program.

3.3.3.5 Non-Communicable Diseases and Injuries In Ethiopia, the most common cancers among adults include breast cancer (30.2%) and cervical cancer (13.4%). About two-thirds of reported annual cancer deaths occur among women. The main reasons for high cancer mortality include low awareness of cancer signs and symptoms, inadequate screening and early detection and treatment services, and inadequate diagnostic and treatment facilities. In 2015, about 16% of the population is hypertensive, with higher prevalence among urban (22%) than those rural dwellers (13%). In addition, the prevalence of rheumatic heart disease was 17 per 1000 children and young adults aged 4-24 years. Diabetes, asthma, chronic kidney disease, and eye diseases are among the major NCDs affecting Ethiopians (NCDI Commission, 2018) . Despite the increasing burden of NCDs, available health services are very limited. The 2018 SARA assessment revealed that only 36%, 49%, 53% and 9% of health facilities, excluding health posts, offered diagnosis and treatment for diabetes, cardiovascular diseases, chronic respiratory diseases, and cervical cancer, respectively. Overall readiness score for these services is very low, ranging from 18% for chronic respiratory disease diagnosis/management to 51% for cervical cancer diagnosis (FMOH and EPHI, 2018).

3.3.3.6 Mental Health In 2019, about 26% of health facilities had integrated mental health services into their general health services. The mental health bed-to-population ratio stands at less than 1%. Inpatient child and adolescent mental health care are almost nonexistent, and there is only one mental health rehabilitation center in the country. Forensic psychiatry service is provided in Amanuel Hospital, which has limited beds for this purpose. There is also a significant treatment gap for priority mental health illnesses. Lack of sustainable availability and unaffordability of psychopharmaceutic agents and limited psychosocial interventions are the other challenges that remain unaddressed.

3.3.3.7 Neglected Tropical Diseases During the HSTP-I period, there were major interventions that targeted NTDs: regular mass drug administration to all people at risk of morbidity and/or infection; and intensified disease management within the primary health care system. This led to remarkable progress towards control and elimination of targeted NTDs. Guinea worm transmission was interrupted in 10 woredas; currently only one endemic woreda is left in Gambela Region. Intensified implementation of trachoma control program enabled 610,000 cases (88% of the TT backlog) to be cleared during HSTP-I period. Coverage with preventive therapeutic coverage for trachoma reached 85% in 2018. Preventive chemotherapy for onchocerciasis, soil transmitted helminths, schistosomiasis, and lymphatic filariasis reached 100%, 95%, 85%, and 94% coverage, respectively. In addition, morbidity and disability management for lymphedema & hydrocele improved, and the number of intensified treatment centers for leishmaniasis increased from 19 in 2016 to 28 in 2019. Inadequate WASH integration, population movement in investment corridors, lack of scientific evidence on human-animal interface in Guinea worm transmission, insufficient scientific evidence for Leishmaniasis control program, and declines in both domestic and international financing for NTD prevention and control are among the major continuing challenges. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 27

3.3.4 Health promotion Health promotion has been central to all policies and strategies in Ethiopia. During HSTP-I, the health sector focused on promoting multi-sectoral actions on nutrition and WASH.

3.3.4.1 Nutrition Ethiopia has one of the highest rates of malnutrition in sub-Saharan Africa, and faces high rates of acute and chronic malnutrition and micronutrient deficiencies. Between 2005 and 2019, the prevalence of stunting decreased from 51% to 37%; underweight declined from 33% to 21%; and wasting decreased from 12% to 7%. The prevalence of anemia in children aged 6 to 59 months, and in women in the reproductive age group, were 57% and 24%, respectively. During HSTP-I, considerable efforts were made to improve food security and nutrition. Multi-sectoral collaborative interventions were implemented with the objectives of improving nutritional status of children and women. In 2015, the government launched a major collaborative platform, a high-level government commitment called Seqota Declaration, to end child under-nutrition by 2030, and this intervention is continuing. In addition, the health sector also implemented nutrition interventions, including micronutrient supplementation, deworming, screening and growth monitoring, and management of malnutrition. Despite national commitment and continued efforts, several cross-cutting issues remain. These include missed opportunities to integrate nutrition into the health sector, introduce nutrition-sensitive RMNCH interventions, and mainstream multi-sectoral nutrition programs into other sectors; along with frequent changes of National Nutrition Program implementing sectors officials at all levels, inadequate capacity of HEWs, and weak supply chain systems.

3.3.4.2 Water, sanitation, and Hygiene During HSTP-I, three major strategic initiatives were implemented under hygiene and environmental health program: rollout of an urban sanitation strategy; scale- up of community- and school-led total sanitation; and hygiene, sanitation marketing, and building adaptation for resilience to climate change in the health sector. Since 2015, more than 370 woredas have established at least one sanitation marketing center from the target of 500 for HSTP-I. According to Joint Monitoring Program (JMP) 2019 estimates, coverage with improved sanitation facilities in Ethiopia is only 14% (7% basic and 7% limited), which is very slow compared to the HSTP-I target of 82% coverage. Similarly, only 14% of drinking water from point of collection was free from contamination (WHO and UNICEF, 2019). According to the 2019 National Assessment of the Health Extension Program, only 11% of rural households have proper solid waste collection and disposal practices, and only 10.8% were practicing proper liquid waste management. This achievement is far lower than the HSTP-I target of 40%. According to the same report, the proportion of households using water treatment and safe storage was 28% (versus the HSTP-I target of 35%) (Teklu AM, 2020). Sanitation in schools and health facilities is also a major problem in Ethiopia: 40% of schools have unimproved latrines; only 6% of schools have basic hand-washing facilities with soap; and 18% have limited services (WHO and UNICEF, 2019). According to 2017 baseline survey on menstrual hygiene management in Ethiopia, 50.9% of girls reported that they discuss menstruation with their close friends, 24% with their sisters, and 16.3% with their mothers (MOH and UNICEF, 2017). During the first phase of the One WASH national program (2015-2019), a total of 1,920 health facilities obtained water supply schemes and 3,109 health facilities obtained access to latrine facilities. The HSTP-I target for health institutions with gender and disability sensitive full WASH packages is 60%. However, only 34% of health facilities have an improved water source in the facility premises. Besides two third (61%) of facilities have access to an improved sanitation facility in the premises and 52% health facilities had safe disposal of infectious wastes according to the 2018 service availability and readiness assessment (OWNP, 2019). Low coverage of sanitation facilities at schools and health facilities, poor household-level hygiene and sanitation, poor community attitudes and behavior regarding hygiene and environmental health, poor regulation of unhygienic practices, and weak coordination among different sectors remain in need of improvement. 28 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

3.4 THE STATE OF EQUITY IN THE ETHIOPIAN HEALTH SYSTEM Despite efforts to reduce regional disparities, inequitable distribution of health outcomes and health services continues across different segments of the population. Health indicators vary significantly by region, place of residence, gender, disability status, education, and socioeconomic status. In general, urban residents, literates, and wealthier segments of society enjoy better health outcomes compared to others (Firew Tekle Bobo, 2017).

3.4.1 Geographic disparities in health Regional variations in health indicators are dominant in Ethiopia, caused by multiple factors such as gender norms and harmful traditional practices, low economic and educational status, low access to basic utilities, poor road communication networks, and food insecurity. Recognizing these challenges, the government has given special attention to addressing equity by designing and implementing initiatives that provide special support to relatively disadvantaged regions. Results of the 2019 Mini EDHS show that although there have been improvements, inequalities persist. However, health disparities are still unacceptably wide across different segments of the population and across regions and the urban-rural divide, calling for innovative solutions to address the root causes (EPHI and ICF, 2019). As shown in Figure 5, the probability of dying during the early childhood period (per 1000 live births) is considerably higher in some regions compared to others. Number of deaths during early childhood period (per 1000 live births), by region, 2019 Somali Benishangul Gumuz Gambella Dire Dawa Oromia Amhara Harari Afar SNNP Tigray Addia Ababa 0 20 40 60 80 100 120 Neonatal peiod Post neonatal period children 1-4 years Figure 5. The probability of early childhood deaths by time of death and regions, 2019 The results of the 2019 mini-DHS showed that coverage with RMNCH services is consistently lower in rural areas and special support regions as compared to that in urban areas and non-special support regions. The widest urban-rural disparity in maternal health service utilization occurred in health facility delivery. The use of modern family planning methods varies significantly across regions. In 2019, the contraceptive prevalence rate (CPR) (modern methods) ranged from 3.4% in Somali Region to 49.5% in Amhara. Vaccination with all basic vaccines varied from 18.2% in Somali Region to 73.0% in Tigray and 83.3% in Addis Ababa. In 2019, the under-5 mortality rate was 59 deaths per 1,000 live births, ranging from 26 in Addis Ababa to 101 in Somali. Similarly, utilization of RMNCH services largely varied by educational status and wealth quintiles. Individuals and households with higher educational status and in the higher and highest wealth quintiles had consistently better health service utilization indicators compared to their less educated and poorer counterparts (Firew Tekle Bobo, 2017) (Figure 6). HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 29 Maternal health service utilization by household wealth quintile 100 80 60 40 20 0 ANC Health Facility Delivery PNC Lowest Second Middle Fourth Highes Figure 6. Maternal health service utilization by household wealth quintile Overall, there are pressing needs to address geographic and regional disparities in health services access, utilization, and outcomes. Major challenges include inconsistency in priorities, limited contextualization of health service delivery systems, low community awareness and utilization of available services, mal-distribution and wrong placement of health workers, and inadequate infrastructure. Addressing these challenges will require context-specific, innovative solutions to tackle the root causes.

3.4.2 Gender disparities in health The last five years saw progress in gender mainstreaming and women’s empowerment in the health sector. Activities implemented include promoting empowerment of females in the health workforce, developing manuals on gender and orienting the health workforce, conducting gender analyses and gender audits in some regions and agencies, and building the capacity of selected health facilities on provision of services for survivors of gender-based violence (GBV). Moreover, a one-stop shopping center for GBV response at federal and regional levels was established and made functional for GBV survivors. However, efforts to address gender disparities in health is still in its early stages. Gender-disaggregated data from the routine health information system, population-based surveys, including the EDHS, and model-based estimations show that women in general have a longer life expectancy than men do. However, women tend to receive health services less frequently than their male counterparts, possibly compromising their quality of life. In Ethiopia, gender disparities in health service utilization may be linked to the women’s limited decision-making power at the household level. Factors such as needing permission to visit a health facility, obtaining money for treatment, distance to a health facility, and unwillingness to go to a health facility alone are important barriers to women’s health service utilization. Among the major challenges in the addressing gender disparities in health are limited enforcement of existing laws and policies on the rights of women and girls, limited capacity among health care workers in designing and implementing gender-responsive health services, and limited capacity for providing comprehensive, multi-sectoral services to survivors of sexual GBV.

3.4.3 Socioeconomic disparities Despite national initiatives to address financial barriers (fee waiver system for the poorest of the poor, fee exemption for selected essential PHC services, and community-based health insurance, or CBHI, with premium subsidy for indigents), socioeconomic disparities in health service utilization are very wide, even for services that do not require user fees, including RMNCH services (Firew Tekle Bobo, 2017). 30 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

3.5 HEALTH SYSTEM INPUTS

3.5.1 Health Workforce Increasing access to compassionate, respectful, and caring health workers was one of the transformation agendas of HSTP-I, and the government sought to increase the availability of health workers. In 2018, health worker density was estimated at 1.0 per 1,000 population (considerably lower than 4.5 per 1000 population standard proposed by WHO to achieve UHC). The inadequate skill mix of health professionals is another issue; there is a relatively high number of nurses but a shortage of medical doctors, midwives, anesthetists, pharmacists, and medical laboratory technologists. To address this, MOH and the MOE have committed to scaling up health professional training in public and private universities and colleges. Key initiatives implemented during HSTP-I include upgrading HEWs and expansion of medical residency (specialization) and nursing specialty trainings and scale up midwifery and anesthesia professional trainings. The Ethiopian Residency Matching Program for 22 medical specialty programs enrolls an average of 1,050 residents per year in 13 public universities; 3,150 residents were in training in 2019. The nursing specialty training program was started with categories for neonatal, emergency and critical care, operating room, pediatric and surgical nursing. However, it fell short of meeting the target with only 1,113 enrolled and 771 graduated in 2019 against a target of 11,780 specialty nurses. To improve the quality of health professional education, the Higher Education Relevance and Quality Agency (HERQA) is working actively to accredit private health education institutions. A Certificate of Competence (COC) program was developed based on Ethiopian occupational standard, serving as a criterion for licensing graduates of technical vocational education training-level trainees. MOH also implemented a National Licensing Examination for first-degree graduates of seven health care types to measure their competencies and issue license accordingly. To address the need for continuous professional development, MOH developed and approved the national continued professional development (CPD) implementation guidelines, followed by identification and accreditation of CPD provider institutions. The CPD program is expected to become a requirement for re-licensing of health workers. In 2009, the MOH introduced the Human Resources Information System (HRIS) to facilitate routine data collection and management. However, the system has not been fully functional at various levels, and has failed to produce comprehensive national HR information. During the HSTP-I period, the MOH took actions to strengthen the HRIS. High staff turnover has been a persistent challenge for the health sector. To motivate and retain health staff, MOH developed a new incentive package for health workers that is allocated based on pre-identified exposure level of risk. Interventions need to continue during HSTP-II to build and sustain a competent, motivated, and compassionate health workforce, with adequate number and skill mix. Moreover, human resource management has to be further improved to retain a motivated health workforce.

3.5.2 Medical products and supplies The HSTP-I mid-term review (2018) documented relatively high availability of program medicines, successful integration of vaccines supply management into the Integrated Pharmaceuticals Logistics System, reduction of pharmaceuticals wastage, and establishment of electronic supply management system at the central Ethiopian Pharmaceutical Supply Agency (EPSA) and its hubs. According to a WHO African Region report, Ethiopia had a health product score1 of 0.51, which was slightly higher than the regional average of 0.48. With the need to shift from product-oriented to patient-oriented services, several initiatives were carried out during HSTP-I, including rollout of auditable pharmaceutical transactions and service (APTS) in 200 health facilities, introduction of clinical pharmacy and drug information services, and increased emphasis on anti-microbial resistance (AMR). However, several challenges remain. For instance, a recent essential tracer medicines availability survey indicates that nationally, 21.8% of hospitals and health centers fulfilled more than 80% of the storage conditions. Hospitals demonstrated better performance, fulfilling more than 80% of storage conditions versus only 18.9% of health centers 1. A score composed of indicators that include readiness of diagnostics and essential medicines, density of pharmacy professionals, and rate of blood donation HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 31 and 4.6% of health posts. Comparison of data between 2015 and 2018 surveys showed that the percentage of hospitals that met at least 80% of the storage conditions has increased from 43.0% in 2015 to 71.4%, whereas the storage availability declined from 63.0% to 44.6% in health centers. Progress on plans to reduce pharmaceuticals wastage rate to less than 2% and increase the contribution of local manufacturers in supplying EPSA to 60% are far behind 2020 targets, but there is a challenge in last-mile delivery of medical supplies. There are also challenges in procurement, maintenance, and inventory management of medical equipment, along with a gap in testing the efficacy of generic drugs produced in Ethiopia, due to lack of bioequivalence centers. The blood safety program has shown improvement in geographical coverage of the population/ hospitals accessing safe blood services from 90% to 100% in 5 years. Thus, through a network of the blood bank sites, safe blood and blood products have been made available to 420 health facilities across the country. Total units of blood collected per annum increased from 121,960 in 2015 to 288,966 unit in 2019/20, mainly provided by voluntary blood donors (99.5%). Despite this significant increase in the amount of blood collected, there is a profound lack of production and utilization of blood products. To ensure safety and efficacy of traditional medicines, efforts are underway to strengthen research on and production of quality-assured traditional medicine in Ethiopia. In the HSTP-II period, actions including proper quantification and forecasting, reduced procurement lead-time should continue to ensure an uninterrupted supply of quality-assured medicines and supplies, to avoid stockouts and ensure timely access to essential medicines and health products.

3.5.3 Health infrastructure By the end of 2011 EFY (2018/19),17,550 HPs, 3,735 health centers and 353 hospitals were available; and 425 health posts, 96 health centers, and 107 hospitals were under construction in Ethiopia. In addition, during HSTP-I, special purpose facilities, including warehouses, trauma centers, mini blood banks and laboratory infrastructures were constructed. The SARA 2018 survey assessed availability of seven basic amenity tracer items.2 These were found only in 1% of the 764 health facilities assessed. The mean availability of tracer items for all facilities assessed was 39%, with referral hospitals scoring the highest and health posts the lowest (30%). Current administrative reports, however, show that water and electricity are available in 59% and 76% of health facilities, respectively. In terms of the network infrastructure system (Health Net), as of September 2019, about 1,636 health facilities are connected with a cabled virtual private network (VPN) and 1,944 sites are connected with wireless 3G option. An additional 25 health facilities with no cabled VPN or Wireless 3G options are connected with customized options. As per the 2018 WHO Africa Regional report, the health infrastructure index3 in Ethiopia (is 0.46 (higher than the regional average of 0.39). However, high inflation of construction materials, security problems in some regions, lack of finance and cash flow for capital projects, inefficiency of some contractors, and capacity gaps at regional and lower levels continue to challenge the development of the health infrastructure. In HSTP-II period, there should be a continued focus on upgrading, maintaining and equipping of health facilities, in addition to construction of primary hospitals and other medical infrastructure projects.

3.5.4 Health financing During HSTP-I, a number of measures were undertaken to enhance health financing and improve the coverage and quality of health services. To mobilize resources for health and protect people from financial hardship, the government implemented several interventions including-provision of a fee waiver for high-impact interventions through an exemptions program; subsidization of more than 80% of the cost of care in government health facilities; implementation of CBHI schemes; and full subsidization for the very poor through fee waivers both for health services and CBHI premiums. 2 Water, electricity, sanitation facilities, emergency transport, consultation room, computer with internet, and communication equipment 3 Composite of amenities, equipment and HF to population coverage and readiness 32 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY In the 7th round NHA (2016/17), Ethiopia’s total health expenditure was estimated at 72 billion ETB ($3.1 billion), accounting for 4.2% of the country’s GDP. The total health expenditure has grown steadily since 1995/96, and grew by 45% from 49.6 billion birr in 2013/14 to 72.1 billion birr in 2016/17. However, this growth was 15% in real terms after adjusting for inflation (Ministry of Health of Ethiopia, 2019). Furthermore, the share of GDP is lower than the expected average of 5% for low-income countries, and well below the global average of 9.2%. The share of government contribution for total health expenditure was 32% in 2016/17—only slightly higher than the 30% contribution in 2013/14. Expenditure on health as a share of total government expenditure increased from 7.6% in 2013/14 to 8.1% in 2016/17. This figure is lower than the low-income country average government health expenditure (8.7%). Average health expenditure per capita is $33, as compared to a regional average of $38 (World Bank, 2016). Although the government allocates 60-70% of total budget to pro-poor sectors, allocations to health fall well short of the Abuja Declaration target or WHO’s recommended $86 per capita spent to deliver UHC. Major financial challenges include low government budget allocation to health, inefficient resource utilization, lack of a strategic purchasing and performance-based financing mechanism, ineffective processes for the selection and financing of the poor absent social health insurance (SHI), and low coverage of the informal sector through the ongoing CBHI scheme.

3.5.5 Health information During HSTP-I, the indicators selected to monitor progress did not align with the burden of disease and had an unbalanced mix. Most performance indicators were not measured, due to lack of appropriate data source and inability to conduct the required surveys and assessments. During the HSTP-I period, the government developed health information systems policy documents and guidelines, and established and staffed health information technology structures at different levels. During this period, 1,588 facilities were connected with copper-wired VPN, and 1,806 facilities with 3G wireless networks. E-health architecture has been designed and implemented, but a large part of the information revolution road map activities remains unimplemented (MOH, 2019). With regard to data quality, report completeness improved from 72% in 2015 to 89% in 2019 (MOH, 2019). Data consistency also improved, leading to reduced discrepancy between the data from routine information system and data in surveys. Various platforms were put in place to strengthen key decision-making, including performance monitoring teams (PMTs), review meetings, a Joint Steering Committee (JSC), and planning forums. The MOH also began engaging local universities in capacity building and mentorship program. The DHIS2 platform was customized and fully scaled up with user-friendly data use features. Other service recording systems for logistics, regulatory system, and other functions were also introduced. An electronic Community Health Information System (echoes) application was developed and implemented in 1250 in rural health posts; and several other applications are in development including a Master Facility Registry, a web-based HRIS, and a National Health Data Dictionary (MOH, 2019). Regarding public health surveillance information system, 23 reportable diseases, including maternal and perinatal death surveillance and response, are reported through the disease surveillance system. A national database center was created at EPHI to handle the Public Health Emergency Management (PHEM) information system. Vital events and civil registration systems are operational, but the coverage is low; and current practices for vital event registration needs improvement, especially at health-facility and community levels. Despite interventions to strengthen health information systems, there are persisted gaps, including limited human resources HIS, inadequate functionality of PMTs at all levels, poor documentation, inadequate implementation of data quality assurance, and limited coverage of VPN-Health Net, LAN, electricity, and computers. Implementation of an electronic medical records began, but its functionality and scale up is very much limited. To strengthen knowledge management, a strategic plan and road map (2016-2020) has been developed. In addition, knowledge management (KM) structures are established at EPHI and AHRI. However, lack of functional coordination mechanism and absence of a systematic/institutional management of knowledge assets limit the ability to create value and meet the tactical and strategic requirements. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 33 A number of studies took place during the HSTP-I period, including EDHS 2016, mini-DHS 2019, review mission/ mid-term reviews, the Malaria Indicator Survey, Data Quality Review (DQA), SARA, and others. The Ethiopian Public Health Institute (EPHI) and Armature Hansen Research Institute (AHRI) also conducted research on health sector topics. In 2019, a total of 119 operational, biomedical, and clinical studies were conducted on infectious and non-infectious diseases, health system, nutrition and traditional medicines. However, most findings from research and technical reports are not synthesized for use in decision-making, indicating weaknesses in research coordination and knowledge management.

3.5.6 Community engagement Community engagement has been a primary principle and strategy for achieving the strategic objectives of HSTP-I. The Women Development Army (WDA) served as a primary community engagement platform at the grassroots level. WDA has been scaled up to almost universal coverage in agrarian settings and partial coverage in urban settings. In pastoralist settings, social mobilization committees serve as community engagement platforms. There have been interventions to build the capacity of WDAs through competency-based trainings, with nearly half a million WDA leaders trained (MOH, 2019). However, in recent years, the functionality of these structures has shown signs of decline. According to the 2019 National HEP Assessment, WDA leaders did not demonstrate model behaviors. Major challenges in community engagement strategies include low capacity and acceptability among WDA leaders and low acceptance by community members. Overdependence on the WDA structure has resulted in underutilization of other community resources, including those of men, religious leaders, and traditional leaders.

3.6 LEADERSHIP, GOVERNANCE AND MULTI-SECTORAL COLLABORATION

3.6.1 Leadership and governance Legal and regulatory system: A strong regulatory system is paramount to ensure the safety and quality of health and health-related products and services. During HSTP-I, efforts were undertaken to strengthen the regulatory system for food, medicine, traditional medicines, equipment and supplies, health professional, and health and health-related facilities. As of 2020, about 4,353 medicines and 4,448 medical devices were registered. Although there is a good inspection system in place, it needs to be further strengthened. Though not optimal, consignment and post-market surveillance testing was performed for food, medicines, and medical devices. Health care facility standards were developed and routine inspection of public and private health care facilities took place. A number of proclamations, regulations, and legal frameworks were developed and implemented during the HSTP-I period, including a tobacco control proclamation, directives on national medicine use, food and pharmaceutical sampling, food registration, and alcohol advertisement. However, there is a need to harmonize and strengthen the enforcement of all regulatory frameworks. Stakeholder engagement and partnership: As a coordination platform with RHBs, the MOH holds regular Joint Steering Committee (JSC) meetings every two months, and Executive Committee Meetings take place with agencies every two weeks. These platforms support the health sector by regularly reviewing and monitoring the performance against set targets and helping to make timely decisions. Joint Consultative Forum (JCF) meetings are held regularly between MOH and donors. The Joint Core Coordinating Committee (JCCC) meetings between MOH and developing partners address technical and operational issues. The Ministry has also been working closely with private organizations and professional associations and has ensured their engagement in planning, review meetings, supportive supervision, and other health activities. Accountability: The Ministry has developed a scorecard system to improve the accountability of the health system by enabling communities to measure the performance of health facilities and provide feedback. Currently, the scorecard system is in use in more than 600 woredas. Despite these initiatives, there is a recognized need to further strengthen accountability framework at each level during HSTP-II period. Leadership capacity building: The Ministry has been working towards improving the capacity of health sector leaders. The Leadership Incubation Program (LIP) was started in 2019 with the goal of producing future leaders—a positive initiative that should continue. 34 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Health policy: During HSTP-I, the 1993 health policy was revised to respond to current sociodemographic, epidemiologic, and economic changes in Ethiopia. The revision also took into account the government’s vision of becoming a middle-income country and the national commitment to UHC and the SDGs. The policy document has undergone a series of consultations and will be submitted to the Council of Ministers for final ratification. Health sector planning: Under the leadership of MOH and RHBs, and in line with the country’s GTP II, the HSTP-I was developed with the aim of transforming the health system and ensure equitable, quality, resilient, sustainable health services to all segments of the population. Guided by the principles of “one plan, one budget, and one report” in the health sector, annual woreda-based health sector plans (WBHSP) are prepared through top-down and bottom-up approaches. The WBHSPs have contributed to the alignment and harmonization of systems for planning, budgeting, resource allocation, prioritization, tracking, and reporting. This has increased capacity for planning and is expected to help staff to focus on the results of activities. Challenges include weak resource mapping, misalignment of the timing with the government budget ratification schedule, and poor utilization of plans for budget negotiations at sub-national level, resulting in disproportionate budgeting for health.

3.6.2 Multi-sectoral collaboration Health is multi-factorial and requires strong multi-sectoral collaboration. However, by design, governments operate in sectoral silos. Despite national policy statements and coordination platforms, when it comes to delivering a truly prioritized set of interventions at the grassroots level, much remains to be done to translate the policy statements into action. To engage effectively with other sectors, the Ministry has initiated the concept of multi-Sectoral Woreda Transformation concept, comprising 11 line ministries. A pilot implementation took place at Gimbichu Woreda, but there needs to be further action.

3.7 SWOT ANALYSIS A strengths, weaknesses, opportunities, and threats (SWOT) analysis was performed to inform preparation of the HSTP-II. Its objective is to identify the factors that are likely to influence the performance of the health sector and broadly classify them into internal factors (strengths & weaknesses) and external factors (opportunities & threats). The table below shows the results of the SWOT analysis. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 35 Strengths Weaknesses § Good coordination and governance mechanism, especially at § Sub-optimal quality of health services Federal and Regional levels § Low public trust and satisfactions on the health service and health § Improved service availability and accessibility, particularly to system PHC § Disparity in health care utilization among the population by factors § Presence of Community-based health extension program such as geography, residence, level of education, wealth and other and community engagement platforms equity parameters § Initiation and implementation of national quality § Poorly coordinated referral system at all levels improvement initiatives and learning collaborative platforms § Lack of organized pre-hospital services (with universal access call § Increased availability of ambulance services number and dispatch center) § Improving health facility management system (governing § Poor planning of human resource for health which resulted in board/management committee) scarcity of staff for some cadres and unbalanced mix of staff § Engagement of CSOs such as professional associations and § Inadequate competency and skill, low motivation and satisfaction stakeholders in the health system of the health work force § Strong diseases surveillance system § High staff turnover including the leadership and absence of § Establishment of national and regional Disaster Medical retention mechanism Assistant Team (DMAT) § Lack of streamlined scope-based work § Initiation and implementation of health care financing § Inadequate pharmaceutical supply chain management system reforms (such as fee retention, private wing, service fee resulting in shortage of supplies, high wastage rate, and unsafe revision) disposal of non-usable items § Community Based Health Insurance § Inadequate implementation of rational medicine use § Increased community contribution (for infrastructure, service § Weak maintenance of medical equipment improvement and ambulance procurement) § Lack of system for safe & environment friendly decommissioning § Regular and participatory review mechanism in place and disposal of non-usable medical equipment § Improved data storage, better and improved reporting and § Fragmented and weak implementation of health care financing data availability supported with ICT infrastructure § Lack of standard cost of health service § Availability of national and international donors for § Inefficient utilization of resources supporting the public health sector § Inadequate implementation of CBHI in pastoral regions § Challenges in financial utilization and liquidation at all levels § Sub-optimal public-private partnership and weak inter-sectoral collaborative efforts § Sub-optimal accountability at all levels of the health system § Limited awareness and leadership capacity § Sub-optimal uniformity in regulatory practices at public and private health and health related institutions § Lack of independent regulatory body § Conflict of interest between regulatory and other sectors § Poor data quality in terms of consistency and timeliness § Lack of standardized electronic medical record (EMR) system in public health facilities § Low utilization of evidence for decision making Opportunities Threats § Economic growth and presence of strong government § High adult illiteracy rate, especially among women structure § Poor health literacy and health system literacy § Positive government attention to global commitments, such § Low economic status of the population (poverty, high as SDGs unemployment) § Increasing risk factors, unhealthy lifestyle and harmful practices § Strong political will to advocate for women leadership § Inadequate information on social determinants and other health § Global PHC/UHC movement related activities § Presence of community engagement mechanism in § Community fatigue in some activities such as HDA developmental activities including health (disease prevention § Inadequate political commitment to support health sector in some movements, ambulance purchase) regions and Woredas § Global advocacy for timely emergency and trauma care § Presence of favorable cultural and traditional self-help practices in the community 36 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Opportunities Threats § Increase in community demand for high quality of health care § Increasing manmade and natural disasters, and emergence and § Improving engagement of stakeholders (CSO and re-emergence of disease epidemics Professional associations) in improving quality of care § Proliferation and/or weakly controlled promotion of processed § Improved government commitment to PPP foods § Increased number of health professionals’ training § Low government expenditure on health institutions (public and private sectors) and programs § Delayed government decision to implement Social Health § Engagement of local universities in HIS and knowledge Insurance generation § Appointment of public health facility management by political § High political commitment to support the expansion and affiliation, not by merit, in local governments building of health infrastructure § Weak inter-sectoral collaboration § Improved road accessibility and transportation facilities § Lack of consistency in implementation of gender mainstreaming § Establishment of third-party insurance for Road Traffic § Weak law enforcements and regulatory mechanisms Accident § Weak/poor infrastructure such as road, water supply, ICT, § Improved education enrolment, particularly girl’s education electricity § Increased number of new graduate health workers § Inadequately managed urbanization and industrialization (availability) § Compromised quality of pre service training § Implementation of various reforms in the country § Increasing brain drain (to other sectors and abroad) § Presence of scientifically proven and globally accepted health § Limited incentive mechanism for private sector investment in technologies health services and products § Advancements in technology both globally and locally, § The effect of global economy (rising cost of pharmaceuticals, improving internet availability, access to various media outlet supplies etc.) and Social Networks § Porous border, increasing number of refugees, instability of neighboring countries and internal political instability § Inadequate aid effectiveness and Low predictability of funding § Climate change, global warming

3.8 STAKEHOLDER ANALYSIS Stakeholders are key players in the health sector, and understanding their needs is crucial to the success of HSTP-II. The table below shows the key stakeholders whose needs and interests should be taken into consideration during HSTP-II implementation. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 37 Behaviors we Stakeholders Their needs Resistance issues Institutional response desire Participation, Access to health Dissatisfaction engagement information and service, Community mobilization, Ownership empowerment, ensure participation Community Opting for unsafe Service utilization Quality of health care Quality and equitable service alternatives and information Stewardship Underutilization Healthy life style Administrative measures Ratification of Policies, Implementation of Parliaments, Prime proclamations etc. proclamations, Policies etc. Put in place strong M&E Organizational Minister’s Office, system and comprehensive restructuring Council of Ministers, Equity & quality capacity building Regional Governments Influence on budget mechanisms Resource allocation Plans & Reports allocation Fragmentation Collaboration Inter-sectoral Evidence-based plan & Line Ministries (Water, collaboration reports Dissatisfaction Finance, Labor, Effective and efficient use Transparency Women’s Affairs, of resources & coordination Agriculture, etc.) Consider health in all Considering health as low policies and strategies Technical support priority Advocacy Knowledgeable, skilled Health professional Technical, policy support, Policy and leadership and ethical health Curriculum revision training institutes guidance support professionals trained Harmonized and aligned Government leadership Financial system Fragmentation Participation accountable and Transparency Development Partners transparent Efficient resource use High transaction cost More financing Involved in planning, implementation and M&E Build financial management Inefficiencies Technical support capacity Harmonization & alignment Dissatisfaction NGOs, CSOs, Participation, resource Involvement in planning, Transparency, Advocacy and professional & TA implementation and M&E Fragmentation associations Participation Capacity building Participate in licensing Scale down and accreditation Financial support Withdrawal Promote professional code of conduct Quality of care; Client Transparency Diaspora and Private oriented; Enabling environment for Mistrust Accountability for-profit entities Knowledge and their engagement Rent seeking technology transfer Dialogue Commitment, Conducive environment Dissatisfaction Motivation Civil servants Participation Transparency Unproductive Involvement CPD Incentive Attrition

3.9 SUMMARY OF LESSONS FROM HSTP-I IMPLEMENTATION Community ownership The Ethiopian health sector is well known for its strong community health program through initiatives such as the health extension program (HEP). The HEP delivers cost effective basic services to all Ethiopians, mainly women and children. HEP is underpinned by the core principle of community ownership, which empowers communities to manage health problems specific to their communities, thus enabling them to safeguard their own health. The HEP 15-year roadmap was finalized during the HSTP period. 38 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY However, during the implementation of HSTP-I, the link between primary healthcare units and HEP began showing signs of slowdown. This was caused by several factors, including inadequate support from political leadership, dissatisfaction and fatigue among HEWs, sub-optimal facility readiness, and community demands that surpassed the scope of the services provided at health posts. The epidemiologic transition also posed new challenges to the health system, in particular the rise in NCD burden. Community-based activities by HEWs, including household visits, have declined in recent years. Further, the implementation of the strategy for generating grassroots community faced such challenges as low literacy, slow progress in community training (level-I training), limited supportive supervision, and lack of incentives, recognition, or appreciations of volunteers. Leadership and coordination As mentioned previously (see “Stakeholder engagement and partnership”), the MOH held regular JSC meetings with RHBs, agencies, donors, and developing partners to track program performance, work out technical and operational issues, and coordinate health sector’s multi-sectoral, multi-level activities. However, high turnover of leadership at all levels has affected the overall implementation, monitoring, and evaluation of the health sector plan. Also, introduction of new strategies without sufficient consideration of local contexts has sometimes delayed implementation. Delays were compounded by weak institutional capacities, low ownership and governance mechanisms, and suboptimal integration of vertical and horizontal components. Health services quality and equity To address the quality arm of the HSTP-I agenda, the National Quality Strategy (NQS) was developed. It focuses on ensuring reliable, excellent clinical care, protecting patients, staff, and attendants from harm, and improving the efficiency of the delivery of care, while increasing access, equity, and dignity of care for Ethiopians. NQS prioritized five major areas: RMNCH, nutrition, communicable diseases, NCDs, clinical services, and surgical services. Accordingly, a number of service and/or program specific quality improvement initiatives were developed and implemented. However, a range of problems undermined implementation, including lack of coordination at national and subnational level, weak accountability mechanisms, sub-optimal quality measurement data and tools, weak information use culture, shortage of a wide range of service inputs (including finance, competent and compassionate workforce, medical supplies and public health infrastructure). Community preference for higher-level care (secondary and tertiary) and lack of integration across service components along the continuum of care (such as poor referral and follow-ups services) contribute to the challenges. Despite intensive ongoing to address the equity gaps, disparities remain in delivery and coverage of high-quality health services, persisting across domains of geography, age, gender, and disability. These disparities, in turn, contribute to inequities in use of health services, health outcomes, and population-level impacts. Public Health Emergencies Management The health impacts of recent global infectious disease outbreaks and other disasters highlights the importance of strengthening public health systems to protect communities from naturally occurring and human-caused threats. Ethiopia has built a public health management system at national and subnational levels to coordinate and strengthen all efforts to improve the preparedness of the health sector, and to prevent or reduce the public health consequences of outbreaks of diseases. Core capacities to prevent, detect, respond to, and mitigate public health emergencies have improved. The country has responded to the COVID-19 pandemic in a coordinated and organized manner using the “whole of government” approach. The health sector has played remarkable and commendable role in the overall preparedness and response to the COVID-19 pandemic. Despite these successes, a number of challenges to health security persist, as detailed in section 3.2.4. Continuing weaknesses in systems for emergency operations, care, prevention, and financing, combined with the emergence of new and emerging infections such as COVID-19 and conflicts leading to many internally displaced persons (IDPs), still stand in the way of building a resilient health system. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 39 Chapter 4 HEALTH SECTOR TRANSFORMATION PLAN II: OBJECTIVES, TARGETS, AND STRATEGIC DIRECTIONS 40 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

4.1 VISION To see a healthy, productive and prosperous society.

4.2 MISSION To promote the health and well-being of the society through providing and regulating a comprehensive package of health services of the highest possible quality in an equitable manner.

4.3 VALUES § Community first § Integrity, loyalty, honesty § Transparency, accountability, and confidentiality § Impartiality § Respect for law § Being a role model § Collaboration § Professionalism § Change/innovation § Compassion

4.4 OBJECTIVES HSTP-II’s objectives are operationally defined as high-level result statements, equivalent to goals that lead to achievement of the vision for the sector. The targets described in section 4.5 will be used to measure achievements under these objectives. The overarching objective of HSTP-II is to improve the health status of the population by realizing these four objectives: 1. Accelerate progress towards universal health coverage 2. Protect people from health emergencies 3. Woreda transformation 4. Improve health system responsiveness Improving health status of the population ( Accelerate progress Improve towards universal Protect people from Woreda health system health coverage health emergencies transformation responsiveness HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 41 Improve health status of the population This overall objective entails strengthening the health system to ensure that people live longer, healthier lives by reducing the causes of premature deaths, including maternal and childhood health conditions, unhealthy lifestyles, and accidents; expanding access to high-quality health care for all; and ameliorating the effects of social determinants of health. It focuses on enabling all people to have a long life and a good quality of life. In addition, the objective embraces the inclusion of all segments of the population, irrespective of gender, age groups, places of residence, geographical areas, level of economic status, education, or other equity dimensions. It aspires to the goal of never leaving anyone behind. The four pillars for improving the population health status are described as follows. 1. Accelerate progress towards universal health coverage This objective focuses on accelerating the progress towards full coverage of essential health services and protecting people from financial hardship, including those in currently underserved populations. Building upon the long-term achievements of the health sector and aligning with SDG3, HSTP-II aspires to attain UHC through increasing effective coverage of essential health services by 2030. This objective ensures the achievement of the following three components of UHC to all population subgroups: § Essential service availability: The Government of Ethiopia revised its essential health service packages (EHSP) in 2019. HSTP-II intends to ensure that all components of care and all essential interventions are available at each service delivery level, mainly at the primary health care level, with an acceptable level of quality. § Essential service coverage: HSTP-II intends to ensure that all individuals and communities receive the services they need. Effective coverage combines three essential components of health care interventions: need, utilization, and quality. § Financial risk protection: This is a key component of UHC, which is defined as access to all needed quality health services without being exposed to financial hardship. HSTP-II intends to ensure that the EHSP service components are accessible, and that they are used by community members without causing financial hardship to service users. 2. Protect people from health emergencies This objective refers to improving health security by protecting the public from the impact of public and medical (routine) health emergencies caused by human-made and natural disasters, conflicts, recurrent and unexpected disease outbreaks and epidemics, accidents, emergencies due to infectious or non-infectious causes, and new health threats. It also includes safeguarding the public from cross-border health problems and ensuring the health security of the population. Essentially, this objective refers to increasing health system resilience. Public health emergency services mainly focus on preparedness, prevention, detection, management, and recovery from all public health emergencies. Medical emergencies include any medical problems that could cause death or permanent injury if not treated quickly. These emergencies can arise due to infectious or non-infectious disease conditions, or due to trauma, that requires stabilization and immediate medical care. Preparing for such emergencies entails establishing and implementing emergency, trauma, and intensive care medical services. Protecting the public from both public health and medical emergencies requires the capacity and resources to ensure preparedness, prevention, early detection, and response. It also entails post-emergency assessment, interventions, and documentation of lessons from the emergency events. 3. Woreda transformation Woreda Transformation has a threefold meaning in the HSTP-II. The first one is it is an aspiration to see a transformed Ethiopia at each Woreda. Woreda is a structural unit which is better positioned for programmatically manageable and politically accountable programing to implement socioeconomic strategies closer to the community mainly with enhanced engagement of individuals and communities. Secondly, woreda transformation is a pathway towards development by using households as building blocks of nations. Hence, it promotes transforming all households from the level they are now to the next socially acceptable level in a manner that does not slide back. This sets 42 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Ethiopia to prosper making all forms of poverty to be part of history. Third, woreda transformation is a means to cascade SDG to sub national level so that no one is left behind by tailoring/customizing national programs to local context and creating ample space for local wisdom and ownership. The need for woreda transformation, in all sectors, is timely as the socioeconomic challenges are troubling almost all households in one way or another. The low access, utilization, quality and efficiency of social services, limited economic opportunity including high unemployment and the equity gaps observed in the country is increasing. Furthermore, the need to convert youth bulge to demographic dividend and the demand for rights are mounting. The lack of reliable information to inform strategic decision aggravates the situations above souring the pains for majority of citizens in need of socioeconomic opportunities fairly. Therefore, there is intense pressure on government in particular and the entire communities in general to take bolder moves to come out of such multitude of challenges stronger. Such moves require the aspiration, the path way and means of cascading our global commitments into action that can be felt by households. Woreda transformation could be one answer if implemented in a concerted manner. It will also make the changes sustainable as the actions are deliberated locally in culturally sensitive and scientifically sound manner, thereby empowering communities to own & lead their development in collaboration with all actors with mutual interest. Health related challenges are among the challenges faced by households as described above. Health is both a means and product of development requiring/demanding a central position for holistic development. It is a measure of social justice as well as a driver for better economic opportunities as a nation and individual citizens. Hence, health agenda is beyond the agenda of health sector. Cognizant of the potential of Woreda transformation, this health sector’s plan is developed making woreda transformation as an objective of HSTP-II. The sector, through its PHC approach, will consider the role of individuals, families and communities in promoting health and wellbeing. Households are considered as the center of gravity to address the challenges of families and tap potentials of the community for inclusive and sustainable development. Therefore, transformed households highly contribute to the nation’s growth and development efforts of ending poverty and hunger and promote health & wellbeing. Transforming households in a given Woreda results in a transformed Woreda, where the environmental, social, economic and other dimensions of development are improved. Such holistic development approach that focuses on household impact will result in better health and well-being by addressing the social determinants of health. Transforming Woredas require community participation, engagement, empowerment and ownership. It also requires a multi-sectoral collaborative effort, another element of PHC approach, to address development issues and social determinants of health. The health sector will contribute towards a multi-sectoral Woreda transformation. The following four pillars may guide how implementation of multisectoral collaboration result in inclusive development including in health of people: § Principle: It is expected that all government sectors buy into the principle of “Households are center of transformation” and accept that woreda priority supersede sectoral interest. This will ease running the principle of one plan, one budget and one M&E framework in woredas. § Packaging: Packaging of interventions into community, service centers and woreda leadership will streamline resources, administration and monitoring for efficiency and synergy. § Partnership: coordinated planning, actions and monitoring of public sectors along the administrative layers focusing on woreda transformation will bring better community mobilization, CSO engagement and enhance private sector role in changing woredas and their households for better in all walks of life. § Performance measure: The measurement of this objective will be based on two dimensions: Multi-Sectoral Woreda Transformation and sector-specific Woreda transformation. Multi sectoral Woreda Transformation (MSWT): Multisectoral woreda transformation is a means to ensure inclusive growth. This focuses on holistic development at the community level, which can be addressed by integrated multi sectoral interventions. The health sector will contribute towards such multi-sectoral development. It will be measured using MSWT performance measures, which will be based on indicators in the following key areas of development: § Livelihood related indicators (food security, income level of households and other economic measurements) HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 43 § Lifestyle indicators (Including household physical condition, household utilities (such as water, latrine, energy…), use of technologies (access to information etc…) § Literacy indicators (adult literacy, girls’ education and other education indicators) § Life expectancy and related indicators (Health impact indicators) Sector-specific Woreda Transformation: The health sector will work in close collaboration with relevant sectors and contribute towards holistic MSWT. The health-sector specific Woreda transformation mainly focuses on strengthening and transforming district health systems through improving key health system investments and implementing high-impact health interventions mainly at household and primary health care levels. It will focus on creating model households, model kebeles and high performing primary health units (PHCUs) through a meaningful community engagement and a transformed Woreda leadership. It also focus on implementation of Woreda management standards, reforms and implementation of health-financing strategies to reduce financial risks to the community. The health-specific Woreda transformation will be measured on indicators that includes the following key attributes: § Creation of model households and model kebeles § Creation of high performing primary health care units (PHCUs) § Implementation and high coverage of health insurance mechanisms such as CBHI § Creation of a resilient Woreda management § Enhanced community participation and engagement in health 4. Improve health system responsiveness Health system responsiveness refers to the level to which health services respond to the needs and expectations of targeted individuals and communities. This objective focused on respecting and responding to preferences and values of individuals and communities during health service provision, ensuring that beneficiaries’ values dictate health service delivery processes. Responsiveness focuses not on the system responds to health needs—which shows up in health outcomes—but on how the system performs relative to non-health aspects, meeting or not meeting clients’ expectations of how they should be treated by providers of prevention, care, or other services. Health system responsiveness includes respecting dignity, privacy, non-discrimination, autonomy, confidentiality, and clear communication; and includes a focus on users focus: choice of provider, short wait times, respect for clients’ voice and values, affordability, and ease of use. Achieving this objective will improve clients’ and communities’ satisfaction and trust, which will in turn improve service uptake and recommendation of services to others.

4.5 TARGETS HSTP-II targets are set by considering baseline, previous trends, burden of disease, national and international standards, efficacy of technologies, anticipated availability of resources, and other concerns, using the OneHealth tool and wider consultation with experts. The targets are set for the year 2017 EFY (2024/25). The performance of HSTP-II will be measured against these targets: General 1. Increased life expectancy at birth from 65.5 to 68 2. Increased UHC index from 0.43 to 0.58 3. Increased proportion of clients satisfied during their last health care visit (Client satisfaction rate) from 46% to 75% Reproductive, maternal, neonatal, child, adolescent and youth health and nutrition 4. Decrease the maternal mortality rate (MMR) from 401 per 100,000 live births to 279 5. Decrease under-5 mortality from 59 per 1,000 live births to 44 per 1,000 live births 44 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 6. Decrease infant mortality from 47 per 1,000 live births to 36 per 1,000 live births 7. Decrease neonatal mortality from 33 per 1,000 live births to 21 per 1,000 live births 8. Increase CPR from 41% to 50% 9. Increase proportion of pregnant women with four or more ANC visits from 43% to 81% 10. Increase deliveries attended by skilled health personnel from 50% to 76% 11. Increase Cesarean Section Rate from 4% to 8% 12. Decrease still birth rate (per 1,000) from 15 to 14 13. Increase Proportion of newborns with neonatal sepsis/Very Sever Disease (VSD) who received treatment from 30% to 45% 14. Increase coverage of early postnatal care (PNC) within 2 days from 34% to 76% 15. Increase proportion of asphyxiated newborns resuscitated and surviving from 11% to 50% 16. Increase proportion of under five children with pneumonia who received antibiotics from 48% to 69% 17. Increase proportion of under five children with diarrhea who were treated with ORS and Zinc from 44% to 67% 18. Increase pentavalent 3 coverage from 61% to 85% 19. Increase second dose of measles containing vaccine (MCV2) measles coverage from 50% to 80% 20. Increase full vaccination coverage from 44% to 75% 21. Reduce mother to child transmission rate of HIV from 13.4% to less than 5% 22. Decrease teenage pregnancy rate from 12.5% to 7% 23. Decrease stunting prevalence in children aged less than 5 years from 37% to 25% 24. Decrease wasting prevalence in children aged less than 5 years from 7% to 5% Disease prevention and control 25. Increase proportion of PLHIV who know their HIV status from 79% to 95% 26. Increase percentage of PLHIV who know their status and receives ART (ART coverage from those who know their status) from 90% to 95% 27. Increase percentage of people receiving antiretroviral therapy with viral suppression from 91% to 95% 28. Increase TB detection rate from 71% to 81% 29. Increase TB treatment success rate from 95% to 96% 30. Increase number of DR TB cases detected from 720 to 1,365 31. Reduce grade II disability among new cases of leprosy from 15% to 5% 32. Reduce malaria mortality rate from 0.3/100,000 population at risk to 0.2 33. Reduce incidence of malaria from 28 per 1,000 population at risk to 8 per 1,000 34. Reduce risk of premature mortality from Major Non-Communicable Diseases from 18% to 14% 35. Increase the proportion of women 30-49 years screened for cervical cancer from 5% to 40% 36. Decrease mortality rate from all types of injuries (per 100,000 population) from 79 to 67 37. Increase proportion of hypertensive adults diagnosed and know their status from 40% to 60% 38. Increase proportion of hypertensive adults whose blood pressure is controlled from 26% to 60% 39. Increase proportion of DM patients whose blood sugar level is controlled from 24% to 60% 40. Increase treatment coverage of severe mental health disorders (Depression from 5% to 30%; Substance Use Disorders (SUD) from 1% to 20%) 41. Increase cataract Surgical Rate (Per 1,000,000 population) from 720 to 1500 42. Increase proportion of Trachoma endemic Woredas with Trachomatous Inflammation Follicular (T.F) to < 5% among 1 to 9 years old children from 26% to 77% Health extension program 43. Increase proportion of Model households from 18% to 50% 44. Increase proportion of health centers and primary hospitals providing emergency surgical care from 1.3% to 19% 45. Increase proportion of high performing Primary Health Care Units (PHCUs) from 5% to 35% 46. Increase proportion of health posts providing comprehensive health services from 0 to 12% HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 45 Hygiene and environmental health 47. Proportion of households having basic sanitation facilities from 20% to 60% 48. Increase proportion of kebeles declared open defecation-free (ODF) from 40% to 80% 49. Increase proportion of households having  hand washing facilities at the premises  with soap and water from 8% to 58% Medical services 50. Increase outpatient attendance per capita from 1.0 to 1.75 51. Increase bed occupancy rate from 41.9% to 75% 52. Increase proportion of patients with positive experience of care from 33% to 54% 53. Decrease institutional mortality rate from 2.2% to 1.5% 54. Increase percentage of blood component production from total collection from 23.3% to 65% 55. Increase ambulance response rate to 90% Public health emergency management 56. Increase Health Security Index score from 0.63 to 0.78 57. Proportion of epidemics controlled within the standard of mortality from 80% to 100% Health system investments (financing, pharmaceuticals & supply, information, leadership, regulatory, human resources, and infrastructure) 58. Decrease out-of-pocket expenditure as a share of total health expenditure from 31% to 25% 59. Increase general government health expenditure (GGHE) as a share of general government expenditure (GGE) from 8.07% to 10% 60. Increase total health expenditure per capita (US$) from 33 to 42.2 61. Decrease incidence of catastrophic health spending from 2.1% to 1.8% 62. Increase proportion of eligible households enrolled in community-based health insurance from 49 % to 80% 63. Increase proportion of eligible civil servant/employees covered by social health insurance (SHI) from 0 to 100% 64. Increase availability of essential medicines at health facility level from 79.2% to 90% 65. Increase proportion of health facilities that meet data verification factor within 10% for selected indicators to 95% 66. Increase proportion of births notified (from total births) from 35% to 80% 67. Increase proportion of deaths notified (from total deaths) from 3.4% to 35% 68. Increase information use index from 52% to 85% 69. Proportion of primary health care facilities implementing Community Scorecard from 61% to 90% 70. Decrease the prevalence of unsafe and illegal food products in the market from 40% to 30% 71. Decrease percentage of substandard and falsified medicine in the market from 8.6% to 6% 72. Increase health workers density per 1,000 population from 1.0 to 2.3 73. Decrease Health care workers attrition rate from 6.2% to 4.5% 74. Increase proportion of health facilities (health centers and hospitals) with basic amenities (Improved water supply from 59% to 90%, electricity from 76% to 100%, improved latrine from 61% to 86%, basic health care waste-management services from 16% to 50%). 75. Increase number of new/improved technology (diagnostics, therapeutics, tools, or vaccines) transferred from 1 to 6 76. Increase proportion of health facilities implementing compulsory Ethiopian health facility standard from 53% to 80% 46 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

4.6 STRATEGIC DIRECTIONS The strategic plan for HSTP-II identifies 14 strategic directions that are detailed below. 1. Enhance provision of equitable and quality comprehensive health services 2. Improve health emergency and disaster risk management 3. Ensure community engagement and ownership 4. Improve access to pharmaceuticals and medical devices and their rational and proper use 5. Improve regulatory systems 6. Improve human resource development and management 7. Enhance informed decision making and innovations 8. Improve health financing 9. Strengthen governance and leadership 10. Improve health infrastructure 11. Enhance digital health technology 12. Improve traditional medicine 13. Ensure integration of health in all policies and strategies 14. Enhance private engagement in the heath sector Description and Major Initiatives of the Strategic Directions

4.6.1. Enhance Provision of Equitable, Quality Comprehensive Health Services Description This direction focuses on provision of health promotion, disease prevention, curative, rehabilitative, and palliative care services in an equitable manner and at the highest possible quality. These comprehensive services deal with the triple burden of diseases (disease, mental health, and injury), and are meant to meet the population’s ever-growing needs for health services, resulting in healthy and productive society. The strategy emphasizes not only reducing common communicable diseases, but also the alarmingly increasing rate of NCDs and injuries. Taking in to account the national PHC approach that views PHCs as a foundation of the health system, a full spectrum of services will be provided based on the recently revised EHSP, in an integrated manner across all level of health care delivery system. Increasing demand for and provision of the EHSP to the general population and vulnerable groups is the critical step in ensuring Ethiopia’s progress towards UHC. Decentralization of more essential health services to the comprehensive health posts, and integration of HEP packages to all primary-level health facilities, will play critical role in this regard. Health services provision will consider the following key interventions/activities: Demand creation (through behaviour change communication, or BCC, advocacy, social mobilization), provision of services through different modalities (static, outreach, mobile…), uninterrupted supply of essential commodities, referral linkage, and service integration when appropriate, which can apply for most programs stated below.

4.6.1.1. Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health-Nutrition These program areas encompass health services provided by organizing services in a continuum of care through the course of life cycle including adolescent health, preconception and pregnancy care, childbirth, child health, and nutrition services. The RMNCAYH-N package contains seven major program areas: 1) family planning and reproductive health, 2) maternal health, 3) prevention of maternal to child transmission of HIV, 4) neonatal and child health, 5) immunization, 6) adolescent and youth health, and 7) nutrition. The main strategies and major activities are described in each of the program areas below. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 47 Family Planning and Reproductive Health Major strategic initiatives § Increase demand for quality contraceptive service through BCC and other demand creation interventions § Universal access to quality and comprehensive rights-based family planning information and services at all levels of health care delivery system, with emphasis to post-pregnancy family planning services § Expand family planning and sexual and reproductive health services to workplaces, private health facilities, people with special needs, universities and colleges, and in humanitarian settings § Improve access to screening and management for SRH and medical problems, such as cervical cancer, infertility, sexually transmitted infections (STIs) § Strengthen Prevention and management of GBV and child marriage § Expand access to quality comprehensive abortion care services Maternal, Neonatal, and Child Health Major strategic initiatives § Provide quality and equitable antenatal, labor, delivery, and postnatal care services, mainly through introduction of at least one ultrasound service for all pregnant women before 24 weeks of gestation, expansion of maternity waiting rooms, implementation of 24 hours stay after delivery and improving community engagement in making transport available § Improve access to comprehensive emergency maternal and newborn care through expansion of OR blocks, equipping and staffing of health facilities § Improve referral network for women and New-born babies during complications, in a way that can access comprehensive services in 30 minutes § Strengthen maternal and perinatal death surveillance and response system § Strengthen prevention and management of obstetric fistula and pelvic organ prolapse § Strengthen and expand advanced neonatal care, NICU and Essential New-born Care (ENBC) services § Strengthen & expansion of services for low birth weight and preterm babies including kangaroo mother care (KMC) § Strengthen PMTCT § Strengthen and expand contextualized integrated community case management of new-born & childhood illness and quality Integrated management of newborn and childhood illnesses services § Introduce and scale up early childhood development (ECD) implementation through a multi-sectoral collaboration approach Immunization Major strategic initiatives § Design and implement innovative strategies to build demand, community participation and BCC (Build trust, confidence, and resilient demand for immunization services) § Improve effective coverage of routine immunization to achieve Universal Immunization through data-driven and evidence based strategies such as implementation of intensified outreach strategies, Reach Every District/Child (RED/C) approach, vaccination of missed children during school entry, expansion of services (such as HPV) and others § Strengthen vaccine supply chain (planning, forecasting, quantification, CCE) in order to implement effective vaccine management strategies at all levels § Enhance and sustain the accelerated vaccine-preventable diseases (polio, measles, MNT) control, elimination and eradication initiatives § Introduce and rapidly scale up (achieve high coverage and geographic reach) new vaccines into the immunization program (HepB birth dose, Yellow Fever, Meningitis A, Measles and Rubella (MR) etc…) § Strengthen the second year of life (2YL) immunization service delivery 48 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY § Strengthen immunization integration with other Health services to ensure access and avoid Missed Opportunity for Vaccination (MOV) § Strengthen surveillance, detection, and communication for vaccine-preventable diseases and adverse events following immunization, to rapidly detect and respond to outbreaks, enhance immunization safety, improve management of outbreaks, and diminish incidence of adverse events Adolescent and Youth Health Major strategic initiatives § Expand provision of comprehensive sexual and reproductive health information, counseling, and services § Support and facilitate the introduction/adaptation, testing and scale up of high-impact, youth-focused, youth– friendly, and innovative interventions to improve effective and person-centered care § Expand provision of comprehensive, sexual and reproductive health information, counseling and services; and access to psycho-social support for adolescents § Promotion of healthy behavior among adolescents (nutrition, physical activity, no tobacco, alcohol, or substance use) § Implement interventions to prevent, detect, and manage sexual and other forms of gender-based violence and harmful practices such as child and forced marriage § Implement parenting skill enhancement program and expand access to life skill training for adolescents and youth § Strengthen the integration of adolescents and youth health with school health initiatives and programs Nutrition Major strategic initiatives: § Enhance food and nutrition information, communication, coordination, and dissemination § Scale up comprehensive integrated nutrition services(CINS) and First 1,000 Days initiative § Implement infant feeding programs in all facilities such as Baby-Friendly Hospital Initiative § Strengthen and scale up deworming and micro-nutrient supplementation (such as Vitamin A supplementation) to children, and women in need including pregnant and lactating women § Strengthen and expand nutritional screening of children, pregnant and lactating women, and HIV-positive individuals and management of moderate and severe malnutrition § Strengthen nutrition service delivery for communicable and non-communicable diseases § Expand and scale up lessons from the Seqota declaration in collaboration with other sectors to end child undernutrition § Strengthen multi-sectoral coordination linkage and nutrition coordination platform across food and nutrition policy implementing sectors

4.6.1.2. Prevention and Control of Communicable Diseases Description This strategic direction focuses on the prevention, control and management of major communicable diseases such as HIV, malaria, tuberculosis, leprosy, and hepatitis. The health system will focus on high-impact interventions aimed at reducing the burden of these communicable diseases, and on on health promotion and disease prevention; and will strengthen screening, diagnosis, and treatment of communicable diseases. HIV Major strategic initiatives § Intensify combination prevention interventions (structural, biomedical and behavioral) targeting key and priority populations and high incidence geographic localities § Scale up pre-exposure prophylaxis for population groups at substantive risk and experiencing high levels of HIV incidence and strengthen post-exposure prophylaxis HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 49 § Strengthen case finding through targeted HIV testing, especially for key and priority populations, using innovative approaches (such as index case testing, partner notification, social network services and HIV self-test) and expand the service to health posts and community level. § Implement Fast-Track Cities Initiative against HIV § Strengthen implementation of ART regimen optimization & rollout of third-line ART treatment § Expand and strengthen viral load testing services § Strengthen HIV prevention and control mainstreaming and social enablers that includes gender based violence prevention and mitigation, economic empowerment of women, elimination of stigma and discrimination, empowerment of communities to respond to the HIV program Hepatitis Major strategic initiatives § Initiate and expand hepatitis testing and treatment service at hospitals and health centers, and also scale up viral load testing § Strategize program implementation toward the elimination of viral Hepatitis by 2030 § Integrate viral hepatitis service into the existing HIV/SRH, TB, MNCH services, and create linkage between viral hepatitis services with blood safety and infection prevention activities Tuberculosis and Leprosy Major strategic initiatives § Enhance implementation of integrated, patient-centered TB prevention and care (shift from a TB control to Ending the TB epidemic mode) § Strengthen TB and leprosy case finding, contact tracing and screening services § Strengthen TB/DR-TB diagnostic services, including sample referral network and access to a more sensitive screening tools such as chest X-Ray and GeneXpert § Enhance provision of Community TB screening and treatment support services § Engage private facilities in TB diagnosis and treatment services § Strengthen and expand TB prevention therapy for HIV+ cases and household contacts § Strengthen and expand universal drug susceptibility testing services § Strengthen and expand drug-resistant TB treatment initiating and follow up sites § Strengthen and expand house-to-house screening, passive case finding and contact investigation of leprosy cases § Capacity building of clinical and laboratory diagnosis, treatment and disability prevention of Leprosy § Strengthen rehabilitation services for people with a major disability Malaria Major strategic initiatives § Strengthen malaria surveillance and epidemic response § Accelerate activities supporting sub-national malaria elimination § Strengthen malaria laboratory investigation through microscopic diagnosis and RDT § Strengthen vector control activities through community interventions, targeted indoor residual spraying, larviciding, and maintaining universal coverage of long-lasting insecticidal nets (LLINs) § Introduce long-acting anti-malaria drugs to prevent transmission of malaria among seasonal migrant workers § Identify and implement potential safe disposal mechanisms for obsolete/expired chemicals and LLIN plastic covers 50 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

4.6.1.3. Prevention and Control of Neglected Tropical Diseases Description This direction focuses on implementation of appropriate interventions to prevent and control neglected tropical diseases in Ethiopia, resulting in the elimination of many. It includes schistosomiasis, soil-transmitted helmenthiasis, onchocerciasis, podoconiasis, lymphatic filariasis, leishmaniasis, trachoma, scabies, and snakebite. Through service integration, multi-sectoral approach and large-scale treatment campaigns, also known as mass drug administration, will be strengthened and continued in HSTP-II. Priority interventions include preventive chemotherapy, transmission control, WASH, innovative case management, prevention of zoonotic diseases, and vector ecology management. In addition, service integration, multi-sectoral approaches and large-scale treatment campaigns or mass drug administration will be strengthened. Major strategic initiatives § Advocate multi-sector engagement and promote community awareness and mobilization for NTD prevention and control § Coordinate the implementation of WASH and NTD interventions at all levels § Strengthen integrated environmental management including vector control interventions § Clear TT surgery backlog cases and build sustainable institutional capacity § Strengthen integrated mass drug administration and implement innovative case management interventions for NTDs § Enhance veterinary public health interventions such as rabies vaccination for canines and rabies post-exposure prophylaxis § Sustain guinea worm disease surveillance and eradication interventions

4.6.1.4. Prevention and Control of Non-Communicable Diseases and Mental Health Description The priority NCD prevention and control interventions are targeted to the reduction of risk factors for the major non- communicable diseases and promotion of healthy life style. In addition, reduction of premature mortality from NCDs is one of the focus areas of this strategic direction. Priority will be given to prevention of NCDs and injuries, treatment of childhood cancer, early treatment of breast cancer, basic palliative care, treatment of acute pharyngitis in children to prevent rheumatic fever, and implementation of high-priority multi-sectoral interventions. Mental health is one of the top priorities in HSTP-II. Mental health promotion, prevention, and management of common mental health problems such as depression, bipolar disorder, and schizophrenia will be addressed through such interventions as advocacy, social mobilization, BCC, strengthening social support, capacity building, and expansion of access to medication, psychosocial interventions, and rehabilitation. Non-Communicable Diseases Major strategic initiatives § Facilitate the development and enforcement of comprehensive policies and legislations to address the rising burden of unhealthy diet and khat consumption § Establish a multi-sectoral coordination mechanism for prevention and control of NCDs and their risk factors § Implement awareness-raising programs on NCDs and risk factors for the general public, at workplaces and schools § Enforce the implementation of regulations on tobacco and alcohol § Promote institutionalization of interventions on the reduction of exposure to environmental and occupational risk factors for NCDs § Scale up programs for primordial, primary and secondary prevention of Rheumatic heart disease § Expand implementation of interventions on NCDs and risk factor to primary health care through task shifting, task sharing, and improved referral networks HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 51 § Support health facilities to fulfill minimum standards to deliver screening, diagnosis, treatment, and care services for NCDs and risk factors Mental Health Major strategic initiatives § Facilitate the development of mental health legislation to protect the rights of people with mental health conditions § Strengthen integration and coordination of mental health care implementation and scale up at each level of the health system § Conduct advocacy, social mobilization and SBC interventions to create public awareness on mental health and mental illnesses § Establish a National Institute of Mental Health § Introduce and strengthen promotion and preventive mental health services in schools, work places, health facilities, religious, and traditional treatment settings § Expand and strengthen prevention and rehabilitation interventions against substance use, suicide and self-harm § Ensure availability of mental health services to vulnerable groups or special populations § Expand access to rehabilitation services for substance abuse • Ensure a dependable and affordable supply of essential medicines and diagnostic technologies for mental health and access to psychosocial care at community level

4.6.1.5. Hygiene and Environmental Health Description This strategic element focuses on addressing environmental determinants of health and thereby promoting health, preventing diseases and other conditions, and improving the quality of health services. It encompasses implementation of multi-dimensional interventions to ensure adequate and safe sanitation; personal hygiene; water safety and quality; food hygiene and safety; indoor air quality; healthy living environment; occupational health safety; and liquid and solid waste management. It also includes contributing to building climate-resilient health system and WASH in institutions, including health care facilities, and during emergencies that require coordinated actions by various sectors. The interventions will take place at various levels and settings, including at household, community, health care facilities, and other institutions; and in rural, urban, and pastoral areas. Major strategic initiatives § End open defecation practice through tailored social and behavior change communication coupled with advocating the needed enabling environment § Ensure access to quality and affordable sanitation and hygiene products and services through sustainable market-based system § Design and promote wide range of inclusive and contextually tailored hygiene, sanitation and environmental health technology options § Improve availability and proper utilization of basic sanitation service at household and community level through intensive demand creation and tailored behavior change approaches § Improve proper solid and liquid waste management at household level through regular promotion and targeted social and behavior change communication § Improve household food hygiene and safety practice from farm to fork § Ensure safe drinking water through promotion of different household water treatment and safe storage options § Improve water source quality and safety through strong water quality monitoring and surveillance system § Ensure sustainable hand hygiene practice, face washing and oral hygiene practices through social and behavior change approaches § Strengthen Menstrual Hygiene practice through culturally tailored social and behavioral change communication coupled with increasing access to safe and affordable products 52 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY § Reduce indoor air pollution through promotion of safe, smokeless energy source options. § Ensure inclusive water, sanitation and hygiene services in all health facilities § Strengthen Infection prevention and control interventions in health facilities § Promote water, sanitation and hygiene services and practices in schools and workplaces § Improve occupational health and safety through regular promotion and monitoring § Promote environmental pollution prevention § Improve resilience of the health system towards climate change and reduce the health system’s contribution for climate change § Strengthen hygiene and environmental health institutional arrangement and implementation capacity § Strengthen multi sectorial integration and coordination for hygiene and Environmental Health interventions

4.6.1.6. Health Extension and Primary Health Care Description This program encompasses two platforms for delivering PHC services to accelerate progress towards UHC: the HEP, and service delivery at health centers. In this strategic period, the Health Extension Program (HEP) will continue to be an effective program for community participation and an effective service delivery platform to reach individuals, families, and communities with a comprehensive package of PHC services. The program will scale up implementation of the HEP optimization roadmap to address evolving community needs for quality health services and fully embrace emerging public health challenges. During the strategic period, creating model households, model kebeles and high functioning primary health care units will be given priority. Activities will be contextualized to fit urban, agrarian, and pastoralist settings through the development and implementation of detailed agrarian and pastoralist HEP implementation guides and an Urban Health Strategy. Guided by the HEP Optimization Roadmap, community quality improvement systems and health post level reforms will also be implemented in this strategic period. This program also focuses on improving PHCUs’ readiness to provide quality care to their catchment population. Therefore, activities will include enhancing PHC management capacity to provide support and oversight to both the clinical and community based activities; improving quality and expanding package of services; implementing reforms and collaborative learning platforms; expanding surgical services at the health centers; ensuring strong PHCU linkage, and strengthening multi-sectoral collaboration. Major strategic Initiatives § Develop HEP implementation strategies to guide the implementation of the HEP optimization roadmap § Test and scale up major features of the HEP optimization roadmap § Expand services provided through the HEP to meet UHC requirements and community needs § Devise and implement strategies to a more inclusive HEP service provision (such as women, men, children, and youth) § Redefine and standardize HEP service packages and restructure service delivery platforms § Implement reforms and standards to ensure quality health services at PHCU level § Enhance the implementation of collaborative platforms including the Ethiopian Primary Health Care Alliance for Quality, twinning partnerships, and catchment area mentoring § Strengthen and expand family health team approach in urban settings, and mobile health team approach for pastoralist and semi-pastoralist settings § Accelerate creation of model kebeles and high-performing primary health care units. § Improve the capacity of the woreda health system leadership § Develop and implement innovative SBCC interventions fitting the changing needs and contexts at community and facility levels § Increase access to health information and services at schools, youth centers, and other public institutions § Introduce emergency obstetric and surgical care services at selected health centers HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 53

4.6.1.7. Medical Services Description During HSTP-II, the sector aspires to create a medical system offering comprehensive medical services, including pre-facility care. These services receive support to provide safe, effective, efficient, equitably accessible, and internationally acceptable care by designing and implementing a range of strategic interventions. This strategic direction includes clinical services, emergency and critical care, quality of health services, blood transfusion services, laboratory, and diagnostic services. For clinical services the emphasis will continue to be on standardizing diagnostic treatment, curative, rehabilitation, and palliative services in health. Standardized, strengthened clinical care leadership, innovative financing in health facilities, improved surgical and anaesthesia care availability and accessibility, improved rehabilitative service accessibility and quality of care, medical tourism, and introduction and scale up of I-CARE will also be priority strategic areas. The emergency care system includes services that range from scene care to facility care with an appropriate referral and communication to maintain continuum of care. The system provides an integrated platform for delivering accessible, quality, time-sensitive health care services across the life course. Establishing and strengthening emergency, trauma, and intensive care medical services is essential for ensuring timely care for the acutely ill and injured. Besides meeting the everyday health needs of the population, a well-organized, prepared, and resilient emergency care system has the capacity to maintain essential acute care delivery throughout a mass event, limiting direct mortality, and avoiding secondary mortality altogether. During emergencies that require a public health response, links will be made with the national PHEM system to respond in a coordinated and integrated manner. Blood transfusion is a life-saving intervention that involves mobilization, recruitment and selection of blood donors, use of appropriate blood collection procedure, processing and testing of blood units and cold-chain maintained storage and transportation, issuing and transportation of safe blood units to health facilities. It also includes compatibility testing and administration to patients. To meet the ever-increasing demand for quality blood and blood products, the program will implement strengthening volunteer blood donation program, expanding blood banks across the country and consolidation of key blood transfusion service functions, strengthening coordination of blood transfusion service, strengthening quality management system to the level of accreditation, and appropriate use of blood and blood products in health facilities. Regarding laboratory service, the health sector will continue to improve access to quality laboratory service through laboratory capacity building, quality assurance programs, infrastructure development and maintenance and expansion of basic and advanced lab services at health facilities. Moreover, the program will implement a laboratory quality management system, a step-wise accreditation process, preventive and curative equipment maintenance, and a laboratory information system. Clinical Services Major strategic initiatives § Improve health service availability and readiness based on the EHSP § Implement specialty and subspecialty roadmap § Expand and improve accessibility of services such as high quality surgical and anesthesia care, ophthalmology service, basic dental service, dermatology service, basic mental care, and other specialty services § Expand tertiary medical care (specialty and sub-specialty programs) § Develop and implement national medical tourism strategic plan § Improve and standardize health facility Leadership and Governance and build clinical governance capacity § Implement Teaching Hospital Improvement Program § Implement health technology (telemedicine, telepathology, tele-radiology, robotic surgery, 3-D printing for prostatic supplies) § Strengthen home-based clinical care § Strengthen accessibility and quality of rehabilitative and palliative care, including pain management § Implement geriatric care service 54 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY § Intensify clinical auditing and mentorship § Establish and implement tissue and organ transplantation program § Develop and implement cancer registry Pre-Facility, Emergency, Trauma, and Critical Care Services Major strategic initiatives § Advocate for emergency care systems, trauma and critical care § Expand and strengthen community first aid response § Standardize and strengthen basic, advanced ambulance and prehospital services § Create surge capacity for responding to emergencies and building resilience at all level § Expand and strengthen basic and advanced critical care services, trauma, poisoning and burn care § Standardize liaison and referral system § Institutionalize continuous system design and quality improvement in the acute care continuum Blood Transfusion Services Major strategic initiatives § Strengthen centralized coordination of blood transfusion services and use of blood and blood products § Advocate and build awareness to increase total blood collection from voluntary non-remunerated blood donors § Strengthen blood donor recruitment and management, including post-donation counseling service § Strengthen quality-assured testing for transfusion-transmissible infections, blood grouping, compatibility testing, and component production and transport of blood § Promote the safe and appropriate use of blood and blood products at the clinical interface and strengthening hemo-vigilance program § Accredit national and regional blood banks with African Society of Blood Transfusion Services § Introduce newer blood transfusion technologies and products Laboratory and Other Diagnostic Services Major strategic initiatives § Strengthen the implementation of laboratory quality management system and stepwise laboratories quality improvement process towards accreditation to ISO 15189 or 17025 standards § Establish a national proficiency testing/EQA production center and expand as needed § Improve availability of national and regional lab infrastructures including bio-security and Biosafety Level Three capacity at the national level § Improve accessibility of essential diagnostic service and enhance specimen referral linkages and networks, including backup services § Improve and strengthen access and quality to pathology services § Improve and strengthen Imaging services including nuclear medicine § Standardize laboratories testing capacity at each tier of the health care delivery system § Introduce and expand auditable laboratory services in hospitals and beyond § Strengthen national capacity for the evaluation and validation of laboratory technology methods and reagents § Establish national genomics and bioinformatics center

4.6.1.8. Prevention and Containment of Anti-Microbial Resistance (AMR) Description Evidences have shown that Antimicrobial Resistance (AMR) is becoming a global health and development threat. AMR is found not only among pathogens that cause common bacterial infections, but also in diseases such as HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 55 TB, HIV, Malaria and fungal infections. AMR leads to prolonged illness, longer hospital stays, higher medical costs and increased mortality. It also threatens to undermine the effectiveness of health programs and reduce public confidence. AMR is becoming a public health threat to Ethiopia. According to the national AMR surveillance reports (2018 and 2019), drug resistance surveillance of anti TB and HIV drugs and other studies, resistance was found to be high among common micro-organism, mycobacteria and HIV. The major drivers are believed to be overuse and misuse of antimicrobials including irrational prescribing, dispensing, poor patient adherence and self-medication with antimicrobials. Ethiopia has developed and been implementing national strategy of AMR Prevention and Containment (2015-2020) in alignment with global action plan. Even though a national AMR surveillance plan is developed, and AMR Surveillance system is established, challenges remain. Only nine hospitals currently provide DST. Awareness is low and inappropriate use of drugs is common. This direction aims at strengthening actions to the prevention and containment of the spread of the ever-increasing AMR as a public health threat. During HSTP-II, the ministry will strengthen priority actions towards prevention of AMR by improving the availability of safe, effective and quality assured antimicrobials and promoting its effective use. The ministry will engage a wide range of actors such as the agriculture and food industry, the pharmaceutical industry, NGOs, CSOs, the private sector and other stakeholders to synergize efforts towards AMR prevention and containment. Major strategic initiatives § Improve awareness and understanding of antimicrobial resistance through effective communication, education and training. Strengthen AMR training in Continuous Professional Development and pre-service training § Strengthen knowledge and evidence through surveillance and research § Optimize the use of antimicrobials and ensure optimal prescribing, dispensing and use. § Improve access to quality antimicrobials and laboratory commodities and initiate DST in public and private hospitals § Strengthen leadership, ownership, and commitment for implementation of AMR prevention and containment activities at national, regional/city administration, and health facility level § Improve infection prevention and contain the spread of resistant microorganisms across human and animal communities and health care settings through individual and environmental sanitation, hygiene, and infection prevention measures

4.6.1.9. Quality in Health Care Description: High-quality health care a health system that: ensures universal health coverage built on quality of care; standardizes and implements evidence-based interventions that demonstrate continual improvement; ensures that all people with chronic conditions are able to minimize the condition’s impact on the quality of their lives; fosters a culture, system, and practices that reduce harm to patients, seeks a benchmark against similar systems that are delivering best performance; emphasizes continuous learning and knowledge management for improvement; and engages communities. Building on the gains made, and addressing major health care quality challenges, HSTP-II will focus on cultivating competent and companionate health care providers who offer service that are safe, evidence-based, timely, people- centered, and clearly communicated. Interventions will engage both clients and communities to optimize services and improve of care outcomes. Quality monitoring will focus on outcomes of care, community trust in services, and effective coverage and competency of care. Major strategic initiatives § Develop and implement national health care quality and patient safety strategy § Institutionalize a concept of health care quality and practice at all levels § Establish a National Health Care Quality Council § Standardize and strengthen health care quality structures and their functions 56 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY § Reform, redefine, and standardize scopes and functions of health facilities § Establish and strengthen collaborative, high-quality learning platforms § Decentralize and share/shift tasks to minimize facility crowding and to maximize efficient utilization of specialized service providers § Develop and implement a support package for public and private health facilities for accreditation § Establish quality improvement hubs § Strengthen regular quality of care measurement and improvement

4.6.1.10. Equity in Health Service Description Equity reduces disparities between geographic areas and groups with underlying social advantage/disadvantage (women, youth, children, the uneducated, the poor, and people with disabilities) in provision of quality health service. Achieving universal health coverage, access to essential health care services and affordable essential medicines and vaccines for all assumes the achievement of universal equity. This principle focuses on ensuring that all Ethiopians, no matter their geography, gender, age, wealth, education or disability status, are able attain the same high levels of health outcomes and access to essential services. Equitable accessibility to high-quality health services will lead to improvements in the health of the population, especially high-priority vulnerable groups, including mothers and new-borns, the elderly, and other vulnerable groups. HSTP-II is committed to working across the following dimensions of health equity in Ethiopia: § Access to and uptake of health care: Ethiopia will continue to scale up access to essential health care and ensure that all members of society have equal access to essential health services: for example, by reducing physical barriers, distance, price, and socio- cultural barriers. § Difference in health status (or outcomes) such as life expectancy, mortality, and nutritional status can occur not only due to differences in health service access and uptake, but also to a wider social, economic, and environmental determinant (the wider determinants of health), pointing to the critical importance of addressing the underlying structural determinants of health. Major strategic initiatives § Mainstream and institutionalize health care equity concept and practice across programs and strategies at all levels § Conduct continuous, regular health equity analysis and disseminate the findings for intervention and policy decisions § Implement alternative and contextualized health service delivery modalities (mobile, outreach) and community engagement platforms to better reach mobile, hard-to-reach and special need communities § Provide targeted technical and financial support to strengthen health planning, implementation, and health systems capacity to areas with the lowest capabilities § Explore financial modalities to target populations with the greatest health needs in low-performing areas and among the most vulnerable groups, and incentivize stronger performance § Enhance health workers retention and motivation mechanisms for geographic and climate hardship areas and mobile communities § Ensure high-quality health services tailored to address disparities in access based on socioeconomic, geographic, gender, demographic, and special needs

4.6.2. Improve Public Health Emergency and Disaster Management Description This strategic direction focuses on public health emergency and disaster management and includes all elements of this process: effective and timely anticipation, prevention, early detection, rapid response, control, recovery, and mitigation of any public health emergency crises with direct or indirect impacts on the health, social, economic, and political well-being of communities and society in general well-being. The range of threats to public health HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 57 faced by countries worldwide is broad and highly diverse and includes infectious disease outbreaks, food and water contamination, chemical and radiation contamination, natural and technological hazards, wars and other societal conflicts, and the health consequences of climate change. The health sector requires solid capacity, strong coordination, and relationships with other sectors to implement a spectrum of public health emergency risk management measures at the community, regional, national, and international levels. The HSTP-II period will focus on strengthening the capacity for preparedness, detection, prevention, response and recovery to all public health emergencies and disasters. An integrated approach to public health emergency management and clinical emergency care reduces the impact of public health emergencies. The result of this strategic direction is minimization of the occurrence and consequences of public health emergencies and disasters. Major strategic initiatives § Develop and implement public health emergency management strategy that will address public health threats and build a resilient health system § Strengthen health sector and public health emergency multi-sectoral coordination, collaboration, and partnership § Strengthen regular risk assessment, profiling (hazard, vulnerability, and capacity analysis), risk communication and early warning system § Strengthen and sustain the International Health Regulation core capacity through implementing and monitoring multi-sectoral National Action Plan for Health Security § Increase the capacity of woredas for emergency preparedness and management § Strengthen Emergency Operations Centers at national and subnational levels § Ensure the availability of adequate and trained surge capacity for PHE response(Disaster Medical Assistant Team (DMAT)/Emergency Medical Teams including Rapid Response Teams (RRTs) at all levels § Ensure continuity of essential health service during and after disasters § Improve the capacity to forecast, detection, prepared and respond to public health emergencies, and to learn and improve after emergency experiences, maintaining the course towards long-term goals § Build the capacities required to create a resilient health system to promptly respond, recovered and rehabilitate in the context of health emergencies § Ensure availability and functionality of adequate isolation, quarantine, and treatment centers at identified and designated point of entries § Ensure that adequate regulatory measures are in place at point of entries to prevent importation of communicable diseases § Mobilize the resources required to adequately fund emergency preparedness, emergency response operations, and recovery § Coordinate and strengthen implementation of diseases and health events that are targeted for elimination/ eradication

4.6.3. Enhance Community Engagement, Empowerment, and Ownership Description This strategic direction focuses on ensuring active participation and engagement of the community in planning, implementation, monitoring and evaluation of health and health related activities. It is about enabling communities to increase control over their lives through creating health literacy and decision power. Re-designing, testing, and implementing a package of alternative approaches tailored to address emerging challenges to the existing community engagement strategies will be a key milestone in this strategic period to advance community engagement and ownership and accelerate the progress towards UHC. The expected result of this direction is to achieve a community with improved health behaviour, health outcomes, and improved accountability. 58 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Major strategic initiatives § Design and implement multi-sectoral coordination approaches at all levels to create model households, keels, schools and communities. § Design and implement interventions to increase health literacy and health system literacy § Design, test, and scale up alternative community engagement options for the HEP and health service delivery and introduce innovative motivation mechanisms for community volunteers § Introduce new and strengthen existing social accountability mechanisms such as community scorecard , town hall meetings; and increase participation of the community in health facility governing boards to enhance accountability and transparency of the health system to the public § Evaluate, refine, and implement competency-based training for community-level structure representatives and model households § Introduce and implement “self-care” initiatives § Design and implement approaches to enhance community resource contribution § Apply human-centered design and other frameworks to foster social innovation in designing novel solutions tailored to prevailing people’s desires and local contexts § Use existing community potentials and indigenous resources such as associations, faith-based, and communi- ty-based organizations as platforms for engaging communities in health § Cultivate and incubate local community-led innovations for local health problems

4.6.4. Improve Access to Pharmaceuticals and Medical Devices and Their Rational and Proper Use Description This strategic direction focuses on strengthening the pharmaceutical supply chain, pharmacy services, and medical device management systems to ensure uninterrupted availability and accessibility of safe, effective, and affordable medicines and medical devices that are needed to address the health problems of the community and ensure that they are used rationally and properly. This strategic direction also addresses reduction of pharmaceutical wastage and strengthening of systematic and environmentally friendly disposal of expired and damaged pharmaceuticals and non-functional medical devices. The direction additionally includes development and implementation of strategies that strengthen local manufacturing of medicines and medical devices, and standardization of procedures for procurement and management of medical devices. Major strategic initiatives § Strengthen Strategic Procurement System through the introduction of e-procurement, establishment of international and regional pooled procurement, and long-term fixed price procurement mechanisms § Develop medicine selection, pricing and reimbursement strategy § Establish Central Order Management System § Develop and implement demand-based forecasting and supply planning § Establish market shaping strategies for pharmaceuticals and medical devices § Optimize good warehousing, inventory, fleet and distribution practice § Establish end-to-end data visibility for the supply management of medicines and medical devices such as implementation of track and trace system § Establish and implement track and trace system for medicines and medical devices across the supply chain § Strengthen medical device management system such as standardization of medical device, maintenance workshops, refurbishment centers , maintenance referral system and disposal § Implement reverse logistics at health facilities and pharmacy retail outlets that extends to households § Develop and implement strategies to reduce medicine wastage and to implement pharmaceuticals waste management and medical devices decommissioning § Strengthen capacity for local manufacturing of medicines and medical devices HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 59 § Establish National Medicine and Poison Information Center § Strengthen the prevention and containment of antimicrobial resistance § Strengthen implementation of auditable pharmaceutical transactions and services § Strengthen clinical pharmacy and drug information services § Revise the National Medicine Policy § Strengthen integration of modern and traditional medicine § Introduce audit-and-feedback and accountability system at all levels

4.6.5. Improve Regulatory Systems Description This strategic direction seeks to protect the public from health risks that arise from poor and substandard products and services. It focuses on ensuring the safety, quality, efficacy, and proper use of medicines; performance of medical devices; safety of food; quality of health and health-related services against standards; competence of health professionals; and regulation of tobacco and alcohol. It also includes the implementation of digital regulation systems to establish an effective, transparent, and accountable system that ensures adherence by all state and non-state actors to national health regulatory standards and legal frameworks. Engagement of all stakeholders such as industry, academia, communities and consumers will be a mainstay of this strategic direction. The Ministry engages professional associations in the process of licensing health professionals (such as developing exams, participating in the examination process) within this strategic period and aspires towards transferring this task afterwards. The MOH will work towards establishment of a semi-autonomous regulatory system for health facility regulation. Major strategic initiatives Regulation of Food, Medicines, Equipment, and Other Health Products § Build and maintain adequate quality control systems, infrastructures, and laboratories (including Min-laborato- ries at each entry and exit port) § Control food adulteration and develop a rapid alert system for health products § Strengthen registration capacity, introduce product- and risk-based auditing pre- and post-licensing inspection, improve post-shipment (consignment) and post-marketing surveillance, and enforce quality control tests of products § Strengthen pharmaco-vigilance and vaccine safety and improve interface with clinical surveillance § Establish a regulatory system for safety and quality of blood, blood products, human tissues, and organs § Establish Regulatory Center of Excellence to provide service, training, and research § Standardize, register, and regulate the safety and efficacy of traditional medicine and practice Regulation of Health Professionals and Health and Health-Related Facilities § Regulation of health professionals and traditional medicine practitioners (professional ethics and code of conduct) § Regulation of health and health-related facilities, both public and private (enforcing adherence to the Ethiopian health facility minimum standard) § Competency assessment of all graduates before joining the health workforce § Introduce and scale up clinical audits to ensure quality of practice in health facilities § Engage private health care facility associations in health regulatory system

4.6.6. Improve Human Resource Development and Management Description This direction entails human resources planning, development and management (training, capacity building, recruitment, deployment, performance management, and motivation) to ensure the presence of motivated, competent, compassionate and committed health professionals in adequate numbers and skill mix. It focuses on improving the 60 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY quality of pre-service training and continuous professional development, and will emphasize promotion of ethics and professionalism in pre-service education and in-service training programs. The human resource management aspect of this direction focuses on need-based training, recruitment, deployment, performance management, and motivation. It also includes leadership development, with attention to the involvement of women in leadership positions. Generally, this direction requires multi-faceted interventions, from recruiting students with the drive and motivation to be health professionals, to continuously engaging health science students to consider being a health professional and inspiring practicing health professionals to demonstrate commitment to their country and its people, and to care for their patients. Major strategic initiatives § Strengthen system of compassionate, competent, and motivated health workforce through quality pre-service education, improved retention and motivation mechanism, continuous professional development (CPD) integrated with professional re-licensing § Strengthen health facility-based education and training in the health system, and also make health facilities conducive to health science training § Enhance demand driven-health workforce forecasting, planning, and development § Establish health professionals council and engagement of health care workers § Integrate academic activities, service provision, and research functions at teaching hospitals § Redesign health workforce intake approaches through joint education-health planning and integration mechanisms § Develop and implement strategies to enhance health workforce safety § Shift HEW career levels to a level IV and above, and improve career structure of the health workforce in general § Ensure the distribution and availability of health workforce to health facilities with adequate number and appropriate professional and gender mix in an equitable manner § Establish National Health Workforce Accounts and national Health Workforce Observatory § Conduct provider competency assessment survey on a yearly basis § Empower women in the health work force by creating conducive environment at workplace, and ensuring their representation at all levels

4.6.7. Enhance Informed Decision-Making and Innovation Description This strategic direction focuses on generation of quality evidence, research, and innovations, building a culture of evidence-based decision-making, and developing and using technology (new and/or improved tools). It also promotes use of data from routine and non-routine data sources, including new research supported with appropriate information communication technology (ICT), and using an established HIS governance framework. The program aims at improving evidence generation and use from numerous sources, including census, civil registration, and vital statistics; as well as surveys, surveillance, routine information systems, researches, and monitoring and evaluation systems. It also focuses on continuously improving the availability and quality of data, building capacity in data use core competencies, bridging the gap between data users and data producers, strengthening organizational data demand and use platforms, documentation and communication of data demand and use successes, data access and sharing, security, and data warehousing. It also includes institutionalizing a knowledge management system. This strategic direction also addresses the process of ideation, evaluation, selection, development, and implementation of new or improved products, services, or programs to improve health outcomes. Health innovation identifies new or improved health policies, systems, products, and technologies, and services and delivery methods that improve people’s health and well-being. Major strategic initiatives § Improve the ownership and quality of health sector woreda-based planning § Strengthen and expand, as needed, all health management information system and surveillance systems § Improve quality of data through a national movement to prevent data falsification; implement comprehensive HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 61 data quality assurance and auditing; improve demand for quality data § Strengthen culture of information use at all levels (nurturing leadership role in championing information use, capacity building, accountability mechanism, advanced data analytics, data use forums/platforms) § Create structures and forums (Research Council) that identifies research needs, coordinates the process, and translates evidence to policy § Mainstream HIS training in all health professional training curricula § Establish and enhance knowledge management system at all levels § Strengthen biomedical research to develop and test diagnostics, therapeutics and vaccines § Strengthen birth and death notification for Civil Registration and Vital Statistics system and system for documenting cause of death § Strengthen health information system governance § Strengthen health biotechnology research and use of biotechnology products § Strengthen short term and long term medical research trainings § Establish system for technology transfer for production of vaccine and diagnostic materials § Design and expand innovation labs § Establish and strengthen a system for technology transfer for vaccines and diagnostics production § Strengthen biomedical research to develop and test diagnostics, therapeutics, and vaccines § Establish incubation centers for health innovations § Establish and strengthen Health Research Council

4.6.8. Improve Health Financing Description This strategic direction is about ensuring adequate and sustainable financing to realize Ethiopia’s progress towards “Universal Health Coverage through strengthening Primary Health Care” without financial hardship for citizens. This strategy requires mobilizing adequate and sustainable financial resources, pooling of resource and risk, purchasing, and paying for health services and improving health system efficiency. It will also include improving accountability and transparency in management and utilization of financial resources. This strategic direction will ensure a transition to more sustainable financing for health through gradual replacement of resources from external to domestic sources. This strategic direction can be realized through devising new implementation modalities and governance arrangements. The strategy will employ current local and global opportunities that take advantage of the dynamisms of the health sector to transform supply- and demand-side health financing mechanisms. Major strategic initiatives § Design and implement innovative resource mobilization, mainly for domestic resources, by revising user fees to reflect cost of care and advocating, through continuous dialogues and negotiation, to increase government allocation to health § Reform the role of MOH in health financing to improve mobilization and allocation of resources based on priorities of health programs § Implement mandatory health insurance, social health insurance system, review premiums based on actual cost of care (not user fees), tailor benefit packages and premiums, and establish higher-level pooling § Strengthen health facility revenue generation and effective utilization: recover full cost of services from either patients or an entity that pays on their behalf, establish pre-negotiated rate for all of user fee exempted services, introduce user fee to cover curative health services at HP level § Design and implement performance linked strategies to improve efficiency and effectiveness (performance-based financing and results-based financing) § Design and implement strategies for efficient utilization of existing resources and capacity by investing on high-impact, cost-effective interventions, strengthening different financial resource tracking systems and conducting regular financial audits 62 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

4.6.9. Enhance Leadership and Governance Description This direction is about ensuring an accountable, transparent leadership and governance system for effective implementation of strategies. It addresses public accountability on resource management and optimal health service provision; and includes designing and implementing sound regulation mechanisms, building effective teams, and institutionalizing appropriate implementation mechanisms and platforms. The components include transparency, accountability, responsiveness, effectiveness and efficiency, participatory, consensus building, equitable and inclusiveness, and adherence to the rule of law. Strategic initiatives incorporate the views of minorities, minimize corruption, and include the voices of the vulnerable in decision-making and implementation of decisions. Major strategic initiatives § Build leadership capacity through leadership incubation programs, CPD (such as leadership management governance) for leaders, and twinning § Mainstream gender in all health programs and operations, and empower women by ensuring their representation at all levels § Promote merit-based assignment of health facility leaders alongside gender equity goals § Redesign, reorganize, and implement institutional structures and management systems to embrace dynamism § Revitalize harmonization and alignment for health (one plan, one budget, and one report principles) § Standardize and institutionalize grievance handling and monitoring mechanisms at all levels § Strengthen partnership and coordination among public sectors, private for profit, CSOs, and NGOs § Design and implement legal frameworks (proclamation, regulations, directives and guidelines) § Implement incentive and accountability mechanisms in the health sector § Design and implement transparent resource allocation mechanism

4.6.10. Improve Health Infrastructure Description This strategic direction aims at improving access to health facilities that are well equipped and furnished, and ensures that existing and new health institutions meet minimum standards. It encompasses developing standard construction designs; building health institutions; and expanding, renovating, and maintaining health and health-related facilities. It also includes equipping, furnishing health institutions, providing utilities (such as water, electricity, sanitation facilities), and ICT infrastructure, and enforcing construction quality standards. Major strategic initiatives § Prepare design of health facilities that suits health service demand considering environmental, climate and geographic factors § Construction, expansion (such as operating room blocks in health centers), rehabilitation (of sub-standard health facilities), maintenance, and renovation of health and health-related facilities to meet national standards § Upgrade and/or construct health posts located in kebeles far from catchment health centers for provision of comprehensive PHC services § Establish medical equipment maintenance centers and strengthen their capacity and functionality § Introduce standard procedures for preventive maintenance of health and health-related facilities, equipment, and furniture § Accelerate the expansion of utilities (water, electricity, ICT infrastructure) for health institutions HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 63

4.6.11. Enhance Digital Health Technology Description Digital technologies provide concrete opportunities to tackle health system challenges, and thereby offer the potential to enhance the coverage and quality of health practices and services. This strategic direction includes four major components: 1) Digitization targeted to clients, 2) health workers, 3) health system managers, and 4) health data services. The range of uses for digital technologies in supporting health systems is wide, and these technologies continue to evolve. Digital health technologies and interventions should be linked to the broader digital health architecture. All digital health systems should be developed by applying interaction design methods to make them user-friendly. Major strategic initiatives § Keep the national eHealth architecture and interoperability framework up to date § Develop standards and guidelines for selection, development and use of digital health solutions § Strengthen digitization of routine and non-routine data collection, management, analysis and use § Develop digital solutions for health worker decision support on prioritized health services § Develop digital solutions to provide capacity building for health workers § Digitize digital health interventions for clients that improve client-provider interaction and increase health literacy § Digitize and implement individual-level data recording system § Strengthen ICT infrastructure at all levels of the health system § Establish data warehouse

4.6.12. Improve Traditional Medicine Description This strategic direction refers to the registration, licensing, research, production, use, and integration of traditional medicine and traditional medical practices. Traditional medicine and practices are directly or indirectly related to protection of societal health, equitable distribution of public health care services, the right to exercise a profession, intellectual property rights, biodiversity conservation, and protection and promotion of indigenous knowledge and culture. This direction promotes public health by ensuring the safety, efficacy, and quality of locally produced traditional medicines and standardizing and regulating the practices of traditional healers. Major strategic initiatives § Develop and implement an inclusive and integrated policy framework and legislation for traditional medicines and practices § Improve conservation and documentation of medicinal plants, traditional medicine knowledge, and practices § Promote intellectual property rights, registration of indigenous knowledge rights, and market authorization of traditional remedies § Promote research and development of traditional medicines, including clinical trials, and engage academia and research institutions § Create incentive package for large scale production of scientifically validated traditional medicines in industries § Establish incubation center for laboratory formulation of traditional medicines and increase laboratory scale formulation of scientifically validated traditional medicines § Build capacity of traditional healers, tertiary level researchers, and the workforce involved in the production and supply management of traditional medicines § Implement preparatory activities towards integration of traditional medicine into primary health care 64 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

4.6.13. Health in All Policies Description Health in All Policies (HIAP) is a systematic approach for considering the health implications of decisions of public policies across all sectors. It anticipates the synergistic effects of public policies, and prevents and mitigates harmful health effects ensuing from policies to advance population health. It advances the accountability of policymakers for health impacts through efficient, effective multi-sectoral actions; and emphasizes the need to be vigilant to prevent any unintended consequences of public policies on determinants of health, well-being, and the health system. By promoting healthy practices across all sectors, HIAP fosters inclusive, sustainable development and helps address the social determinants of health, reduce multi-sectoral risk factors, and promote health and well-being. Major Strategic Initiatives § Utilize Multi-sectoral Woreda Transformation platform to enhance planning, budgeting, execution, and monitoring and evaluation of multi-sectoral development interventions in pilot Woredas to bring about the four L’s (Livelihood, Lifestyle, Literacy and Longevity) § Advocate for the inclusion of health and health-related perspectives in all relevant sectorial policies and regulation § Advocate for allocation of sector-specific budget line for social determinants of health initiatives § Scan existing policies and strategies from all sectors and identify priority collaborative areas for multi-sectoral engagement § Conduct joint planning, monitoring, and evaluation of multi-sectoral actions, including evidence generation and use § Develop and a implement legal framework and implementation arrangement for effective implementation of multi-sectoral actions § Formulate lessons from existing multi-sectoral initiatives such as the One WASH program, Seqota Declaration, and multi-sectorial woreda transformation, and scale these up more broadly § Promote environmental impact assessment to mitigate health impacts of huge projects

4.6.14. Enhance Private-Sector Engagement in Health Description: This strategic direction is about a deliberate and systematic collaboration of government and the private sector to move national health priorities forward, beyond individual interventions and programs. It aims to improve the engagement of the private sector in improving access and quality of health services, and to increase their engagement in a comprehensive range of health-related activities, from service delivery to supply forecasting to management to health systems strengthening. This direction includes the engagement of both private for-profit and private nonprofit institutions. A sub-element of the engagement arrangement, partnership with the private sector, could strengthen health service delivery, improving the quality, quantity, and affordability of essential health inputs by facilitating local manufacturing of pharmaceuticals and medical devices. This partnership also increases production of skilled health human resources; mobilizes additional resources for the health sector; and contributes to meet the increase demand for access and utilization of health care. Major strategic initiatives § Review and revitalize the policy framework and strategies to enhance public-private engagement in health § Create an enabling environment for public-private partnerships (PPP) for health, including establishment of transparency, accountability, and responsiveness within the partnership modalities § Create an enabling environment for private sector to engage in health promotion, disease prevention, curative, rehabilitative, and palliative care § Engage the private sector in the development of competent health force, production, and distribution of medical products and supplies, planning, implementation and monitoring and evaluation of the health system § Strengthen mutual accountability system between government and private health sectors § Introduce PPP arrangement in selected areas of health services § Build a medical city in Addis Ababa HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 65

4.7 PRIORITIES /TRANSFORMATION AGENDAS OF HSTP-II From the 14 strategic directions, the health sector has identified the top key priorities or health sector transformation agendas based on the major challenges identified in the situational analysis. These are investment areas that form the foundation of our health system, and if successfully implemented, they will transform the health sector and enable it to provide competent care that results in better health for all. Accordingly, the following are the priorities/ focus areas of HSTP-II. This transformation agenda refers to ensuring delivery of quality health care (reliable, patient-centered and efficient) to all in need in an equitable and timely manner. It is about ensuring availability of the best care to all, so that the quality of care provided does not differ by any personal characteristics including age, gender, socioeconomic status or place of residence, or disability status. Improving quality of care requires broad solution space that addresses both the demand for quality of care by the community, and the care itself. Only a few methods have been used up to now to improve the demand side. People with high expectation Quality and equity demand quality of care and vice versa. Some of the interventions are described here, but more innovative approaches are needed. Facilities should also design accountability mechanisms to redress poor quality of care, and should be transparent to inform people about the level of care provided. In addition, HSTP-II will address the supply side by emphasizing quality of care. Activities will include regular monitoring of the state of equity at all levels of the health sector implementation of tailored interventions, such as redesigning mode of service delivery, incentive packages and others, to reinforce quality of care. The overall goal of the information revolution is to improve the capability of the health system to generate and use high-quality data for evidence-based decision-making and advance towards better health systems performance. The information revolution is not only about changing the techniques of data and information management; it is also about bringing fundamental cultural Information and attitudinal change regarding perceived value and practical use of information. HSTP-II, efforts will focus on three pillars of the Revolution information revolution: transforming a culture of high-quality data use; digitization of the health information system (HIS); and improving HIS governance. This priority area/transformation agenda refers to ensuring availability of an adequate number and mix of quality health workforce Motivated, that are Motivated, Competent and Compassionate (MCC) to provide quality health service. Creating motivated, competent and Competent and compassionate health workforce depends on several but inter-related factors. These include well-regulated, high-quality pre-service Compassionate education, in-service training, and CPD to build the required number of well-qualified professionals and managers; fair recruitment, (MCC) health selection, orientation, and placement; and creation of an enabling work environment with clear roles and responsibilities, equitable workforce remuneration packages, and performance support (supportive supervision and timely feedback) through strong human resources management policy and practices. Transformation in health financing is about reforming the financing and management system of the health system so as to mobilize sufficient, sustainable health finance and improve efficiency. High out-of-pocket expenditure, catastrophic expenditure, and inefficient allocation and utilization of resources are major challenges to achieving universal health care coverage. HSTP-II Health financing will address these finance-related barriers through these major interventions: proactively mobilizing adequate resources from domestic and international sources, reforming resource allocation & prioritization, optimizing the health insurance system, forming public-private partnership, reforming cost recovery mechanisms, implementing performance-based financing, and designing and implementing strategies for efficient use of resources and capacities. Transformation in leadership is about enhancing the leadership and governance system at all levels of the health system to drive attainment of the strategic objectives. Lack of clear accountability, transparency, shared vision, evidence-based decisions, regulation, and coordination are some of the leadership and governance challenges of the sector. Leadership is a crucial pillar of a health system and exerts direct influence on the performance of health systems. Translation of plans to results will require Leadership leadership at all levels of the health system functions well. HSTP-II will implement these major interventions to transform leadership: redesigning & restructuring the health system, institutionalizing accountability mechanisms, strengthening clinical governance, ensuring regulatory system autonomy, strengthening stakeholder engagement and partnership, building leadership capacity at all levels, and incorporating the Health in All Policies approach throughout the government. 66 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Chapter 5 COSTING AND FINANCING HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 67

5.1 COSTING Costing and financing of HSTP-II is computed using OneHealth Tool (OHT) (Figure 7). This tool is built on six health system building blocks, drawing upon the WHO health system framework that includes the health workforce, infrastructure, logistics and supply chain, health information system, health systems financing, and leadership and governance. OHT is a policy projection-modeling tool that allows users to create short- and medium-term plans for scaling up health services. It is used for health planning, costing and budgeting with a focus on integrating planning and financial space analysis. The tool is also organized into three components: health systems, health services delivery, and impact module. Fiscal HS4. HS5. HS6. Space Health Information Governance Financing Policies and Leadership National (HQ) Health Systems Health Services NCDs and Physiotherapy Child Health and Immunization Maternal, Newborn and RH Environmental Health Neglected Tropical Disease Emergency and Blood Safety Other Specializations 4. National Referral Health Promotion HIV and STI/RTI Nutrition Tuberculosis Malaria 3. County 2. Primary 1. Community HS1. HS2. HS3. Infrastructure Human Resources Logistics and Equipment Figure 7. OneHealth Tool Framework Where there are financial limitations, the tool facilitates a process of prioritization and/or scenarios with more realistic levels of ambition for developing the plan. The OneHealth tool uses a modular approach; the user can either decide to use only one module (e.g., Malaria or Human Resources) independently, and/or can make use of other modules in sequential order. Once the user selects which interventions s/he intends to focus, s/he then allocates these into different modules. Subsequently, the disease modules are defined. This flexible approach allows variation between the structures of vertical disease programs in countries OneHealth tool is based on Spectrum, which is a Windows-based system of integrated policy models. The integration builds on DemProj, which is used to create the population projections that support many of the calculations in the other components, such as FamPlan, the AIDS Impact Model, and the Lives Saved Tool. The assessment of costing and financial feasibility is integrated into the planning process. In addition to this investment are linked to results in terms of system outputs and predicted health outcomes and impacts. The cost estimate is based on: 1. The best accessed information on disease profiles 2. Official figures for base year population demographics 3. Assumptions that all available facilities are functioning 4. Assuming that the required staff is in place 5. National protocols and expert opinions are used for clinical practices 6. Expansion targets are set to meet the standards as based on population figures and other criteria 68 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

5.1.1. Assumptions: Base and High Scenario Targets were estimated using available baseline evidences from surveys such as EDHS, SARA; estimates and projections; researches; routine HMIS data, and expert opinion as a last option. Inputs for the tool were completed through iterative consultative workshops with program experts and relevant stakeholders. Lists of high-impact interventions in each program area were identified and prioritized prior to entry to the OneHealth tool for costing and target setting. Considering this, the tool generated cost and targets on two scenarios: base case scenario and high case scenario. Base case scenario considers existing interventions and similar investments to estimate targets and cost. The high case scenario additional investment such as expansion of infrastructure and increases high-impact intervention coverage to estimate impact level targets and cost. The base case scenario achieves the targets set in HSTP-II with a minimum cost and lower health outcomes, while the high-case scenario has relatively higher targets and better health outcomes (Table 2). Some of the major impact indicators based on the estimated cost are shown below. For example, in base case scenario, maternal mortality ratio (MMR) will decline from 401 to 279 and 220 per 100,000 live births in 2024, in base case and high case scenario, respectively.. To achieve MMR SDG target of 140 per 100,000 live births, we have to use the high case scenario, which requires increasing the coverage of high-impact interventions and mobilization of sufficient resources (Figure 8). Similarly, under 5-mortality rate will decline from 59 in 2019 to 44 and 36 per 1,000 live births in 2024 in base case and high case scenarios, respectively (Figure 9). MMR targets 2019 to 2024, base case and high case scenarios 450 401 400 350 300 279 250 220 200 150 100 50 0 2019 2020 2021 2022 2023 2024 Base Case Scenario High Case Scenario Figure 8. Maternal Mortality Ratio targets (per 100,000 live births): Base and high case scenarios Under-5 mortality rate target: Base Case and High case Scenarios 70 59 60 50 44 40 36 30 20 10 0 2019 2020 2021 2022 2023 2024 Base Case Scenario High Case Scenario Figure 9. Under-5 mortality rate targets (per 1,000 live births): Base case and high case scenarios HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 69 Table 2. Basic Assumptions of Costing for Base and High Case Scenarios Inputs and health Baseline Base Case High case outcome Targets for Life expectancy Increase from 65.5 years 68 years 69 years impact and MMR - Reduces from Reduce from 401 To 279 per 100,000 To 220 per100,000 LB outcome LB indicators Neonatal Mortality Reduce from 33 To 21 per 1,000 live To 15 per1,000 live births Reduces from births Infant mortality Reduce from 47 To 36 per 1,000 live To 30 per 1,000 live births births Under five mortality Reduce from 59 To 44 per 1,000 live To 36 per 1,000 live births births TFR Reduce from 4.6 3.23 3 CPR Increase from 41% 50% 54% Intervention/service Targets set to help achieve the health Relatively Smaller Higher than base case coverage status of the population Drivers Base Case High Case Supply Adjusted with the services planned for base case Increases for covering targets Inputs Infrastructure Infrastructure to population ratio § HP is 1:5,000 pop (rural) § HP (2nd Generation construction Reach to 1000 Reach to 12,121 and renovation) § HC is 1:20,000 pop (rural) and 1: Reach to 3884 Reach to 4889 40,000 pop (urban) § Primary Hospital is 1:100,000 pop Reach to 500 Reach to 1,275 (rural) § Gen Hospital is 1:1-1,500,000 pop Reach to 109 Maintain at 109 (total) § Specialized Hospital is 1:5,000,000 Remains at 15 Maintain at 15 pop (total)

5.1.2. HSTP-II Cost Estimates: Base and High Case scenarios The total cost estimation for the base and high case scenarios is $21.88 billion and $27.54 billion, respectively, for the next five years. The biggest cost difference between base and high case scenarios is observed in infrastructure and pharmaceutical supply.

5.1.2.1. Cost Estimation: Base case Scenario The total cost estimation for the base case scenarios is $21.88 billion for the next five years. Out of the total cost of the base scenario, 50% ($10.87 billion) is costed for procurement of medicine & medical equipment, 19 % ($4.26 Billion) for human resource development and management, 13% ($2.77 billion) for health infrastructure (construction, rehabilitation and maintenance of health facilities, equipment and furniture, ICT materials, vehicle), and 8% ($1.67 billion) for health service programme management cost which includes short-term trainings, supervision, advocacy, and other program-specific costs, in the base case scenario (Table 3, Figure 10). 70 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Table 3. HSTP-II Summary Cost - Base Case Scenario (USD in ‘000) Total Cost Area 2020/21 2021/22 2022/23 2023/24 2024/24 USD ‘000 Health Service (Program Management) 355,688 319,578 342,277 342,739 316,010 1,676,292 8% Medicines, commodities, and supplies 1,658,318 1,879,407 2,303,523 2,343,421 2,685,527 10,870,196 50% Human Resources 748,470 796,532 849,321 905,336 964,745 4,264,403 19% Health Infrastructure 553,592 554,608 553,843 555,165 554,583 2,771,791 13% Health Care Financing 40,461 18,098 44,652 21,418 22,453 147,082 1% Health Information Systems 222,095 232,320 238,862 238,333 234,306 1,165,916 5% Regulatory 63,219 66,246 71,610 74,907 77,487 353,470 2% Governance 113,724 110,191 125,294 138,542 149,634 637,385 3% Grand Total 3,755,568 3,976,979 4,529,383 4,619,860 5,004,745 21,886,536 100% 2% 3% Health Service 1% (Programme Management) 5% 7% Medicines, Commodities and Supplies 13% Human Resources Health Infrastructure 19% 50% Healthcare Financing Health Information System Figure 10. Percentage share of the various components of HSS to base case costing Out of the total cost allocated for program cost, which is $1.67 billion, the highest proportion (17%) is allocated for each Health Extension Program (HEP), (12.2%) for diagnostic management, 11.9% for immunization, and 8.7% quality of health services, and 7.8% for maternal, new-born, adolescent and reproductive health. The health system, as per the OneHealth tool, includes human resource, infrastructure, logistics supply management, health financing, HIS, research and technology, regulatory activities, and other governance-related activities. The total cost allocated for the health system is $20.21 billion. The highest proportion is for medicines, commodities supplies and logistics management (53.8%), followed by human resources (21.1%) and infrastructure (13.7%) (Table 4, Table 5). HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 71 Table 4. HSTP-II Cost - Base Case Scenario by program and health system building blocks (USD in ‘000) Program Area 2020/21 2021/22 2022/23 2023/24 2024/225 Total Health Service (Program Management) Maternal, Newborn, Adolescent and Reproductive 22,183 30,673 26,139 26,565 25,319 130,878 Health Child Health 1,261 891 738 499 396 3,785 Immunization 32,409 38,707 45,086 39,042 44,434 199,679 Nutrition 18,381 17,124 16,500 15,773 15,185 82,964 Hygiene and Environmental Health 15,087 14,788 14,733 14,542 14,504 73,654 HIV/AIDS 5,228 5,146 5,396 5,725 6,863 28,358 TB and Leprosy 17,879 15,925 16,568 17,522 17,291 85,184 Malaria 11,510 5,289 8,349 15,049 6,322 46,519 Non-communicable diseases 8,730 3,588 5,153 3,048 6,781 27,301 Mental, neurological, and substance use disorders 195 270 171 186 239 1,061 Neglected Tropical Diseases (NTD) 23,261 24,077 22,210 22,210 22,190 113,948 Clinical Services 13,196 13,161 12,936 13,157 12,677 65,127 Injury Prevention; Emergency and Critical Care 49,472 18,024 18,039 18,226 18,309 122,070 Diagnostic Services 33,948 38,037 40,255 43,703 48,278 204,221 Blood Safety 4,067 3,326 3,635 3,987 4,089 19,105 Health Extension Program (HEP) 64,960 57,690 65,526 64,135 32,806 285,117 Hepatitis 1,831 211 211 213 258 2,724 Quality of Health Services 25,018 25,116 32,325 30,822 32,295 145,576 Equity of Health Services 5,967 6,087 5,971 5,669 5,554 29,248 Gender 1,106 1,446 2,337 2,664 2,220 9,774 Total program costs (management) 355,688 319,578 342,277 342,739 316,010 1,676,292 Health Systems 0 0 0 0 0 0 Human Resources 748,470 796,532 849,321 905,336 964,745 4,264,403 Health Infrastructure 553,592 554,608 553,843 555,165 554,583 2,771,791 Medicines, commodities, supplies and Logistics 1,658,318 1,879,407 2,303,523 2,343,421 2,685,527 10,870,196 Management Health Financing 40,461 18,098 44,652 21,418 22,453 147,082 Health Information & Innovation 155,467 162,624 167,203 166,833 164,015 816,141 Health technology 66,629 69,696 71,658 71,500 70,292 349,775 Regulatory activities 63,219 66,246 71,610 74,907 77,487 353,470 Other Governance activities 113,724 110,191 125,294 138,542 149,634 637,385 Total Health Systems 3,399,880 3,657,401 4,187,106 4,277,122 4,688,735 20,210,244 Grand Total 3,755,568 3,976,979 4,529,383 4,619,860 5,004,745 21,886,536 72 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Table 5. HSTP-II Cost - Base Case Scenario by HSTP-II strategic Directions (USD in ‘000) Strategic Direction/Programs 2020/21 2021/22 2022/23 2023/24 2024/25 Total in % Enhance equitable and quality 1,962,274 2,153,853 2,605,838 2,646,575 2,958,474 12,327,013 56% comprehensive health service Improve health emergency and 19,028 20,660 22,429 24,349 25,923 112,389 1% disaster risk management Ensure community engagement and 90,713 84,385 94,551 104,700 115,837 490,187 2% ownership Strengthen pharmaceutical and medical equipment supply 51,732 45,133 39,962 39,585 43,063 219,475 1% management Improve regulatory systems 63,219 66,246 71,610 74,907 77,487 353,470 2% Improve human resource development 748,470 796,532 849,321 905,336 964,745 4,264,403 19% and management Enhance informed decision making 155,467 162,624 167,203 166,833 164,015 816,141 4% (information and Innovation ) Enhance health financing 40,461 18,098 44,652 21,418 22,453 147,082 1% Strengthen governance and leadership 1,106 1,446 2,337 2,664 2,220 9,774 0% Improve health infrastructure 553,592 554,608 553,843 555,165 554,583 2,771,791 13% Enhance digital health 66,629 69,696 71,658 71,500 70,292 349,775 2% Improve traditional medicine 996 1,281 2,069 2,364 1,957 8,667 0% Health in all policies and strategies 996 1,281 2,069 2,364 1,957 8,667 0% Enhance private engagement in the 885 1,138 1,839 2,101 1,740 7,702 0% sector Total 3,755,568 3,976,979 4,529,383 4,619,860 5,004,745 21,886,536 100% Regarding the share allocated for strategic directions, the highest cost allocation for the strategic direction “improve access to equitable and quality health services,” “improve human resource management,” and “improve health infrastructure” accounts for 56%, 19%, and 13% respectively (Table 5).

5.1.2.2. Cost Estimation: High case Scenario The total cost estimation for the high case scenarios is $27.55 billion for the next five years. As indicated in table 6 below, in the high case scenario, 45% of the total cost ($12.32 billion) is for procurement of medicines/commodities and supplies, 22% ($6.10 billion) for health infrastructure, 16% ($4.33 billion) for human resources development and 9% ($2.47 billion) for health services program management (Table 6, Figure 11). HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 73 Table 6. HSTP-II Summary Cost - High Case Scenario (USD in ‘000) Total Cost Area 2020/21 2021/22 2022/23 2023/24 2024/25 USD ‘000 Health Service (Program 481,149 498,404 504,227 498,064 493,455 2,475,300 9% Management) Medicines, commodities, supplies and logistics 1,740,683 2,094,279 2,609,319 2,731,768 3,147,656 12,323,705 45% management Human Resources 754,814 809,683 869,702 933,482 964,745 4,332,426 16% Health Infrastructure 1,197,576 1,304,019 1,230,803 1,236,197 1,131,502 6,100,095 22% Health Care Financing 40,461 18,098 44,652 21,418 22,453 147,082 1% Health Information and 222,095 232,320 238,862 238,333 234,306 1,165,916 4% innovations Regulatory 63,219 66,246 71,610 74,907 77,487 353,470 1% Governance 114,222 111,361 127,322 141,621 153,972 648,497 2% Grand Total 4614220 5134409 5696496 5875790 6225577 27546493 100% 1% 2% 1% Health Service (Programme Management) 4% Medicines, Commodities, Supplies 9% and logistic management Human Resources 22% Healthcare Infrastructure Healthcare Financing 45% Health Information and Innovation 16% Regulatory Governance Figure 11. Percentage share of the various components of HSS with a high case scenario costing From the total cost in high case scenario, program management cost accounts for 9% ($2.47 billion), and the other health system related cost accounts for 91% ($25.07 billion). From the program management cost, the highest proportion is costed for nutrition (22.3%) followed by diagnostic management (14%), and Health Extension Program (11.5%) . Regarding health system cost in high case scenario, the highest proportion is costed for Medicines, commodities, supplies and logistics management (49.2%) followed by infrastructure (24.3%) (Table 7). 74 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Table 7. HSTP-II Cost - High Case Scenario by program and health system building blocks (USD in ‘000) Program Area 2020/21 2021/22 2022/23 2023/24 2024/225 Total Maternal, Newborn, Adolescent and Reproductive 22,183 30,673 26,139 26,565 25,319 130,878 Health Child Health 1,261 891 738 499 396 3,785 Immunization 32,409 38,707 45,086 39,042 44,434 199,679 Nutrition 112,381 111,124 110,500 109,773 109,185 552,964 Hygiene and Environmental Health 15,087 14,788 14,733 14,542 14,504 73,654 HIV/AIDS 5,228 5,146 5,396 5,725 6,863 28,358 TB and Leprosy 17,879 15,925 16,568 17,522 17,291 85,184 Malaria 11,510 5,289 8,349 15,049 6,322 46,519 Non-communicable diseases 8,730 3,588 5,153 3,048 6,781 27,301 Mental, neurological, and substance use disorders 195 270 171 186 239 1,061 Neglected Tropical Diseases (NTD) 23,261 24,077 22,210 22,210 22,190 113,948 Clinical Services 13,196 13,161 12,936 13,157 12,677 65,127 Injury Prevention; Emergency and Critical Care 39,459 40,180 40,037 40,063 40,540 200,280 Diagnostic Services 56,096 64,459 68,786 71,409 84,801 345,552 Blood Safety 4,067 3,326 3,635 3,987 4,089 19,105 Health Extension Program (HEP) 64,960 57,690 65,526 64,135 32,806 285,117 Hepatitis 1,831 211 211 213 258 2,724 Quality of Health Services 44,344 61,364 49,745 42,604 56,986 255,043 Equity of Health Services 5,967 6,087 5,971 5,669 5,554 29,248 Gender 1,106 1,446 2,337 2,664 2,220 9,774 Total program costs 481,149 498,404 504,227 498,064 493,455 2,475,300 Health Systems 0 0 0 0 0 0 Human Resources 754,814 809,683 869,702 933,482 964,745 4,332,426 Health Infrastructure 1,197,576 1,304,019 1,230,803 1,236,197 1,131,502 6,100,095 Medicines, commodities, supplies and logistics 1,740,683 2,094,279 2,609,319 2,731,768 3,147,656 12,323,705 management Health Financing 40,461 18,098 44,652 21,418 22,453 147,082 Health Information & Innovation 155,467 162,624 167,203 166,833 164,015 816,141 Health technology 66,629 69,696 71,658 71,500 70,292 349,775 Regulatory activities 63,219 66,246 71,610 74,907 77,487 353,470 Other Governance activities 114,222 111,361 127,322 141,621 153,972 648,497 Total Health Systems 4,133,071 4,636,006 5,192,269 5,377,726 5,732,121 25,071,193 Grand Total 4,614,220 5,134,409 5,696,496 5,875,790 6,225,577 27,546,493 Regarding the share allocated for strategic directions in high case scenario, the highest cost allocation is for the strategic directions “improve access to equitable and quality health services,” “improve health infrastructure,” and “improve human resource management,” accounting for 52%, 22.1% and 15.9% respectively. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 75 Recurrent and Capital Cost: Base case and High Case Scenario The total recurrent cost in base case and high case scenarios is $20.45 billion and 422.9 billion, respectively. Regarding capital cost, the total in base case scenario is $1.39 billion and in the high case scenario$4.63 billion. In base case scenario, recurrent cost accounts for 93.6% and capital cost accounts for 6.4%. In High case scenario, recurrent cost accounts for 83.2% and capital cost accounts for 17.1% (Table 8). Table 8. Recurrent and Capital Cost: Base Case and High Case Scenarios (USD in ‘000) HSTP-II Estimated Cost in 000 USD (2020 -2024) YEAR Base case Scenario High case Scenario Recurrent Capital Total Recurrent Capital Total 2020/21 3,516,781 238,788 3,755,568 3,724,308 889,912 4,614,220 2021/22 3,687,167 289,813 3,976,979 4,082,522 1,051,887 5,134,409 2022/23 4,240,614 288,769 4,529,383 4,739,707 956,789 5,696,496 2023/24 4,330,602 289,258 4,619,860 4,944,157 931,633 5,875,790 2024/25 4,717,244 287,501 5,004,745 5,423,133 802,444 6,225,577 TOTAL 20,492,408 1,394,128 21,886,536 22,913,827 4,632,666 27,546,493 Cost by Service Delivery Levels: Base case and High Case Scenario The total cost is also estimated by service delivery levels in the two scenarios. Out of the total estimated cost, 58.8% ($12.86 billion) in base case and 59% ($16.26 billion) in high case is allocated for the PHCU (household/community level, Health Post, Health Center, and Primary Hospital level interventions). At secondary and tertiary level of care (general and specialized hospitals), the total estimated cost is $6.79 billion (31%) and $7.6 billion (27.6%) in base case and high case scenarios respectively. In addition, the remaining cost is allocated for national and sub-national level program support such as for trainings, workshops, and supportive supervision is estimated and described in Table 9 and Table 10. Table 9. HSTP Summary Cost by Service Delivery Levels of Base Case Scenario (USD in ‘000) Level 2020/21 2021/22 2022/23 2023/24 2024/25 Total 1 Primary Health Care Unit (PHCU)

1.1 Household / Community 172,892 198,609 309,037 288,101 332,020 1,300,659

1.2 Health Post 169,449 166,221 277,840 201,900 252,540 1,067,949

1.3 Health Center / Primary Hospital 1,642,394 1,867,408 2,112,484 2,296,530 2,575,954 10,494,771 PHCU total 1,984,735 2,232,237 2,699,361 2,786,531 3,160,515 12,863,379 1 Hospital (General & Specialized) 1,250,263 1,283,608 1,372,985 1,406,366 1,479,266 6,792,487 2 National program 561,624 530,162 556,499 555,754 532,197 2,736,235 Grand Total 3,755,568 3,976,979 4,529,383 4,619,860 5,004,745 21,886,536 76 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Table 9. HSTP-II Summary Cost by Service Delivery Levels of High Case (USD in ‘000) Level 2020/21 2021/22 2022/23 2023/24 2024/25 Total 1 Primary Health Care Unit (PHCU)

1.1 House Hold / Community 171,494 201,386 312,511 284,481 334,206 1,304,078

1.2 Health Post 373,175 564,627 694,630 620,756 676,757 2,929,945

1.3 Health Center / Primary Hospital 2,039,147 2,217,164 2,401,414 2,602,544 2,770,770 12,031,038 PHCU total 2,583,816 2,983,177 3,408,554 3,507,781 3,781,733 16,265,061 1 Hospital (General & Specialized) 1,331,742 1,417,883 1,538,076 1,617,407 1,696,892 7,601,999 National and sub national program 2 698,662 733,349 749,866 750,602 746,952 3,679,432 management Grand total 4,614,220 5,134,409 5,696,496 5,875,790 6,225,577 27,546,493 Per capita health expenditure: Base case and High Case Scenario The per capita public health spending is expected to increase from $33 to $45 in 2019 to $45.0 in 2024 in base case scenario. In high case scenario, the per capita public health spending is expected to increase from $33 in 2019 to $56 in 2024 (Figure 12). 120.0 56.0 53.5 54.0 100.0 49.3 45.4 80.0 60.0 42.5 42.4 45.0 36.9 38.2 40.0 20.0 0.0 2020 2021 2022 2023 2024 High Case Base Case Figure 12. Estimated Total Public Health Expenditure per capita (in USD): Base case and high case scenario

5.2 FINANCIAL SPACE AND COSTING ANALYSIS As Ethiopia has planned to move towards a lower middle-income country over the next five years, external financing is likely to decline. This is reflected in the five-year commitment projected by the development partners (SDG-PF). To maintain existing remarkable health achievements and improve poor performance areas, increasing public health expenditure is mandatory. Otherwise, if external assistance declines without the government’s alternative funding option, the country’s health care system will deteriorate. The available resource projections for HSTP-II look at opportunities to increase the fiscal space for health and to make it easier for the Ministry of Health’s budget negotiations to implement the Health Funding Strategy. A financial space analysis for HSTP-II (2020/21 – 2024/25) was conducted to estimate the available resource to obtain from various sources. In the analysis, international fiscal space analysis framework was adopted to the Ethiopian local context. Ethiopia’s local and international health financing commitments were taken into account for the projection. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 77 To attain UHC and quality of health care, Ethiopia requires strong fiscal commitment and efficiency in utilization of resources. In the seventh round NHA (2016/17), Ethiopia’s total health expenditure (recurrent and capital) was estimated at ETB 72 billion ($3.10 billion). In 2016/17, total health expenditure accounted for 4.2% of the country’s GDP, which is lower than the expected average of 5% for low-income countries, and well below the global average of 9.2% (WHO, 2016). A more intensive review of health financing in Ethiopia demonstrates that it faces critical difficulties. Due to a change in the funding landscape and substantial decline in foreign aid, the Ethiopian health sector, like that of other developing countries, has been heavily dependent on external sources. On the other hand, the government has shown a strong commitment to increasing public health spending and has coordinated the use of program-based strategies, such as pooled funding, to mitigate the effect of fragmented aid in the sector. Given the change in funding landscape and the decline of foreign aid to health, there is a need to understand fiscal space for health. The fiscal space analysis primarily focuses on domestic resources with specific attention to potential expansion from the improved use and performance of public resources.

5.2.1. The fiscal space for health analysis framework Building on the International Monetary Fund’s work and Heller’s initial definition, in 2010 the World Bank outlined a framework for assessing fiscal space for health from five potential sources: conducive macroeconomic conditions, reprioritization of health within the government budget, earmarked income and consumption taxes directed toward the health sector, better efficiency of existing health expenditure, and external aid. The use of this fiscal space for health assessment is to forecast the financial resource availability for HSTP-II: 2020/21 to 2024/25 implementation. Furthermore, the analysis helps to explore various options to create fiscal space for health using sensitivity analysis with three scenarios: low (base), medium, and high (best) variants. The analysis forecasts available financial resource for 10 years from 2020 to 2029 by considering the five potential sources of fiscal space creation. The analysis employs all standard assumptions including Low middle-income country average targets, Abuja and other well-known global targets for setting the cut-off points for defining the scenarios. The analysis results are presented in an interactive dashboard. Finally, the forecasted data is categorized as government, private, which includes OOP, insurance, and foreign assistance. The analysis has taken into account the following standard parameters to forecast available financial resources for HSTP-II. The standard parameters are further broken down as follows: Insurance as CBHI and SHI, and foreign assistance as health grants channelled through MOF (Channel I), Channelled through Ministry of Health (Channel II), and health grants channelled through non-government institutes (channel III).

5.2.2. Sources of Finance for Health Sector Macro-economic conditions The Ethiopia Plan and Development Commission in collaboration with Ministry of Finance has projected GDP for ten years from 2020/21 to 2029/30. Accordingly, as part of the Mid-Term Expenditure Framework, government expenditure for 10 years was also projected. However, those projections were completed before COVID-19 pandemic. In order to adjust the projections with the economic impact of COVID-19, the HSTP-II financing projection employed the Plan and Development Commission COVID-19 economic impact estimates. According to the commission, at moderate case, Ethiopia’s GDP growth declines by 2.6 percent due to COVID-19’s economic impact. General government health expenditure General government health expenditure (GGHE) as percent of general government expenditure (GGE) is estimated based on the Ethiopian government commitment towards health sector and the Abuja Declaration. The forecast applies three options to the proportion of GGHE as share of GGE. The low-case scenario suggests that GGHE has a total 8.1 percent share of GGE, while the medium scenario predicts that 10 percent of GGE is allocated to health. For the high-case scenario, MOH would like to achieve the 15% GGE Abuja Declaration for low- to middle-income counties in 10 years. So for HSTP-II, 12% of general government spending is estimated to be allocated to health by 2024/25, with an annual proportional growth rate. Table 10 summarizes the three scenarios projections in relation to the MTEF projection. 78 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Table 10. Summary of Three Scenario Projections in relation to the MTEF Projection (In Billion ETB) 2020/21 2021/22 2022/23 2023/24 2024/25 GGE (B ETB) 471,672.9 517,043.5 584,500.9 666,054.8 808,279.4 GGHE (8%) of GGE 40.63 46.87 54.16 62.70 72.70 GGHE (10%) of GGE 42.48 51.24 61.92 74.96 90.87 GGHE (12%) of GGE 44.06 55.12 69.08 86.73 109.05 Exchange 1USD =37 birr Out-of-pocket expenditure As the ultimate goal of health care financing strategy is to ensure equity by making quality health service to all regardless of individual financial status. OOP is estimated based on out-of-pocket expenditure as percent of the total health expenditure. It is known that OOP is managed by households or individuals, and therefore should not be considered as a budget available to the government or MOH, but would rather help to show the cost of HSTP-II with the full envelope of estimated available resources. The NATIONAL HEALTH ACCOUNT 2016/17 (NHA VII) report finds that the share of OOP spending in health financing has continued to decline, but not enough to protect households from catastrophic and impoverishing spending. Efforts to expand financial protection through the various programs (including CBHI and SHI) need to triple to increase health utilization and reduce OOP spending at the point of use. For financial resource prediction, the three OOP scenarios are designed on the basis of proposed strategic measures to minimize OOPs by enhanced prepayment mechanisms such as CBHI and SHI. The low case scenario suggests that the OOP share of overall health spending stands at 31%, whereas the medium case scenario at 27.8% and the high case at 24.90%. Earmarked domestic resource to health Countries adopt various types of earmarked domestic resources to health through innovative financing options. Some earmarked resources from sin taxes, such as tobacco, are approved and others are being explored in Ethiopia. However, for this available resource projection, only health financing through insurance is considered as earmarked domestic resource to health. Insurances (CBHI and SHI) as percent of Total Health Expenditure (THE) have taken in to consideration. Insurance’s contribution to health financing proportionally go with the level of reduction in OOP. The CBHI and SHI data and assumptions are derived from the Ethiopian Health Insurance Agency strategy. Pooling of health resources through health insurance is one component of health financing functions. Over the last few years, Ethiopia has seen remarkable achievement in CBHI enrolment and resource pooling. However, the 2016/17 NHA reported that about 1% of total heath expenditure was pooled into the government system through CBHI, while private employers and insurance companies contributed 3% of total health expenditure in 2016/17. The available resource projection considers the expansion of insurance for the three scenarios as 38% of HH (household) and 77% of woreda enrolment with no SHI (social health insurance) for the low case scenario (or base case—continuation of business as usual with limited government health investment), and 50% of HH and 77% of woreda enrolment with SHI for civil servants starting by 2024 as medium case scenario. The high case scenario is 80% enrolment for both HH and woreda, with an early start of SHI for civil servants in 2023. External funding for health as a share of total health expenditures External funding is further broken down into channel 1, channel 2, and channel 3. The channel breakdown while creating fiscal space for health is important for setting expectations appropriately and mobilize resources accordingly for the MOH. To estimate external resources, information regarding pledged grants were collected from development partners. Major developing partners have declared their five-year commitment to finance the health sector at minimum and maximum thresholds. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 79 In addition, for channel 3, historical data from the MOH resource tracking and mapping database were used. Due to the lack of full and timely financial details on channel 3, the financial prediction for this channel may not be wholly accurate. In response to the changing financing landscape, health financing in Ethiopia will rely increasingly on the government’s financing capacity. As the country’s health sector currently depends on external assistance, increasing domestic health spending is expected to absorb the projected reduction in this assistance. However, as a major increase in government health expenditure stems from economic growth, increased domestic health spending must be preceded by the projected growth of GDP from the Ministry of Finance and realization of the Commission’s Plan. Efficiency gain Fiscal space analysis for health is not necessarily the only mean of adding resources rather than using existing resources efficiently. For efficiency gain estimation, various options considered using the studies conducted so far on primary, secondary and tertiary health care level efficiency analyses. However, the savings from the efficiency assumptions totally depends on implementation of the action points and recommendations from efficiency studies; it may not be far from showing the theoretical possibilities only. The cost saving from estimated efficiency gains be seen as bridging the funding gap, as indicated in the section on recommendations for the funding gap.

5.2.3. Scenarios assumption Scenario modelling provides a range of options for estimating available health resources. Scenarios developed for HSTP-II describe low-, medium-, and high-range outcomes (Table 11). These possibilities rely on the estimation of GDP, but other possible fiscal space sources presume the expected health financing priorities of Ethiopia and the global funding landscape. The scenarios vary from “business as normal” (low) to high, which places the government in a stronger position to make government the major source of funding to health care. Added to this, the scenarios favor OOP spending reductions. The high-case scenario implies that more health resources are generated from domestic sources, with high insurance enrolment, leading to a lower share of OOP in total health expenditures, or THE. On the other hand, the low-case scenario, the “business as usual” projection, presumes no health reprioritization from government. The medium case scenario reflects the health financing targets of low-middle-income countries, along with the Ethiopia Health Care Financing Strategy 2017-2025 targets. Table 11. Financing Option Scenarios for HSTP-II Low Medium High 1) Government allocates 8% of its total 1) Government increases health expenditure 1) Government increases health expenditure expenditure to health ( maintaining from 8% to 10% of its total expenditure by from 8% to 12% of its total expenditure by the current share without budget 2024/25 2024/25 reprioritization to health) 2) External assistances keeps the current 35% of THE share. Assumes new and existing donors 2) External assistances declining from 35% to will increase their allocation to health sector 2) External assistance declines from 35% 25% of THE by 2024/25 3) OOP with significant decline from 31% to 25% to 20% of THE by 2024/25 3) OOP with moderate decline from 31% to of THE by 2020/24 3) OOP with minimal decline from 31% to 27% of THE by 2020/24 4) Insurance: 80% of HH and 80% of woreda 30% of THE by 2020/24 4) Insurance: 50% of HH and 77% of woreda enrolment; SHI start by 2023 only for civil 4) Insurance: 38% of HH and 77% of enrolment; SHI start by 2024 only for civil servants. woreda enrolment; NO SHI servants The Ethiopia Health Care Financing Strategy (HCFS) includes a number of innovative financing options that could potentially bridge the funding gap and ensure sustainable financing. The Council of Ministers is expected to approve the HCFS at the beginning of 2013 EC. The implementation of innovative financing schemes will be determined upon approval of the Health Care Financing Strategy and the socioeconomic condition of Ethiopia. Therefore, it is not possible quantify how the level of resources that can be mobilized through innovative financing options under HSTP-II. There is strong international evidence of the potential of innovative financing options for the mobilization of significant health resources, such as the airline levies, sin-taxes (tobacco is already approved in Ethiopia), extractive industries, airtime levies, private contributions (corporate social responsibility), a national health lottery, mobilization of more philanthropists, and public-private partnerships. 80 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

5.2.4. Financial space projection Total resource projection According to the three scenario assumptions, the total financial forecast shows an increasing pattern with an annual average amount of $3.74, $3.94 and $4.37 billion USD, respectively, for low, medium and high scenarios. The total available resource for the 2020/21 to 2024/25 five-year HSTP-II forecast is projected at $18.69, $19.70 and $21.87 (billions), respectively, for the three scenarios. The prediction of funding availability was intended to demonstrate the anticipated change in health financing to domestic, sustainable financing in Ethiopia. Government plays a vital role in domestic financing by reprioritizing health and promoting access to health. However, since health funding increases will largely on the country’s economic development, the prediction of the available resources goes along with the GDP growth estimate (Figure 13). Available Resource for HSTP-II Projections (in Billion USD) 6.00 5.70 4.93 4.82 5.00 4.29 4.33 In Billion USD 4.00 3.26 3.69 3.84 4.41 3.50 4.03 3.21 3.69 3.00 3.41 3.16 2.00 1.00 - 2020/21 2021/22 2022/23 2023/24 2024/25 Base Medium High Figure 13. Available resource projection The above figure shows that available resources significantly increase over time for all scenarios, reflecting an increasing GDP growth trend projection in Ethiopia. Source of finance For the three cases, the financial forecast considers various financial sources to health. The Government of Ethiopia’s commitment to moving to domestic, sustainable health care support is evident in these projections (summarized at the end of this section in Table 12). For the business as usual case, though the total THE projection remains low, the government’s share of health expenditure increases to offset the declining external assistance trend (Figure 14). The nominal increases of the government expenditure, without reprioritizing health, are derived from government budget projections in the Mid-Term Expenditure Framework or MTEF. For the business as usual case scenario, the GGHE as a share of GGE maintains it current share at 8%. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 81 Available resources for hstp-ii projections: source of finance base 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 2020/21 2021/22 2022/23 2023/24 2024/25 Government External Assistance OOP Insurance Figure 14. Source of finance: low case scenario The medium case scenario projection assumes that government reprioritize health and increases the GGHE as a share of GGE from 8% to 10% in five years. In this scenario, the government provides the lion’s share of total health expenditure by contributing about half of these expenditures by 2024/25. This scenario envisions a moderate decline in OOP as a result of increased CBHI coverage and the start of SHI at the fourth year of HSTP-II. Unlike in the low case scenario, external assistance is assumed to follow moderate declining trend, because the MOH, as part of the Health Care Financing Strategy, plans to mobilize more resources from both domestic and international sources in the coming years (Figure 15). Available Resource for HSTP-II Projections: Source of Finance medium 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2020/21 2021/22 2022/23 2023/24 2024/25 Government External Assistance OOP Insurance Figure 15. Source of finance: Medium case scenario In the high-case scenario, as in the medium-case scenario, government health reprioritization results in GGHE representing 12% of GGE by 2024/25. The external aid funding landscape could improve as a result of the COVID-19 pandemic. For this scenario, SHI is assumed to be launched at third year of HSTP-II, but only for civil servants. Figure 16 shows a significant increase on the share of insurance in total health expenditure from 1.2% to 3.7%. This is an indication of the importance of SHI for domestic resource mobilization; a significant reduction in OOP would not be possible without SHI, even with full enrollment of CBHI-targeted beneficiaries. 82 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Available Resource for HSTP-II Projections: Source of Finance medium 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2020/21 2021/22 2022/23 2023/24 2024/25 Government External Assistance OOP Insurance Figure 16. Source of finance: High Case Scenario Table 12. Available Resource Projection by Source (in Billion USD) Financing Government External Assistance OOP Insurance Option GC Base Medium High Base Medium High Base Medium High Base Medium High 2020/21 1.10 1.15 1.19 1.06 1.06 1.06 0.94 0.94 0.94 0.06 0.06 0.07 2021/22 1.27 1.38 1.49 1.06 1.06 1.15 1.02 0.99 0.97 0.06 0.06 0.08 2022/23 1.46 1.67 1.87 1.06 1.06 1.26 1.11 1.04 1.00 0.06 0.07 0.17 2023/24 1.69 2.03 2.34 1.06 1.06 1.37 1.21 1.09 1.03 0.06 0.15 0.18 2024/25 1.96 2.46 2.95 1.06 1.06 1.49 1.32 1.15 1.06 0.06 0.15 0.19 Total 7.49 8.69 9.84 5.31 5.31 6.33 5.61 5.21 5.00 0.28 0.49 0.70 Per capita expenditure Health expenditure per capita is one of the key indicators of whether health expenditure is aligned with population growth. Ethiopia’s per capita spending is far below that of low- to middle-income countries overall—although better health results have been recorded with lower health expenditure. Projected per capita spending from HSTP-II costing is much greater than the estimated per capita expenditure of HSTP-II available resource projection shown in Table 12. Table 13 shows that the per capita health spending for all scenarios ranges from $36.11 to $42.17 on average, while for HSTP-II cost estimates range from $42.30 to $53.24. For Ethiopia, as one dollar per capita represents about $100 million or more, a small change in per capita expenditure has a significant impact on the overall health resource estimation. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 83 Table 13. Per Capita Health Expenditure Based on Projected Available and Required Resources GC Base-available Medium-available High-available Base-required High-required 2020/21 31.67 32.21 32.72 37.68 46.29 2021/22 33.56 34.46 36.40 39.19 50.59 2022/23 35.77 37.18 41.55 43.85 55.15 2023/24 38.31 41.18 46.87 43.96 55.91 2024/25 41.23 45.10 53.31 46.83 58.25 Average 36.11 38.03 42.17 42.30 53.24

5.3 FINANCIAL GAP ANALYSIS The HSTP-II funding gap analysis is derived from the available resource projections under the business as usual or base case scenario. For this case, the assumptions are no significant policy changes in health financing. As a result, OOP payments remain high at 31% of THE on average. External finance shrinks to an average of 20%, and GHE remains relatively stable averaging 8% of THE. Figure 17 shows the projected available THE in the HSTP-II period. At base case scenario THE is projected to grow nominally. Business as usual THE Projections (Billion USD) Government External Assistance OOP Insurance GGHE as GGE THE as % of GDP 5.00 11.0% In Billion USD 4.00 9.0% 7.0% 3.00 5.0% 2.00 3.0% 1.00 1.0% - -1.0% 2020/21 2021/22 2022/23 2023/24 2024/25 Figure 17. Business as usual THE Projections According to the HSTP-II cost estimate, $21.89 billion and USD 27.55 billion at base and high case scenario respectively is required for the next five years, while the available financial resources for the HSTP-II years are projected at $18.69, $19.70 and $21.87 billion for low, medium, and high case scenarios, respectively. The funding gap is large, except for the high case scenario. The funding gap for HSTP-II between business as usual (base/low) available resource projection and required resources at base case is $3.2 billion, which is 14% of the HSTP-II budget. This gap is amplified for high case required resource with 8.86 billion USD which is 32%. The “Financing the Gap” section discuss potential financing options to fill this funding gap. Just to highlight, HSTPII required resources, while moving from business as usual (low) to medium and high case available resource projections, the funding gap substantially declines to 18.7% and 0.1%, respectively. 84 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Required vs Available Resources for HSTP II Projections (in billion USD) 7.00 6.00 5.00 4.00 3.00 2.00 1.00 2020/21 2021/22 2022/23 2023/24 2024/25 Required Base-Required Required High-Required Available Base-Available Available Medium-Available Available High-Available Figure 18. Planned expenditures versus financial space (total health expenditure) in base/low and high case scenarios

5.4 THE FINANCING GAP: BUSINESS AS USUAL HSTP-II costs were estimated in two scenarios as base and high case. The base case scenario considers existing interventions and similar investments to estimate targets and cost. The high case scenario assumes additional investment such as expansion of infrastructure and increases high-impact intervention coverage. Figure 19 and 20 illustrate the results for the base and high case scenarios for the HSTP-II cost projection when presented against available resource projections in business as usual case scenario. The total financing gap for five years, in the low/ base case scenario (Figure 19) is $3.20 billion, with an annual average of $0.64 billion. The total funding gap is about 1% of general government expenditure. Financing Gap for Business as Usual with Base Cost Scenario 6.00 5.00 4.00 3.00 2.00 1.00 - 2020/21 2021/22 2022/23 2023/24 2024/25 -1.00 -2.00 THE (business as usual) - base HSTP II cost-base Financing gap Figure 19. Financing gap for business as usual with base cost scenario The high case scenario HSTP-II cost estimation against business as usual (base case scenario) available resource projection gives a financing gap of an annual average of $1.77 billion from 2020/21 to 2020/24. In sum, this leaves $8.86 billion financing gap in five years, which is about 2% of GGE (Figure 20). HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 85 Financing Gap for Business as usual with high cost scenario 7.00 6.00 5.00 4.00 3.00 2.00 1.00 - 2020/21 2021/22 2022/23 2023/24 2024/25 -1.00 -2.00 -3.00 THE (business as usual)-base HSTP II cost-hIgh Funding gap Figure 20. Financing gap for business as usual with high cost scenario

5.5 FINANCING THE GAP The main source of HSTP-II resource deficits is the fact that MOH initiatives seek to achieve financial risk protection by reducing the OOP share from total expenditure of 31%, current, to 20% in ten years. The MOH also seeks to increase health financing from domestic sources by reducing overall external assistant share of the total expenditure from 35%, current, to 20% in 10 years. On the other hand, the resource availability projection assumes that the proportion of general government health expenditure within general government expenditure will from 8.1%, to 15% in 10 years. Based on the available resource projections, the medium and high case scenarios estimate higher available resource as compared to business as usual. This can happen only if government reprioritizes health and increases the GGHE as a share of GGE from 8% to 10% and 12 %, respectively, for the medium and high cases; and if external assistance decreased to 25% and 30% of THE by 2024/25 for the medium and high case scenarios. Under these conditions, the financing gap could be diminished (Table 14). Table 14. Financing Gap for HSTP-II Base Scenario Cost with Available Resource Projections (in Billion USD) Available Available Available HSTP II Financing Financing Financing GC resource-base resource-medium resource-high cost-base gap-base gap-medium gap-high 2020/21 3.16 3.21 3.26 3.76 -0.60 -0.55 -0.49 2021/22 3.41 3.50 3.69 3.98 -0.57 -0.48 -0.28 2022/23 3.69 3.84 4.29 4.53 -0.83 -0.69 -0.24 2023/24 4.03 4.33 4.93 4.62 -0.59 -0.29 0.31 2024/25 4.41 4.82 5.70 5.00 -0.60 -0.18 0.69 Total 18.69 19.70 21.87 21.89 -3.20 -2.19 -0.02 Average 3.74 3.94 4.37 4.38 -0.64 -0.44 -0.00 Funding Gap in % -14.6% -10.0% -0.1% The financing gap dramatically decreases from business as usual scenario to medium and high case scenarios, to about 14% for medium and 10% for the high case scenario against the HSTP-II base cost estimates (Table 15). 86 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Table 15. Financing gap for HSTP-II high scenario cost with available resource projections (in Billion USD) Available Available Available HSTP II Financing Financing Financing GC resource-base resource-medium resource-high cost-high gap-base gap-medium gap-high 2020/21 3.16 3.21 3.26 4.61 -1.46 -1.40 -1.35 2021/22 3.41 3.50 3.69 5.13 -1.73 -1.64 -1.44 2022/23 3.69 3.84 4.29 5.70 -2.00 -1.86 -1.40 2023/24 4.03 4.33 4.93 5.88 -1.85 -1.55 -0.95 2024/25 4.41 4.82 5.70 6.23 -1.82 -1.41 -0.53 Total 18.69 19.70 21.87 27.55 -8.86 -7,85 -5.68 Average 3.74 3.94 4.37 5.51 -1.77 -1.57 -1.14 Funding Gap in % -32% -28% -21% In general, the high case scenario cost estimates of HSTP-II exceed projected available resources in all scenarios. The HSTP-II period will be in deficit for the implementation of high case scenario health targets unless additional resources from international assistance are considered or the government or the government allocates 12% to 14% of its budget to health. On the other hand, the reduction of health objectives involves trade-offs between cost reduction and compliance with local and international health commitments.

5.6 OTHER FINANCING THE GAP OPTIONS The Ministry of Health is fully aware of the funding gap in the projected costs and financing. The Ministry will implement the strategies described below to address the gap: Potential efficiency gains: Health sector inefficiencies and significant loss of resources due to inefficiencies are global concern. UHC cannot be achieved by raising resources alone; resources will have to be used more efficiently. Globally, 20-40% of all health resources are wasted due to inefficiencies. According to the 2016 /17 Ethiopia health, system efficiency studies inefficiencies due to HR, drugs and supplies, and indirect costs were reported at all levels (Ethiopia Economic Association, 2016) (Peter Berman, 2016). The costs saved from addressing these reported health sector inefficiencies was estimated between $37 and $90 million per year. This could fill the whole funding gap for the base case and high case resource projections. Health system efficiency improvement is one of the priorities in HSTP-II, and one of the strategic objectives of the Health Care Financing Strategy. The sector will continue to take advantage of the bulk procurement that enhance values for money in the next five years. Furthermore, the sector will explore and implement human resource productivity-enhancing interventions to ensure that available human resources produce more outpatient equivalents than they currently do. Additional planned improvements include strengthening distribution of and management of health commodities and building capacity to carry out health budgeting at all levels. Innovative financing: One of the major health financing flagship initiatives is the launch of innovative financing. Data from HSTP-I have been synthesized to describe convenient forms of innovative health financing for Ethiopia, such as sin-tax, airtime levy, airlines levy, and so on, as described previously; and major service providers, such as financing sectors and banks could play a role in innovative financing through their corporate social responsibility (CSR) programs. As the feasibility of innovative financing in Ethiopia context was manifested in HSTP-I era, implementation is expected to happen in HSTP-II. The sin-tax proclamation was recently launched, but the amount earmarked for health has not yet determined. It is difficult at present to quantify the resources that can be mobilized through innovative financing; but the expectation is that this model will contribute significantly to reducing the financing gaps during HSTP-II. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 87 Performance Based Financing: PBF can be help achieve better results in the health sector compared to the traditional approach to financing inputs—provided the approach is planned with detailed prospective cost analyses and a careful, holistic multi-level approach. Leveraging the SDG Pool Fund and other external assistances, the MOH and development partners will consider the design and implementation of a PBF mechanism that: § Defines clear eligibility criteria for sub-national organizations to access the PBF fund, including those addressing health inequity § Incentivizes subnational levels to allocate more resources to the health sector § Motives these entities to improve efficiency and effective delivery of results by linking disbursement of funds with achievement of set outcome indicators and efficiency gains § Ensures data quality through establishing a relevant verifying agent. Financial and administrative issues for PBF such as fund flow, mechanism to address equity, and others should be outlined separately. Multi-sectoral collaboration: Health outcomes depend not only activities/programs run by the health sector but to other sectors as well, particularly education, WASH, transport and others. Non-health sectors health expenses are not accurately accounted for within health expenditure. As part of the woreda transformation agenda of HSTP-II, proper alignment of plans and well-organized expenditure tracking of non-health investments improves the efficient use of resources and also helps to count every penny directly or indirectly channeled to the health care system in Ethiopia. Implementation of the Health Care Financing Strategy: One of the HCF strategic objective is to mobilize adequate resources from domestic and external sources through traditional and innovative approaches (MOH, 2017). This strategy aims to increase the health sector resources to address the HCF resource gap that Ethiopia is likely to face in the coming years by maximizing available resources from all sources through sustainable, innovative, and scalable approaches. The HCF strategy is expected to be approved by the Council of Ministers at the beginning of 2013 EC. In view of this funding gap, the implementation of HCF strategies be prioritized in HSTP-II. Introduce HSTP-II expenditure and financing monitoring system: Expenditure and financing monitoring was a major concern throughout HSTP-I. It is therefore essential to develop an effective expenditure plan to manage and control the costs of any project from the outset. This will strengthen the monitoring system for effective utilization of the HSTP-II budget, but will also address how the cost baseline, control costs, and cost variance management will be effectively managed. This system will enable more frequent monitoring of HSTP-II expenditure and financing, and will facilitate rapid and proactive decision-making on budget utilization and funding gaps. The expenditure monitoring system is primarily intended to monitor and control costs. It checks cost variance from the baseline cost. This process should take place regularly throughout the HSTP-II period, and more frequently as project costs increase. 88 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Chapter 6 IMPLEMENTATION ARRANGEMENT HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 89 The implementation arrangement of HSTP-II aims at facilitating the implementation of the health sector transformation plan at all system level and by relevant stakeholders. The main implementation arrangements of HSTP-II are described below. Implementation of HSTP-II entails eight initiatives. The first two require the attention of sectoral leadership at all levels to keep them focused on integrated activities and practice good governance to build ownership of all initiatives and help all implementers deliver on their missions towards common vision. Hence, identifying integrative activities is important, including the transformation agenda. Building on the transformation agenda of HSTP-I, systematically packaging sets of initiatives/programs or major activities of transformation agenda to streamline communication, resource utilization, and monitoring of HSTP-II implementation. The third implementation arrangement helps to address the lack of a detailed implementation plan for cascading the strategic plan into operationalization plan to align existing resources or inputs (financial, human, time and other relevant resources) with anticipated services to be delivered to clients. Ethiopia’s health sector planning and budgeting model, woreda-based national health sector planning, has been in place for about a decade, serving as planning framework at all levels. Optimizing the this model as a health sector planning and budgeting mechanism, by objectively assessing its lessons, will be critical in translating HSTP-II to tangible actions on the ground. There must also be detailed implementation plans for flagship initiatives/programs, indicating a clear pathway for all, and providing all actors with the resources required for meaningful impact within reasonably faster time. Based on the experience to date, emergencies happen all the time, so that nothing can be left to assumptions. Hence, the strategic and annual operational plans should factor in the need to respond to public health emergencies, including resource mapping exercises with relevant stakeholders (risk-oriented planning and budgeting). The fourth arrangement addresses the challenges to organizational structures at national, regional, and sub-regional health sector in measures supporting implementation of sector-specific and multi-sectoral strategies. Based on the situational analysis observed in chapter II & III, restructuring must be considered as a way of building a quality health system. The fifth implementation arrangement aims at optimizing monitoring and evaluation (M&E) to inform decisions on adjusting plans over the course of strategic periods. Evidence must assess whether current activities are working well, drop/abandon ineffective or failed activities, and trigger new actions or developments including innovations as needed. Review of sectoral performance should include research, as appropriate, as well as generating new evidence. The research agenda should focus on developing and testing solutions (including innovations and product development) that respond to challenges in improving the health status of the nation and building quality throughout the health system. The sixth and seventh implementation arrangements focus on fostering partnership and collaboration by promoting multi-sectoral collaboration and private-sector engagement, respectively. Though, these coordination arrangements existed in HSTP-I, they were not backed up by relevant structures, resources, and monitoring frameworks. The eighth approach is forward-looking, aimed at expediting the implementation of the plans and fostering innovation by introducing health technology assessment and adaptation mechanism including development aspects of local researches. The ninth approach is about communication, health diplomacy, and visible leadership. The details of the approaches are narrated in detail as follows.

6.1. INTEGRATION OF INITIATIVES Building on the experiences of the implementation of HSTP-I, sets of initiatives and programs will be packaged and put into practice to realize the transformation agenda within HSTP-II. The implementation of these initiatives will be harmonized, aligned, and mainstreamed across all program activities. During implementation, execution of the transformation agendas will focus on integration, and will include cross-cutting issues such as gender, equity, and quality. All of the planned activities are designed to incorporate dimensions of equity across gender, geography, socioeconomic, and special vulnerability categories. Moreover, point of service delivery will also include integration of related interventions and services. . Routine M&E will be conducted jointly. 90 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY At national level, efforts will also be made to integrate and mainstream elements of the health policy within the policies and programs of all other sectors, fostering inter-sectoral collaboration. Health sector plans and activities will be particularly linked with sectors like food security and nutrition, education, environment and climate change, information, communication and technology, and agriculture, to support achievement of universal health care. All activities will focus on aligning with global initiatives and agreed upon international declarations.

6.2. HSTP-II GOVERNANCE Ensuring good governance is crucial in the realization of the ideals put in the vision and mission of the plan, and in ensuring that the outlined activities are executed in an efficient and accountable manner. Given its sector-wide approach to development, HSTP-II is designed to link to activities by development partners, the private sector, non-governmental organizations, and the community at large. Its governance thus encompasses development, organization, and management of the plan across all actors involved in operationalizing HSTP-II. As a holistic and multi-sectoral plan, HSTP’s management and ownership involve entities beyond the health sector. All citizens, non-government and community organizations, development partners, and civil society and professional associations are stakeholders with different levels of governance responsibilities in the implementation and evaluation of the HSTP-II activities. Therefore, plan should be structured to encourage: § Responsiveness (making services need-based) § Inclusiveness (taking different groups and needs into consideration) § Accountability (making roles and responsibilities clear) § Transparency (being clear on the where, when and how decisions are reached) § Participatory (involving all relevant stakeholders). The organizational structure and institutional culture (which includes different management- and communication- related guidelines and protocols) are the basic frameworks on which all the other components and stakeholder elements coalesce for effective governance of the plan. All necessary legal and regulatory frameworks to support and back up the enforcement of health actions are in place, even though they need to be properly compiled for easy reference by the public and generalist audiences. There are also initiatives for capacity building and enhancing the leadership skills of the health sector management at all levels. The MOH is also working towards splitting provider and regulatory functions to create an open and transparent mechanism of governance for health sector activities. Within the period of HSTP-II, it will conduct preparatory activities for establishing semi-autonomous professional and facility regulation through the involvement of professional associations and other stakeholders. It is currently revising the Health Harmonization Manual (HHM) in the spirit of strengthening coordination and accountability and for eventually moving towards “full” harmonization with “one plan, one budget, and one report (MOH, 2019).” Accordingly, the coordination and implementation of the HSTP-II will have an institutional framework built on consultation and review, which is meant to optimize the dialogue between the MOH and health partners for to obtain effective development assistance to the health sector. The principles for such dialogue are ownership by the Government of Ethiopia, alignment of partners to the government, harmonization among partners, mutual accountability between the Government and partners, and financing for results. The overall governance and implementation arrangements are clearly outlined within the HHM in the following text. Joint MOH and health partners/donors governance forums § Joint Consultative Forum (JCF): The highest governance body, which decides, guides, oversees, and facilitates the implementation of HSTP-II. It is also a forum for dialogue and consultations on the overall policy direction, reform, and institutional concerns about the health sector between the Government, development partners, and other stakeholders. The JCF plays a leading role in expanding the involvement of the private and NGO sectors in health service delivery. It will be chaired by the Minister of Health, co-chaired by Health, Population and Nutrition (HPN) chair, and the secretariat will be the Policy, Plan, Monitoring and Evaluation Directorate (PPMED). The membership of JCF consists of high-level representatives of the appropriate federal government bodies, representatives of the HPN development partner groups (multilateral and bilateral development partners), NGOs, the private sector, and health professional associations. Its functions will be revitalized through processes for collaborative agenda setting and close follow-up of planned actions. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 91 § The Joint Core Coordinating Committee (JCCC): This committee serves as the technical arm of the JCF, and assists and works closely with MOH in following up the implementation of the decisions of the Joint Consultative Forum and the recommendations of the review missions (mid-term and annual review meetings, and final evaluation). The JCCC is also responsible for assisting MOH in organizing the review, conducting M&E, and coordinating operational research and thematic studies. The JCCC will be composed of PPMED, staff, and senior members from the HPN Group, and is chaired by the Director of PPMED. With the ongoing revision and full implementation of the HHM, the functioning of the JCCC will be revitalized by revising its composition (implemented by the JCF) and by developing performance accountability measures among federal and regional government levels and with development partners. MOH internal Management and Coordination forums § MOH-RHBs Joint Steering Committee (JSC): This forum brings together the Ministry of Health, MOH agencies, and the Regional Health Bureaus. The meetings are chaired by the Minister of Health, and participants include State Ministers of Health, Regional Health Bureau Heads, heads of departments/services of the Ministry, director generals, M&E heads of MOH Agencies and Plans, and M&E heads of RHBs. The committee meets at least every two months to facilitate smooth, effective implementation of HSTP priority activities. JSC meetings focus on the implementation and progress of the plan and challenges faced during the course of its implementation. The committee is also responsible for updating the plan; introducing new initiatives, policy guidelines, and programs; and creating systems and mechanisms for communication and information/experience sharing. § Management Committee (MC) and Executive Committee (EC): At MOH, the MC, composed of the Minister, state ministers, and directors of all directorates, will meet regularly to guide and follow the implementation of HSTP. An executive committee, which is composed of the Minister, state ministers, directors of MOH and director generals of agencies, will meet regularly to guide and follow the implementation of the plan. § Regional/Zonal/Woreda-level management committee and partner forums will be established and will monitor the implementation of HSTP at each level. Program specific advisory groups and technical working groups will be established as deemed necessary.

6.3. PLANNING AND BUDGETING HSTP-II follows the “one plan, one report and one budget” principles, where “one plan” signifies that all the major activities happening at various levels of the health system are included in one joint plan that all stakeholders agree to be part of. While still having their own internal plans for their own use, development, and implementation, partners position their inputs in a way that fits the one broad plan of the sector. Development partners also ensure that their implementing partners and sub-contracted NGOs adhere to the HSTP harmonization manual (HHM), so that their activities and resources are reflected in the health sector’s plans and budgets. Agreements based on the health sector Code of Conduct, and signed by major development partners, should reflect the priorities and targets of the government’s strategic and annual plans. The agreements also stipulate that funding from all sources will be translated into the Ethiopian chart of accounts and fiscal years. The overall planning framework consists of strategic and annual plans; and strategic plans such as HSTP-II are to be cascaded to annual operational plans for their actual implementation. Both strategic and annual plans are the result of consultation entailing top-down and bottom-up processes. The top-down process ensures alignment of national priorities and targets with those of the regions and woredas. This process also helps to create consistency between health sector plans and the national prosperity plan. The bottom-up process ensures that the priorities and targets within regions and districts take local challenges and capacity into account. Each decentralized entity (health facility and health management structure) and programs will have its own strategic plan that emanates from the broader HSTP-II. The sub-strategic plan is a reflection of HSTP, while the annual plan breaks down the strategic plan further into shorter periods. Annual plans describe health sector activities in the geographical areas, and start with resource mapping that lists all the planned expenditure by government, donors, NGOs, and other stakeholders. 92 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY The principles governing both strategic and annual plans are: § Government ownership and leadership in all health planning processes: This principle means that the MOH, RHBs, Zonal Health Departments, and Woreda Health Offices at all levels own the process, and have the responsibility to organize and lead the planning sessions. It also ensures all stakeholders (government, development partners, NGOs, CSOs, private sector, the community) will have active roles in the consultation. The plan and budget should also be approved by the relevant local government authority through the formal approval process. § Linkage: Linkage to resource mapping from all stakeholders (government, development partners, NGOs, CSOs, private sector), which includes financial and non-financial resources in line with the “one budget” principle. § Alignment to other plans vertically (strategic-annual) and geographically (federal → regional → zonal → woreda), and horizontally (including activities of all stakeholders operating at that particular level). Annual plans represent the detailed operationalization of the five-year strategic plan, reflecting the priorities and stipulated targets in sufficient detail within the specified period. § Comprehensiveness in terms of all of the following: scope of covering all activities (including those of stakeholders) in the health sector; resource mapping with estimates of the total resources available from all sources; implementation schedule (quarterly/monthly) with major activities and responsible bodies for implementing each activity; monitoring framework with key performance indicators, baseline data, annual targets, sources and mechanisms of collecting data; and reporting and feedback mechanisms. Planning and management capacity will be strengthened at all levels under HSTP-II, especially at the woreda level. To promote performance-based resource allocation and accountability, performance agreements and/or MOUs can be developed and instituted between the health sector and partners and implementers as tools to enhance collaboration, by clarifying mutual expectations, responsibilities and accountability. To enhance utilization and absorptive capacity of regions and lower-level units, an agreed procedure can be instituted for reviewing statements of accounts that are linked with performance indicators of agreed-upon programs. The Partnership and Cooperation Directorate of the MOH has developed a strategy document to improve coordination of stakeholders and oversight of health care financing activities at all levels. This document also addresses grant management, procurement, and audit, and strategies to enhance absorptive capacity at federal and regional levels, including establishing grant management units at lower levels, especially at RHBs. The organization of the SDG pool fund will also strengthened within one of the strategic initiatives of the Health Care Financing Strategy (“Generating additional finances from innovative financing mechanisms”) (MOH, 2017). Conditions for support through the pool fund are to the extent possible coordinated and harmonized among the partners considering support for addressing issues of quality, equity, and resilience of the health system, with agreement between the government and partners on a common set of indicators and procedures that will be verified through joint review and regular prioritization sessions. While continuing to encourage all partners to move towards direct budget support (channel I), the government also plans to increase the number of contributors to the pool fund, by encouraging other partners to join and by ensuring that pooled funds are managed by the public sector and disbursed using public-sector procedures. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 93

6.4. HEALTH SERVICE DELIVERY ARRANGEMENTS The Ethiopian health service delivery will continue to be structured into three tiers providing primary-, secondary-, and tertiary-level health care (Figure 21). Ethiopian health tier System Specialized Hospital Tertiary level 3.5 - 5.0 Million healthcare General Hospital Secondary level (1-1.5 Million) people healthcare Primary Hospital (60,000 - 100,000) people Health center Health center Primary level 40,000 (15,000 - 25,000) people healthcare People Health post (3,000 - 5,000) people URBAN rural Figure 21. Ethiopian Health Tier System The primary health care unit (PHCU) consists of health posts, health center, and primary hospitals. One health center is attached to five satellite health post to provide services to approximately 25,000 people altogether. According to the HEP optimization roadmap, health posts will be either comprehensive or basic. The comprehensive health posts will be staffed by HEWs, nurses, midwives, and other health professionals to provide more comprehensive service, while the basic HPs will be staffed by health extension workers, and will provide various preventive and health promotion services, in addition to treating cases such as malaria, pneumonia, scabies, trachoma, and other mild illnesses. Both health post types also refer clients to health centers for services requiring higher-level care. The HEWs are supported by volunteer community-level workers to reach every household and execute their package of interventions. Health centers provide both preventive and curative services, and also serve as referral centers and practical training sites for health extension workers. Primary hospitals offer inpatient and ambulatory services to about 100,000 people, and also provide emergency surgery (including caesarean sections and blood transfusions). General hospitals are categorized under the second tier of health care. These hospitals provide similar services to those of primary hospitals, and serve on average 1 million people. They are referral centers for primary hospitals and training centers for health officers, nurses, and emergency surgeons. The third tier in the Ethiopian health care system, tertiary health care, consists of a specialized hospital that covers a population of approximately 5 million. It also serves as a referral center for general hospitals. Currently, MOH has seven agencies that are responsible for guiding and implementing health and health-related activities, including: § Ethiopian Public Health Institute (EPHI): Responsible for public health- and nutrition-related surveys and researches, quality laboratory systems, and public health emergency management § Armauer Hansen Research Institute (AHRI): Primarily responsible for generating and delivering scientific evidence, developing new tools and methods through biomedical, clinical, and translational research; and serves as a hub for technological transfer and capacity building in medical research and training 94 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY § HIV/AIDS Prevention and Control Office (HAPCO): Primarily responsible for coordination of multi-sectoral HIV prevention and control activities § Ethiopian Health Insurance Agency (EHIA): Primarily responsible for establishing and implementing an efficient, effective health insurance system § Ethiopian Food and Drug Authority (EFDA): Responsible for assuring the safety, efficacy, and quality of health and health-related products and services through control and supervision of food safety, pharmaceutical quality, tobacco and tobacco products, cosmetics and related products, and other regulatory activities. § Ethiopian Pharmaceuticals Supply Agency (EPSA): Responsible for ensuring a sustainable supply of quality- assured pharmaceuticals to health facilities at an affordable price § National Blood Bank: Responsible for ensuring the availability of blood and blood products in Ethiopia HSTP-II will continue to focus on strengthening and expanding health services facilities within the framework of primary health care by improving governance and ensuring equitable access to and utilization of quality health services. The transformation perspective will also redesign and restructure the service delivery system through a systemic reform process that rationalizes the health system so that high-quality services are provided at the right level, by the right provider, and at the right time to optimize outcomes (The Lancet Global Health Commission, 2018). This implies transforming service delivery to respond to the dynamic epidemiologic transition that is sweeping the country, in addition to making the health system resilient to withstand emergencies, epidemics, and pandemics.

6.5. OPTIMIZING MONITORING AND REVIEW SYSTEMS The M&E framework for HSTP-II is extensively outlined in chapter seven and in a separate HSTP-II M&E plan document. The critical issues in optimizing the M&E system will be strengthening the health management information system, and creating/strengthening linkages between health-related evidence with policy and practice. Evaluation of the performance of HSTP-II will take place at midterm and final implementation periods. Joint MOH-HPN review teams will conduct performance reviews during the implementation period. The health management information system is being updated with recent technological development, and DHS2 is being rolled out at all levels. Data completeness and timeliness are among the critical challenges that the information revolution is expected to address—and one of the key transformation agenda of the HSTP. There is also an ongoing initiative to catalyze and accelerate data use within the health sector. The MOH and EPHI collaborate and work closely with the Central Statistical Agency, or CSA, and the newly restructured Immigration, Nationality and Vital Events Agency by conducting population and facility-based surveys and streamlining and strengthening the vital events registration system within the country. Despite these initiatives, the monitoring review system within the health sector remains plagued by the absence of functional linkages across the central, regional, and woreda levels; inability to sustain timely and complete reporting; and low levels of data use for action and decision-making. With regard to research in particular, there is concern at all levels that the translation of evidence to policy and practice is very poor. Research activities also tend to be mostly descriptive, rather than being operational in terms of improving the monitoring performance of plans or being translated into concrete practice at policy and program levels. Other research concerns include poor coordination and the limited funding resources available for research. Strengthening functioning and linkages for the existing health sector research advisory councils (is one step in tacking these challenges. Another step is to secure senior-level management for strengthening activities initiated within some directorates of the MOH to work with universities and to tap their network of demographic surveillance sites.

6.6. MULTI-SECTORAL COLLABORATION Though health is a critical element of all socio-economic development, maximizing a society’s health requires actions by various sectors, not only the health sector. This implies that improvements in the health status of populations cannot be achieved by only focusing on health sector activities (through the biomedical approach of treating diseases and injuries). Multi-sectoral collaboration for health is one of the five principles within the primary health HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 95 care movement, and was re-affirmed within the Millennium Development Declaration, which focuses on a broad multi-sectoral approach for any national development plans, including health. Implementation of HSTP-II will take place through multi-sectoral collaboration to address all the determinants of health (personal, social, environmental, economic, and political). This entails collective actions by wide-ranging actors outside the health sector, such as education, environment, agriculture, housing and infrastructure, and water, within the ecological framework of health determinants. Engaging these sectors involve the coordination different stakeholders within the public sector, private sector, non-government agencies, civil services and community-level organizations. Among the key sectors for collaboration are: § Education, to train health workers and school health promotion § Water resources to ensure availability of an adequate, safe water supply § Agriculture to support improved nutrition, and prevention and control of zoonotic diseases § Finance and economic development for harmonizing and improving resources for health § Media for creation of health awareness and dissemination of health-related messages § Women, youth, and sports affairs for gender equity and addressing adolescent health needs § Transport for prevention and control of road traffic accidents § Housing and environment for proper infrastructure development and to address pollution § Immigration, Nationality and Vital Events Agency for vital statistics § Others In the next five years, our main platform to bring multi-sectoral collaboration is the multi-sectoral woreda transformation platform. The aim of multi-sectoral woreda transformation is bringing household transformation by bringing improvement in 4 Ls (Livelihood, Lifestyle, Literacy and Longevity). Transformed households will be a building block to transformed kebeles, Woredas and the nation in general. The multi sectoral ministerial steering committee established in 2019 had selected Gimbichu Woreda to pilot the interventions. The ministerial steering committee was led by the health sector based on the experience of the health sector’s woreda transformation. However, he health sector alone cannot take such a huge role. It will require a national-level mechanism to bring all these actors together for a common goal and improve health through their concerted actions. The health sector can lead the technical coordination, but Ministry of finance should take the lead role in financing, donor mobilization and governance. The mechanisms for multi-sectoral collaboration include joint planning, implementation, review, and evaluation of sectoral programs at all levels. Coordination committees will be established at regional, Zonal and woreda level to ensure ownership of the development efforts and engage community and all stakeholders.

6.7. PUBLIC-PRIVATE PARTNERSHIP It is obvious that the private sector has strong presence in the health sector in Ethiopia, though it is largely limited to major urban centers. Historically, it existed long before the public health system was properly organized. In addition to its quality gradient for some services, the private sector expands the resource base within the health sector, since the investments it brings are additional. Therefore, through proper regulation, this sector can be leveraged provide and finance most curative services (and some preventive care). The government can also subsidize or facilitate development of an insurance system to deal with private curative services without incurring catastrophic costs. The government will also facilitate the private sector’s usual engagement in the expansion of health infrastructure, local production of pharmaceuticals, and medical devices, as well as training and continuing development for health professionals. 96 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

6.8. FOSTERING INNOVATION THROUGH HEALTH TECHNOLOGY ASSESSMENT AND ADAPTATION Although research and development of technologies is the domain of the Ministry of Innovation and Technology, Ministry of Health should also foster technological innovations that facilitate and expedite the implementation of HSTP-II activities. The government can create a conducive environment for innovation in use and development of health technologies across the spectrum of invention, technological assessment, adoption, and diffusion. In terms of innovation, the health sector can support basic and applied research by universities and other research institutions. Governments can and should play an active part in supporting innovative approaches and facilitating the health technology assessment process for effective adoption of successful endeavors. Particularly nowadays, the growing presence of mobile technology can have a positive influence in the implementation of health care activities. Mobile and other IT-related applications can foster solutions to the challenges of expanding health care access across large geographic areas, local communities, and individual patients and providers. In terms of health technology assessment, the MOH also has established a Health Economics and Financing Analysis team within the Partnership and Coordination Directorate. This team spearheads application of evidence-based health care decision-making by compiling evidence and defining effectiveness measures for different health technologies and programs (Zegeye EA, 2018). Health technology assessment has been established as a tool for priority setting in the health sector—a tool that helps to systematically evaluate innovative interventions and inform policy decisions on their application and resource allocation. The EPHI and AHRI are among the institutions that are conducting research on a range of interventions and technology assessment programs. Therefore, health technology innovation and assessment is critical to adopting and diffusing new, cost-effective health technologies to improve health sector performance.

6.9. HEALTH DIPLOMACY, COMMUNICATION AND VISIBLE LEADERSHIP As globalization progresses, it is becoming clear that matters that were once confined to national policy are now issues of global impact and concern. Pandemics, newly emerging communicable diseases, and bioterrorism are now clearly understood as direct threats to national and global security. An increasing number of health challenges can no longer be resolved at the technical level only; they require political negotiations and solutions, and often involve a wide range of actors. Health diplomacy takes place at many levels domestically and globally. The main goals of health diplomacy are: 1) better health security and population health; 2) improved relations between states and commitment of a wide range of actors to work together to improve health; and 3) achievement of outcomes that are deemed fair and support the goals of reducing poverty and increasing equity. Health diplomacy can support countries in protecting joint interests and in taking positions on matters of common concern, such as access to health security, health promotion, disease control, access to medicines and technologies, food security, water, and the SDG. Locally, diplomacy—for instance, in the form of negotiation with important government sectors such as Ministry of Finance—is vital to increase evidence–driven, multi-sectoral collaborative actions to build a healthy, productive society. Regional, continental and global responses, led by global multi-lateral organizations such as World Health Organization (WHO), also have an impact on the success of the domestic response plan through globally accepted guidance, lesson exchange, and sharing burdens. The MOH will share HSTP-II implementation successes and challenges in global and regional forums such as World Health Assembly and UN General Assembly. These diplomatic initiatives will strengthen existing collaborations and attract new partnership platforms to more lives and build resilient systems. In the next five years, MOH will strengthen its capacity in health diplomacy at all levels at domestic and international levels for successful implementation of the HSTP-II by aligning its policy and strategies with global and national multi-sectoral response directions. Success stories and lessons will be shared both locally and at global platforms to advocate for changes in global public health practices. In addition, the MOH will build the capacity of Ethiopian diplomats across the globe so that they can advocate for health investment in Ethiopia. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 97 Regarding communication and visible leadership, MOH is accountable for public interest and user experience of health services, and accepts feedback by making the status of HSTP-II implementation visible to the public through such media as official press releases, public news platforms, and social media outlets, and through regular reports submitted to Council of Ministers and House of Representatives. The Communications and Public Relations Department at all levels of MOH will be responsible for increasing the visibility of activities carried out during the implementation of HSTP-II.

6.10. RISKS AND MITIGATION During the implementation of HSTP-II, the sector may encounter risks that impede achievement of results. Table 15 shows the risks identified through SWOT and stakeholder analysis, and the strategies identified to address or mitigate them. Table 16. Risks and mitigation strategies S.N Risks Mitigation Strategy 1 COVID-19 and its effect The MOH, in close collaboration with the government and different Ministries, will actively work on the on the health system prevention and control of COVID-19. As a priority public health concern, its control will be enhanced through implementation of appropriate and effective public health measures. In line with COVI-19 control, MOH will implement strategies that ensures the continuity of the other essential health services. Strengthening treatment centers, quarantine, and isolation centers, making adequate availability of logistics at health facilities, such as PPEs and appropriate focus on the safety of health workers, will be given a due attention. 2 Occurrence of Health The MOH will strengthen the public health emergency management system by improving the capacity for Emergencies emergency preparedness, prevention, early detection and response of emerging and re-emerging diseases and other emergencies. The MOH will also strengthen the intra-sectoral and multi-sectoral collaboration and coordination among different stakeholders, improve capacity as per the IHR recommendations and enhance regular risk assessment at all levels. Emergency preparedness will be strengthened for an effective emergency response to any emergency at all levels. Health screening at POAs will also be strengthened. 3 Inadequacy of financial The health sector will focus more on domestic financing to fill the financial gap required during the HSTP-II resource period. The following efforts will be done: Sudden reduction - Implementation of innovative domestic financing strategies to mobilize adequate finance domestically of donor funds (Low will be implemented predictability of external - Strengthen the implementation of CBHI and initiate implementation of Social Insurance as an internal funding due to world mechanism to increase financing to the health sector economic recession) - Strengthen public-private partnership 4 Inadequate budget The health sector will work with the government and use strong evidence informed advocacy on adequate allocation by the budget allocation to the sector. There will be improved political commitment at all levels of the health government to health system. 5 Weak inter-sectoral The MOH will work closely with the government and line Ministries to collaborate in addressing social collaboration determinants of health 6 Inadequate private The MOH will work with other government ministries and agencies, civil society organizations, the private sector involvement sector to attract investment; strengthen public-private partnerships 7 Population The MOH will work closely with other government ministries and agencies, civil society organizations, and displacements, neighboring countries to prevent and control cross-border health and health-related health challenges at in-migrations and centers for IDPs and refugees. instability of neighboring countries Establishing service delivery points at IDP sites and refugee centers and strengthening health services in these sites. 98 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Chapter 7 MONITORING AND EVALUATION PLAN HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 99 This Section includes the main M&E components of the strategic plan. Detailed descriptions, definitions, indicator matrix and other components are broadly described in a separate “Monitoring and Evaluation of HSTP-II” document.

7.1 MONITORING AND EVALUATION FRAMEWORK Description of the M&E framework This M&E framework is meant to guide the monitoring and evaluation of HSTP-II implementation. The logic model is based on the Ethiopian health system framework and adaptation of the recent WHO’s Monitoring and Evaluation Framework. It includes the logical relationship from health system inputs to outputs to outcomes and then ultimately to impact (Figure 22). The framework includes domains at input, output, outcome, and impact levels. It also contains a summary of data sources, data management mechanisms (data analysis and synthesis), and communication and use; and identifies key principles that the sector should follow during M&E. Figure 22. HSTP-II Monitoring and Evaluation Framework Monitoring and Evaluation Framework of HSTP II PRINCIPLES Integration Simplification Standardization Participatory Continuity Inputs and processes Output Outcome Impact Coverage of Service Delivery Essential Health Financing Improved Leadership and Governance Availability of Health Services Health Status Medical products and Essential suppies Health Service Health Security (Promotion, prevention, curative and Domains Health Workforce Resilience in Financial Risk Community service provision Protection rehabilitative service) health Infrastructure Demand for Healthy Life Style Economic Health Services Health Information Gain Health System Responsiveness Household and Facility Based Assessments, Routine Information System: HMIS, CHIS, HRIS HCMIS, LIS, RIS, Vital Population Based Surveys, BD Study, Data sources Statistics, Insurance Information Systems and others Researches, HMIS, Civil Registration and Facility Assessments: SARA, SPA Others Analysis & Data Quality Assurance; Triangulation of Data from different sources; Comparison of performance against benchmarks synthesis (Targets, baselines, standards and international and national commitments...) Communication Regular reporting, review by performance monitoring teams, regular review at JSC, ARM and other forums; midterm and and use final evaluation, Global reporting, share information products by different platforms

7.2 INDICATORS M&E for HSTP-II will use 76 core indicators to monitor and evaluate the implementation of the strategic plan. The impact, outcome, output and, input indicators were selected in a balanced way, using thoroughly defined selection criteria including relevance, availability of data sources, measurability, sensitivity, and alignment with national and international priority health interventions and requirements. Besides the most commonly used types of indicators, indices/composite indicators are included. The indicators include baseline, midterm targets (2022), and endline targets (2025). The period for data collection and analysis varies for each indicator. Some indicators are analyzed on a monthly basis, others quarterly, annually, at 2-3 years, and at 5 years’ time. Target setting was done using a OneHealth tool and considering criteria such as previous trend, baseline, capacity, and national and international commitments. The process was participatory, with iterative, consultative engagement of program experts and stakeholders; and participants—learning from HSTP-I lessons—sought to make the targets realistic. 100 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY The current list of indicators identified in the HMIS will be revised according to the HSTP-II requirement. In addition, agencies and programs in the health sector will have specific indicators related to their operational and program monitoring and evaluation. The indicator matrix for the 76 core indicators is detailed in Annex I.

7.3 INDEX MEASUREMENT IN HSTP-II Monitoring Equity In addition to measuring average or aggregate levels of indicators, it is essential to look at performance by disaggregation (equity measures) to determine the equity of health service use, health outcomes, and desirable healthy practices using key equity lenses. The commonest equity parameters include demographic (age and sex), geographical (urban/rural and regional differences) and socioeconomic characteristics (wealth and education). Selected tracer indicators will be analyzed by equity parameters. The plan is to regularly monitor and design interventions to reduce the inequality in selected parameters. Equity analysis report will be developed at least every year or two, based on the type of indicator, and distributed to stakeholders. The targets for the tracer equity indicators appear in Annex 2. Monitoring Quality of Care Quality measurement and improvement is an ongoing process and is an integral part of the national health M&E system. In this HSTP, quality of services at health facility level will be measured based on the quality standards and measurement tools set for selected health services at hospitals and PHCU levels. The aim is to continuously measure and improve quality of health care at point of service delivery, based on various quality dimensions. Quality of services will be measured with quality of health care indicators such as reports of “positive user experience” during essential services, safety assurance during the care process, and effectiveness of the care process. Monitoring Universal Health Coverage Universal health coverage (UHC), which is about attaining effective coverage of essential health services and protecting people from financial hardship, will be measured using an index in this HSTP-II period. The index is composed of 18 tracer indicators selected based on international recommendations, and adapted from WHO’s tracking UHC. Definitions for the index were developed to ensure international comparability. The tracer indicators may be changed, as there is an international revision process by WHO that we may adapt to the Ethiopian context. In 2019, the UHC index for Ethiopia was 0.43; the target in 2024/25 is 0.58. Monitoring Health service responsiveness The description and component of health service responsiveness is clearly stated in the separate “Monitoring and Evaluation Plan of HSTP-II” document. It is adapted from WHO’s framework to assess the status of health and health systems. The health service responsiveness index mainly measures the quality of the non-clinical aspect of health care provision. Health service-responsiveness assessment will be conducted every 2-3 years. Currently the baseline is 0.52, and the target at the end of the HSTP-II period is 0.60. Monitoring Demand Index Effective demand for essential services reflects the potential for households and communities to utilize the essential preventive and curative services they need. Demand can be analyzed based on repeat services to identify how well the services provided are aligned to the needs of the people. The poorer the demand, the lesser value given by the population to the services. The demand index will be measured using the following indicators: 1. ANC1 _ ANC 4 dropout rate 2. Penta1 _ Penta3 dropout rate 3. BCG – MCV1 dropout rate 4. TB treatment dropout rate HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 101 Monitoring Health Security Index The health security index is measured by IHR core competencies, which are organized under four major health security domains (prevention, detection, response, and others). The Ethiopian Public Health Institute will conduct a health security assessment on a yearly basis. HSTP-II plans to increase the health security index from 0.63 to 0.78. Resilience Index The resilience index is derived from analysis of responses from key informants in relation to resilience attributes in their systems, which include awareness, diversity, versatility and self-regulation, and mobilization, adaption and integration. This assessment will be conducted every 5 years. The Ethiopian Public Health Institute will be responsible for conducting a survey to determine the resilience of the health system. Based on the report from WHO for Africa region, the resilience score for Ethiopia in 2019 is 0.49, and the plan in the HSTP-II period is to increase it to 0.50.

7.4 TRANSFORMING DATA INTO INFORMATION AND ACTION: THE DATA CYCLE HSTP-II identified evidence-based decision-making as one of the strategic directions to transform use of information in decision-making in the sector, including the M&E system. The cycle includes how data is gathered, analyzed, interpreted, reported, shared, and used in decision-making. This section will describe the components of a data cycle. To address the requirements for M&E of the HSTP-II, a national HIS strategy will be developed and implemented. Data sources The common data sources used to measure and inform HSTP-II include routine and non-routine data sources. Routine health information sources: This includes routine sources such as HMIS, the regulatory information system, the health commodity management information system, the human resource information system, civil registration and vital statistics, the health insurance information system, the integrated financial management information system, and administrative reports. Data from both public and private sectors will be gathered to provide a full picture of health system performance. Non-Routine health information sources: This includes population and housing census surveys, Demographic and Heath Surveys, and other surveys and assessments, as well as research findings and other non-routine data sources such as burden of disease studies, modeling for HIV estimates, and others. E-health architecture The Ethiopian eHealth Architecture illustrates how distinct IT components form a coherent and holistic national HIS that provides an increasingly sophisticated set of business capabilities to the health sector. The eHealth architecture supports coordination of IT choices and appropriate resource utilization, minimizing duplication of effort and facilitating access to and integration of data. During the strategic period, the e-Health architecture will be implemented with the aim of improving data quality and use, interoperability between and across eHealth applications, performance monitoring, and sharing of information. Data quality Improving the quality of data for a meaningful decision-making process will be a focus in this HSTP. Interventions in this domain will tackle technical, organizational, and behavioral factors affecting the quality of data. Improving data quality requires the effort of every actor in the health sector, primarily every health workers, and comprehensive implementation of techniques for improving data quality. Data quality-assurance techniques will be implemented holistically at each level of the health system. As part of external verification process, and to enhance reliability and credibility, data quality audit (DQAs) will be conducted every two years by the Ethiopian Public Health Institute. 102 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Reporting A standard reporting format, channel and schedule will be used for reporting of routine health data. HSTP-II will regularly assess reporting mechanism and implement interventions to ensure accountability towards “Zero Tolerance for Parallel Reporting.” Ethiopia will contribute to global reporting to produce global statistics and assessment in support of global goals (such as Sustainable Development Goals) and will comply with International Health Regulations concerning selected epidemic-prone diseases and public health emergencies of international concern. Use of Information for Action Improving data demand, information culture, knowledge management, learning, and capacity to change data into meaningful information and use it for action will be priority at all levels, particularly service delivery points. Local levels will employ simple analysis mechanisms, while regional and federal levels will apply advanced data analytics to produce estimates, projections, and modeling, and to synthesize research and findings and articulate insights for coordinated development and revision of policies and strategies. Development and use of digital tools will enhance data analysis, reporting, visualization, and tracking. Data use at the facility level will predominantly be led by the performance monitoring team, which will also guide and oversee other data use platforms, such as departmental-level data reviews, quality improvement processes, clinical review sessions, and other data use forums. Additional platforms will also be employed for data use. Performance review Regular, participatory performance review meetings will be undertaken every two months, quarterly, biannually and annually at different levels. During performance reviews, all relevant stakeholders will meet and review the performance of the sector. The overall annual performance of the sector will be reviewed during the Annual Review Meeting. Each level of the health system will conduct programmatic and general evidence-based performance review regularly.

7.5 EVALUATION Evaluation of HSTP-II activities will take place at mid-term (2022/23) and end-term (2025) to assess the status of attainment of set objectives and targets. The mid-term evaluation will assess progress towards achievement of results and generate lessons learned, while the end-term will inform development of the subsequent strategic plan. In addition, Joint MPH-HPN Review Mission (JRM), will be executed as scheduled in the HHM. MOH will strengthen the capacity of regions to conduct self-evaluation that considers their specific context. Impact evaluation will also be conducted for selected interventions as deemed necessary.

7.6 DISSEMINATION AND COMMUNICATION Monitoring and evaluation findings will be disseminated to stakeholders using different channels. Monthly, quarterly, and annual reports will be produced according to the Health Harmonization Manual. Biannual and annual performance reports will be produced and submitted to the relevant government bodies; and M&E digests, health bulletins, newsletters, and fact sheets will be produced as per established schedules. Health and health-related indicators will be produced annually at RHBs and MOH level. MOH will strengthen electronic outlets, such as the website and social media, for dissemination of results. Documentation of best practices and dissemination of results will also be promoted at the international level through participation in international conferences, contribution to the debate on global health issues, and publication of scientific articles in international journals. Data access and sharing A data access and sharing protocol will be developed and implemented in the strategic period, designed to institutionalize a proactive approach for releasing data to stakeholders and to the public. The protocol lays out a process for routine and ad-hoc release of health data at all levels of the health system. Relevant data will be shared with the public via websites and other channels. HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 103

7.7 COORDINATION, POLICY AND INSTITUTIONAL ENVIRONMENT FOR MONITORING AND EVALUATION § The Ethiopian Public Health Institute is mandated to conduct health related survey and research. However, overall coordination of M&E will be the responsibility of the Planning and M&E unit of MOH. Additionally, this unit will map, coordinate, and lead the planning and execution of surveys, operational research, and evaluation, and documentation, and sharing of findings. § A Research Coordination Unit will be established at MOH. It will be responsible for the translation of researches into action through policy dialogues, and by producing policy briefs and other evidence synthesis documents. § HSTP promotes involvement of all stakeholders in the planning, implementation, review, and M&E process. The community will be involved in rating the health system; and the level of community involvement/ contribution in the health sector will be assessed. Community scorecards will be implemented to regularly measure the responsiveness of the health system and community satisfaction, and to identify priority areas within the health sector. § Joint coordination platforms will be used for planning, monitoring and evaluation. The platforms include, Joint Steering Committee, Joint Consultative Forum, and Joint Core Coordinating Committee (described in the “Implementation Arrangement” chapter) . 104 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Annexes HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 105 Annex 1 INDICATORS AND TARGETS OF HSTP-II The indicator matrix includes the name of the indicator, its category, type, data source, baseline and targets of HSTP-II. Table 17. HSTP-II core indicator matrix Level of Frequency of Type of Mid- term Target Indicator Data Data Source data collec- Baseline Indicator Target 2022 (2024/25) Collection tion/Analysis General 1 Life Expectancy at Birth Census/ (years) World health Impact Population 5 years 65.5 68 Statistics/ BOD study 2 UHC Index Mixed (HMIS, Outcome Facility 2-3 years 0.43 0.50 0.58 DHIS, EHIA) 3 Proportion of clients satisfied during their last health care visit (Client Outcome Facility KPI Report Quarterly 46% 60% 80% satisfaction rate) Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health and Nutrition (RMNCAYH-N) 4 Maternal Mortality Rate Impact Population EDHS 5 years 401 279 - Per 100,000 live birth 5 Under 5 Mortality Rate – EDHS/ 5 years/2-3 Impact Population 59 51 43 per 1,000 LB MiniDHS yrs 6 Infant mortality rate per EDHS/ 5 years/2-3 Impact Population 47 42 35 - 1,000 LB MiniDHS yrs 7 Neonatal mortality rate EDHS/ 5 years/2-3 Impact Population 33 28 21 - per 1,000 LB MiniDHS yrs 8 Contraceptive Outcome Population EDHS 5 years 41% 45% 50% Prevalence Rate 9 Proportion of pregnant Facility/ Monthly/ 5 women with four or Outcome HMIS/EDHS 43% 60% 81% population years more ANC visits 10 Proportion of deliveries Facility/ Monthly/ 5 attended by skilled Outcome HMIS/EDHS 50% 62% 76% population years health personnel 11 Early Postnatal Care Facility/ Monthly/ 5 Outcome HMIS/EDHS 34% 53% 76% coverage, within 2 days population years 12 Cesarean Section Rate Facility/ Outcome HMIS Monthly 4% 6% 8% population 13 Still birth rate (Per 1000) Impact Facility HMIS Monthly 15 14.5 14 14 Proportion of asphyxiated newborns Facility/ Outcome HMIS Monthly 11% 29% 50% resuscitated and population survived 15 Proportion of newborns with neonatal sepsis/ Facility/ Monthly/ 5 Outcome HMIS/EDHS 30% 37% 45% Very Sever Disease (VSD) population years who received treatment 106 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Level of Frequency of Type of Mid- term Target Indicator Data Data Source data collec- Baseline Indicator Target 2022 (2024/25) Collection tion/Analysis 16 Proportion of under five Facility/ Monthly/ 5 children with Pneumonia Outcome HMIS/EDHS 48% 57% 69% population years who received antibiotics 17 Proportion of under five children with diarrhea Facility/ Monthly/ 5 Outcome HMIS/EDHS 44% 54% 67% who were treated with population years ORS and Zinc 18 Pentavalent 3 Facility/ Monthly/ 5 Outcome HMIS/EDHS 61% 72% 85% Immunization coverage population years 19 Measles (MCV2) Facility/ Monthly/ 5 Outcome HMIS/EDHS 50% 64% 80% immunization coverage population years 20 Fully immunized children Facility/ Monthly/ 5 Outcome HMIS/EDHS 44% 58% 75% coverage population years 21 Mother to Child Modeling/ Transmission Rate of Impact population 2-3 years 13.4% <5% Spectrum HIV 22 Teenage pregnancy Impact Population EDHS 5 years 12.5% 10.0% 7% rate (%) 23 Stunting prevalence in EDHS/ 5 years/2-3 children aged less than 5 Impact Population 37% 32% 25% MiniDHS yrs years (%) 24 Wasting prevalence in EDHS/ 5 years/2-3 children aged less than 5 Impact Population 7% 6% 5% MiniDHS yrs years (%) Disease Prevention and Control 25 Proportion of people living with HIV who Outcome Population EDHS 5 years 79% 86% 95% know their HIV status 26 PLHIVs who know their status and receives ART (ART coverage from Outcome Facility HMIS Monthly 90% 92% 95% those who know their status) 27 Percentage of people receiving antiretroviral Outcome Facility HMIS Monthly 91% 93% 95% therapy with viral suppression 28 TB case detection rate Outcome Facility HMIS Quarterly 71% 76% 81% for all forms of TB 29 TB treatment success Outcome Facility HMIS Quarterly 95% 95% 96% rate 30 Number of DR TB cases Outcome Facility HMIS Quarterly 642 967 1365 detected 31 Grade II disability among Outcome Facility HMIS Quarterly 13% 9% 5% new cases 32 Malaria mortality rate (Per 100,000 population Impact Population HMIS Monthly 0.30 0.3 0.20 at risk) 33 Malaria incidence rate (per 1000 Population Impact Population HMIS Monthly 28 18 8 at risk) 34 Premature mortality WHO report from Major Non- Impact Population 2-3 years 18% 16% 14% 2016 Communicable Diseases 35 Proportion of Women age 30 - 49 years Outcome Facility HMIS Monthly 5% 21% 40% screened for cervical cancers HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 107 Level of Frequency of Type of Mid- term Target Indicator Data Data Source data collec- Baseline Indicator Target 2022 (2024/25) Collection tion/Analysis 36 Mortality rate from all Population/ types of injuries (per Impact HMIS Monthly 79 73 67 facility 100,000 population 37 Cataract Surgical Rate (Per 1,000,000 Outcome population HMIS Quarterly 720 1071 1500 population) 38 Proportion of hypertensive adults Facility/ 5 years/ Outcome STEPS/HMIS 40% 50% 60% diagnosed for HPN and Population Annual know their status 39 Proportion of hypertensive adults Outcome Facility HMIS Monthly 26% 41% 60% whose blood pressure is controlled 40 Proportion of DM patients whose blood Outcome Facility HMIS Monthly 24% 40% 60% sugar is controlled 41 Coverage of services for severe mental health disorders - 5% 16% 30% Outcome Facility HMIS Monthly Depression 1% 9% 20% Substance Use Disorders 42 Proportion of Trachoma endemic woredas with Trachomatous Impact Population NTD Survey 2-3 years 26% 49% 77% Inflammation Follicular (T.F) to < 5% among 1 to 9 years old children Hygiene and Environmental health 43 Proportion of HMIS/ 5 years/ households having basic Outcome Household 20% 38% 60% Survey quarter sanitation facilities 44 Proportion of kebeles Outcome Kebele HMIS Annual 40% 55% 80% declared ODF 45 Proportion of households having  hand washing facilities at the Output Household DHS 5 years 8% 31% 58% premises  with soap and water HEP and Primary Health Care 46 Proportion of Model Outcome Household HMIS Quarterly 18% 32% 50% households 47 Proportion of health centers and primary hospitals providing Input Facility HMIS Annual 1.3% 9.0% 19% major emergency and essential surgical care 48 Proportion of high performing Primary Outcome Facility HMIS Quarterly 5% 19% 35% Health Care Units (PHCUs) 49 Proportion of health posts providing Input facility HMIS Annual 0% 5% 12% comprehensive health services Medical Services 50 Outpatient attendance Outcome Facility HMIS Annual 1.02 1.35 1.75 per capita 51 Bed Occupancy Rate Output Facility HMIS Monthly 41.9% 57% 75.0% 108 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY Level of Frequency of Type of Mid- term Target Indicator Data Data Source data collec- Baseline Indicator Target 2022 (2024/25) Collection tion/Analysis 52 Proportion of patients with positive experience Outcome Survey 2-3 years 33% 42% 54% of care 53 Institutional mortality Impact HMIS Monthly 2.2% 1.9% 1.5% rate 54 Percentage of Blood Bank component Production Output Blood Banks Reporting Annual 23.30% 42.00% 65% from total collection System 55 Ambulance Response Output Facility HMIS Monthly NA 90% 90% rate Public Health Emergency Management (PHEM) 56 Health Security Index Outcome Facility Assessment 2-3 years 0.63 0.70 0.78 57 Proportion of epidemics PHEM controlled within the Outcome Facility Monthly 80% 90% 100% Report standard of mortality Health System Input Indicators 58 Availability of essential Annual/ medicines by level of Input Facility SARA/HMIS 79.2% 84.0% 90% Monthly health care 59 Prevalence of unsafe National and illegal food products food Outcome EFDA 2-3 years 40% 36% 30% in the market consumption survey 60 Percentage of substandard and Regulatory Outcome EFDA 2-3 years 8.6% 7.0% 6% falsified medicine in the survey market 61 Out of Pocket Expenditure as a Outcome Population NHA 2-3 years 31% 28% 25% share of total health expenditure (THE) 62 General government expenditure on NHA/ health (GGHE) as a Population/ 2-3 years/ Outcome Finance 8.1% 9.0% 10.0% share of total general FMOH Annual report government expenditure (GGE) 63 Total health expenditure Input Population NHA 2-3 years 33 37 42.2 per-capita (USD) 64 proportion of eligible Insurance households enrolled Outcome Information Annual 49% 63% 80% in Community Based System Health Insurance (CBHI) 65 Proportion of eligible Insurance civil servants covered by Input Population Information Quarterly 0 45% 100% Social Health Insurance System (SHI) 66 Incidence of catastrophic Household Impact Population 2-3 years 2.1% 2.0% 1.80% health spending Survey 67 Proportion of Primary Health Care Facilities Admin Input Annual 61% 74% 90% implemented Report Community Score Card 68 Information use index Outcome Facility Assessment Annual 52.5% 67.1% 85.0% 69 Proportion of health facilities that met a data verification factor within Input Facility Assessment Annual 82% 46% 95% 10% range for selected indicators HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 109 Level of Frequency of Type of Mid- term Target Indicator Data Data Source data collec- Baseline Indicator Target 2022 (2024/25) Collection tion/Analysis 70 Proportion of births notified (from total Input Facility HMIS Monthly 35% 55% 80% births) 71 proportion of deaths notified (from total Input Facility HMIS Monthly 3.4% 18.0% 35.0% deaths) 72 Health workers density Input Facility HRIS/HMIS Annual 1 1.6 2.3 per 1,000 population 73 Health care workers’ Outcome Facility HRIS Annual 6.2% 5.4% 4.5% attrition rate 74 Proportion of health facilities (health centers and hospitals) with basic amenities (water, electricity, latrine,...) 59% 73% 90% • Improved water supply Input Facility HMIS Annual 76% 86% 100% • Electricity 61% 78% 86% • Improved latrine 16% 31% 50% • Basic health care waste management services 75 Number of new/ improved technology AHRI/EPHI (Diagnostics, input AHRI/EPHI Annual 1 3 6 report Therapeutics, Tools, or Vaccines) transferred 76 Proportion of health facilities implementing Input Facility RIS Annual 0.53 0.65 0.8 compulsory Ethiopian health facility standard 110 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY

ANNEX 2 EQUITY INDICATORS AND TARGETS No Equity Indicators Data Source Baseline Target 1 Ratio of deliveries assisted by Skilled Birth Attendants between pastoralist and HMIS/survey 0.54 0.80 non-pastoralist regions 2 Ratio of deliveries assisted by Skilled Birth Attendants between Rural and Urban HMIS/Survey 0.25 0.50 3 Ratio of SBA between lowest and highest wealth quintiles Survey 0.16 0.50 4 Ratio of pentavalent 3 coverage between the lowest quantile and highest quantile EDHS 0.57 0.75 5 Ratio of average Pentavalent 3 coverage between woredas below and above the HMIS NA national median 6 Ratio of OPD attendance between Males and Females HMIS 0.89 0.92 7 Ratio of OPD attendance between Rural and Urban HMIS NA 0.90 8 Ratio of OPD attendance Between Pastoralist and Non pastoralist regions HMIS NA 0.90 9 Ratio of Stunting between urban to rural EDHS 0.65 0.75 10 Ratio of “Coverage of currently on ART” between pediatrics (<15) and Adults (>15) HMIS 0.54 0.80 11 Ratio of facilities with basic amenities (water, electricity, sanitation facilities and ICT SARA 0.62 0.90 network) between rural and urban 12 Availability of essential drugs by Rural and Urban facilities LMIS NA 0.90 HSTP II | 2020/21-2024/25 2013 EFY - 2017 EFY 111

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